by Shahid Ali, MD; Charles P. Mouton, MD; Shagufta Jabeen, MD; Ejike Kingsley Ofoemezie, MD; Rhan K. Bailey, MD; Madiha Shahid, MS; and Qiang Zeng, MD
All from Meharry Medical College in Nashville, Tennessee.

Innov Clin Neurosci. 2011;8(12):24–28

Funding: No funding was received for the development of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key Words: Drug abuse, teenager, risk factors, early detection, drug screening, symptoms of drug use, illicit drugs, detoxification

Abstract: The illicit use of drugs, including alcohol, by teenagers has been extensively studied and documented. It is not uncommon for teenagers to be involved in illicit drug use before exhibiting signs and symptoms of drug use. Unsuspecting parents may be unaware of drug use in their children. The authors’ objective in this article is to review the literature on illicit drug use in teenagers and highlight the risk factors for teen involvement. The authors also review the warning signs that a teen is using illicit drugs. The aim of this article is to assist parents and healthcare workers involved in substance use intervention programs to be more aware of these risk factors and warning signs in order to adopt early screening and intervention measures.


Illicit drug use among teenagers has been well documented, and it appears to be more widespread than parents and guardians may suspect.[1,2] There is statistical evidence that teens are getting involved in drug use as early as the 6th to 8th grade (12–14 years old).[3–7] In a study of drug use among racial and ethnic minorities,8 the National House-hold Survey on Drug Abuse (NHSDA) concluded that the risks of starting illegal drug use, alcohol use, and tobacco cigarette smoking are largely found during the adolescent and young adult years. The study provided new information about the risk stratifications of starting to use each drug of interest during adolescence. They pointed out that drug-taking behavior represents a shifting and dynamic phenomenon. The study observed that there were increasing numbers of new initiates for various different drugs occurring during the last years of the twentieth century.[8]

The data and statistics on illicit drug and alcohol use and the consequences of such activities among teenagers are very frightening. Several authors have reported the association between alcoholism and illicit drug use among teenagers and motor vehicle accidents, risky sexual behaviors, increase suicidality, homicides, mental health problems, and high rate of school dropout.[1,8–15]

The adverse health effects of illicit drug use can be very significant, although this varies greatly depending on the specific drug, the combination of drugs consumed, the methods of intake, amount, and frequency of use. Among those who inject drugs, mortality is high due to overdose and associated medical complications since many drug users either share needles or use contaminated materials.[16–18]

There are also legal and social consequences associated with illicit drug use. Youth violence and other criminal activities attributable to illicit drug use exert its toll in many communities.[4,17] Illicit drug consumption has been identified as a major factor in the spread of communicable and sexually transmitted diseases, including human immunodeficiency virus (HIV) infection.[4,12]

When pregnant teenage girls get involved in illicit drug use, the pregnancy outcomes have been shown to adversely affect both mother and fetus in many ways, which includes poor maternal health, inadequate nutrition and prenatal care, assisted or instrumental deliveries, premature deliveries, and low birth weight infants.[8,19] Teenage drug use also increases the risk for child abuse from neglect, infanticide, and family violence.[20] There is also documented evidence that children of parents who use drugs are more likely to use illicit drugs later in life.[21–23]

One of the most powerful tools at our disposal in reducing the prevalence of teen drug use is communication.[24] For inexplicable reasons, communication is dreaded and seldom used by parents or if used at all, not on a continuing basis. Some of the proposed reasons for this lapse are that parents are busy with other personal interests, working, or they do not want to invade the privacy of their teenage sons and daughters who are suspected of using drugs.[1,17,24–27]

We live in a dynamic and fast-paced society, and with the advances in technology, parents and communities may find it difficult to raise and maintain drug-free children and young adults. Technology and the internet have been identified as one of the recruiting tools and facilitators of easy access to illicit drugs and dangerous substances among teenagers.[28,29]

More cost-effective measures need to be adopted with less emphasis on punishment and incarceration and more emphasis on preventive strategies. By exploring the risk factors that predispose teens to illicit substance use, we may be able to intervene and prevent use in high-risk teens. Hopefully, this knowledge will contribute toward instituting appropriate intervention programs to address the issue.

We believe there is a need in our society to adapt or seek new methods of fighting the problem of illicit drug use in teens. This article will review risk factors for illicit drug use in teenagers and propose methods of curbing this behavior.

Risk Factors

There are various risk factors that can predispose a teenager to drug use.[3,4,21,30,31] The age at which these risk factors are encountered by susceptible teens may dictate what influences they have on them and the progression of the illicit behavior.[6,32] These risk factors can be broadly classified under family risk factors, individual risk factors, and miscellaneous risk factors.[2,14,23,29,31,33] Family risk factors include inadequate parental supervision, poor communication, family tension and conflicts, inconsistent or unduly severe parental discipline, broken homes, and family history of parental alcohol or drug abuse.[24,27,34] Examples of the individual risk factors include history of early childhood negative and aggressive behavior; history of physical or sexual abuse; being male, Caucasian, and an older adolescent; emotional, social, or academic difficulties; poor impulse control; unstable emotions; thrill-seeking behaviors; and very low perception of the dangers inherent in drug use.[13,28,34,35] The miscellaneous factors include low socioeconomic status, level of education, living in a high crime and drug-use neighborhood; ease of drug availability; peer-group pressure; and history of mental illness.[21,34,36–39]

Warning Signs

One of the earliest warning signs that predicts teenage drug use is changes in behavior and mannerism.[14,33,40,41] The first change that is usually observed is frequent change of friends.[37,41,42] The teen may either have a gradual or sudden frequent change of friends with whom parents or guardians are not familiar or do not approve. The teen may make up unsatisfactory excuses for the observed behavior or might get angry unnecessarily when confronted. Substance-using teenagers may exhibit withdrawal from usual family bonding, routines, and activities. They may prefer to be left alone in their rooms, skip family dinner, or remain uncommunicative with parents and siblings. Some may choose to stay home rather than participate in regular family routines like family outings, holiday trips, movies, and completing house chores.

In addition, the drug-seeking habits of teenagers who are using drugs may become apparent when they suddenly begin to violate agreed upon hours of curfew restrictions.[27,33,37] This behavior may be confused with normal teen truancy, such as hanging out with his or her usual buddies or a girlfriend or boyfriend, but a teen who is seeking drugs or alcohol will often invent stories or behaviors to cover his or her tracks.

Some of the drugs a teen may use are psychotropic and may cause many types of uncharacteristic behavior. A teen under the influence of a psychotropic drug may exhibit unusual and violent behavior following trivial arguments or simple requests.[21,44] Confronting a teenager on any substance may trigger an inappropriate, uncharacteristically defiant, or caustic reaction. The reaction may be totally unprovoked since there is a sense of vulnerability and emotional instability associated with withdrawal symptoms.

Many of the drugs of abuse, most especially marijuana and alcohol, can impair the sense of judgment or produce disinhibition.[4,12,44] This may cause apparent slurring of speech and other difficulties in verbal expression. When under the influence, a teen may limit his or her communication or become unusually talkative with incoherent words and sentences or use drug jargon. A red flag that may alert a parent or healthcare professional to teenage drug use is the deterioration of school grades and skipping of classes.[33,37,42] However, some teens are savvy enough to invent situations to effectively mask this problem. Parents should receive notifications from school teachers or other school officials if their child is skipping classes or is exhibiting poor grades.

Lack of motivation is another sign of drug use.[11,15,45] A red flag for illicit drug use is when the teenager suddenly begins to show apathy, poor morale, low productivity, lack of self-control, aggressive behavior, difficult temperament, and poor interactions with family members at school and within the community. The teen may start pilfering money or stealing things to pawn in order to pay for their drugs. Coworkers or classmates may report multiple thefts or missing personal items. Neglect of personal hygiene and appearance and adoption of unusual dress habits may signal involvement in drug use. This may include wearing wrinkled or dirty clothes and paying little or no attention to hair grooming and cleanliness, which are a reflection of low self image. Some teens may dress inappropriately, wear inappropriate make up, and get body piercing or tattoos.

Changes in personality may be exhibited as deception and disrespect to authority figures. A teen involved with drugs may suddenly begin to tell lies to cover the acts, including their movements and associations. More often than not, attempts to caution or correct this behavior are vehemently resisted as an unwanted intrusion and a violation of their privacy. Manipulative and secretive traits are another tell-tale behavior of teens on drugs. They may start making and receiving frequent phone calls, mostly in hushed or whispered tones, and act sneaky and suspicious. Their email or cell phone records may leave a trail of evidence.

Some teens who use drugs display irrational behaviors or many become dramatic in their actions. In order to maintain their drug habits, often with limited resources, the teen may become irritable, verbally abusive, and even violent with siblings and parents. They may threaten to quit school, run away from home, drop out of school, or destroy family property. Others may threaten to cause bodily harm to them or even threaten suicide.[12,38,43,44]

Depression, mood instability, and apathy are also warning signs of potential teen drug and substance abuse.[12,15,20,27,45] Teens using drugs may become alienated and disinterested in things they were passionate about in the immediate past or become introverted and holed up in their room. Other symptoms include crying spells and mood swings.

Changes in appearance and the exhibition of some symptoms are some of the most definitive ways of identifying teens that are using illicit drugs. The appearance of bloodshot eyes, widely dilated pupils, or pin-point pupils are very indicative of drug use. Bloodshot eyes may signify that the teen is on marijuana.[37,39,43,45] Pupillary dilatation can indicate the teen is using drugs such as cocaine, amphetamines, or hallucinagenics. Pin-point pupils are associated with the use of barbiturates and heroin.[37,45]

There may be noticeable changes in body habitus, such as unexplained and sudden weight loss, weight gain, or poor oral hygiene.[37,41,42] The observation of skin changes, such as needle tracks in the antecubital region, are an indication that the teen may be using injectible substances like heroin. The teen may start wearing long-sleeved garments even in very warm weather to cover up these marks. Cocaine use may be associated with raw, dripping nostrils from snorting, and opiates may cause sensation of crawling insects all over the body.[5,38,43,45] The withdrawal symptoms of cocaine or amphetamines may be evident as the teen constantly scratches or picks at his or her skin and hair. It is important to rule out other organic causes (e.g., diabetic neuropathy, syphilis) or prescription drugs side effects (e.g., methylphenidate).

A teen that is on illicit drugs may be unusually drowsy or become easily or constantly fatigued. This may be a sign of crashing after a period of hyper-excitability, high energy, and euphoria from drug use or may result from fatigue due to poor eating habits.[15,37]
Finally, the possession of drug paraphernalia stands out as the most definitive indication that a teen is using illicit substances. The possession of items like tin foil, weight scales, smoking pipes, butane torches, bongs, ziplock bags, square folded paper envelops (bindles), cigarette lighters, small porcelain bowls, hypodermic needles, balloons, aluminum foil wrappers, mirrors or flat metal, short straws, glass pipes, capsules, and vials are indicative of drug use.[37,42]


There is an urgent need for parents, school teachers, and healthcare providers to be familiar with the early signs and symptoms of drug and substance abuse to be able to implement preventive measures. A comprehensive health approach that takes into consideration the involvement of primary care practitioners needs to be adopted. Other equally important considerations should include the special characteristics and vulnerabilities of special populations at risk, family structures, social and demographic characteristics, poverty, and housing and living conditions. Multiple avenues, including the internet, should be included in the larger prevention and intervention protocols.

To improve outcomes in identifying teens at risk of using illicit drugs, we recommend that strategies be adopted and incorporated at the primary care level for identifying and screening at-risk teenagers. Healthcare providers need to be routinely updated in their knowledge and skills to identify the early warning signs of illicit drug use, especially within this population. Parents and guardians of teens with risk factors for drug use need to be provided with the information and tools to identify these signs and seek help promptly. Where the parent is the drug user, every effort should be made to reduce the exposure and the impact of this behavior on their teenager. The agencies saddled with the responsibility of addressing the issues of drug use need to direct their energy and resources to measures and strategies that will curb exposure and access to illicit drugs instead of focusing more on punishment and incarceration which have failed to reduce the use of illicit drugs.

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