Re: Identifying Problematic Substance Use in a National Sample of Adolescents Using Frequency Questions

To the Editor: Chavez et al. determined age-specific cutoffs for the frequency of alcohol, tobacco, cannabis, and illicit drug use among adolescents that would put them at a higher risk for substance use disorder.¹ Specifically, for alcohol and cannabis use, these cutoffs were determined to be >3 days/year for children aged 12 to 15 years and >12 days/year for those aged 15 to 20 years. Although these cutoffs may be useful for assessing use among adolescent patients at an average risk for substance use disorder, they may be too lax for higher risk teens. Complacency toward any substance use among higher risk patients creates a missed opportunity to prevent serious complications from substance use disorders.

Childhood trauma, mental health disorders, and being a member of a minority population all place certain individuals at a higher risk for developing substance use disorder. Adolescents who have experienced physical abuse, sexual abuse, or bullying or have been exposed to domestic violence have been found to be diagnosed with substance use disorders and require treatment at a younger age than their peers.² In addition, being diagnosed with major depressive disorder and posttraumatic stress disorder have been found to be predictors of substance use disorder among adolescents.² Systematic barriers to health care for minority populations, also known as minority stress, have been associated with many poor health outcomes, including substance abuse. Sexual minority youth have been found to be more likely to engage in high-risk drug use than heterosexual patients of the same age.³

Substance use among adolescents does not exist in a bubble. Comorbid conditions, psychosocial influences, and past experiences all contribute to the development of substance use disorder in younger patients. Higher risk patients often do not have the resources or ability to seek the care that they need, and they may turn to substance use as a way to cope or self-medicate. Because these populations are especially vulnerable, they need a physician to advocate for them and identify risky patterns before they develop into a dependence. To view substance use by these at risk patients through the lens of an acceptable cutoff point is doing them a disservice. It is the responsibility of primary care providers to identify their young patients who are at risk for developing substance use disorder as early as possible, before their use becomes “problematic.”