Pediatrics · Year 3 · from Pediatrics
Case 3: Substance Use Disorder
Patient Demographics
- Age: 17-year-old male
- Sex: Male
Chief Complaint
"I'm here because my parents found weed in my room."
History of Present Illness
A 17-year-old male is brought in by his parents after they discovered marijuana and a vaping device in his room. He is initially defensive but opens up when interviewed alone. He reports using marijuana "almost every day" for the past year, usually smoking after school and before bed to "relax and deal with stress." He started vaping nicotine at age 14 and now goes through about one pod per day. He admits to drinking alcohol on weekends at parties, typically 5-6 drinks per occasion. He has tried Xanax twice that he obtained from friends "just to see what it was like." He missed several days of school last semester and his grades have dropped. He was caught driving under the influence of marijuana 2 months ago but charges were dismissed after completing a diversion program.
CRAFFT Screening
| Question | Response |
|---|---|
| C: Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? | Yes |
| R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? | Yes |
| A: Do you ever use alcohol or drugs while you are by yourself, or ALONE? | Yes |
| F: Do you ever FORGET things you did while using alcohol or drugs? | Yes |
| F: Do your FAMILY or friends ever tell you that you should cut down on your drinking or drug use? | Yes |
| T: Have you ever gotten into TROUBLE while using alcohol or drugs? | Yes |
Score: 6/6 (high risk)
Physical Examination
- Vital Signs: HR 88 bpm, BP 118/74 mmHg, RR 16/min
- General: Casually dressed, mild marijuana odor on clothes
- Eyes: Mild conjunctival injection
- Lungs: Clear to auscultation
- Otherwise: Normal examination
Diagnosis
Cannabis use disorder, moderate; Nicotine use disorder, moderate; Alcohol use disorder, mild
Clinical Reasoning
The CRAFFT score of 6/6 indicates high-risk substance use requiring intervention. This patient meets criteria for cannabis use disorder with daily use, use despite legal consequences (DUI), tolerance, and interference with school. Nicotine dependence is evident from daily vaping. The pattern of weekend binge drinking (5-6 drinks) meets criteria for alcohol use disorder. Risk factors include early onset of use (nicotine at 14), polysubstance use, and legal involvement. Protective factors include engaged parents who brought him for evaluation. The brief intervention should assess readiness for change and enhance motivation.
Management
- Brief intervention (motivational interviewing):
- Explore his perspective on his use ("What do you like about using?")
- Provide feedback on risks in a non-judgmental way
- Assess readiness to change (precontemplation, contemplation, preparation)
- Explore discrepancy between goals and current behavior
- Support autonomy in decision-making
- Referral to adolescent substance abuse treatment: Outpatient counseling for cannabis and alcohol use
- Nicotine cessation: Offer nicotine replacement therapy or discuss varenicline for older adolescents
- Mental health screening: Screen for underlying depression and anxiety (common comorbidities)
- Harm reduction: If not ready to quit, discuss reducing use, never driving impaired, carrying naloxone if ever around opioids
- Parental involvement: With patient's agreement, engage parents as supports
- Follow-up: Frequent visits to monitor progress and reinforce motivation
Clinical Image
Image Description: The CRAFFT substance use screening tool designed for adolescents, showing the mnemonic questions used to identify high-risk alcohol and drug use in young patients.
Source: Wikimedia Commons - Substance Use Screening URL: https://commons.wikimedia.org/wiki/File:Substance_screening.svg License: CC BY-SA 4.0