Drug overdose deaths continue to increase, negatively affecting communities throughout the United States. This rise in drug overdose deaths has increasingly been driven by synthetic opioids such as illegally made fentanyl and fentanyl analogs (referred to as IMF hereafter), particularly since 2013 (CDC, 2023a). In 2021, 106,699 drug overdose deaths occurred, a 14% increase in the age-adjusted rate from 2020 (Spencer et al., 2022). Adolescents are among those impacted by this overdose crisis. Overdose deaths increased 94% from 2019 to 2020 among adolescents, and 20% from 2020 to 2021, a greater increase than observed among the overall population (Friedman et al., 2022). In 2021, 77% of overdose deaths among adolescents involved IMF, mirroring the rapid proliferation of IMF into the illicit drug supply (DEA, 2022a; Friedman et al., 2022; Jiang et al., 2021).

Although there is no standard defined age range, adolescence is the phase of life between childhood and adulthood and is frequently a period of engaging in risky behaviors such as substance use (Sawyer et al., 2018; Frey and Roxanne, 2020; Simon et al., 2022; WHO, 2024). While adolescent substance use is of particular concern during the ongoing opioid epidemic, it is also associated with negative consequences such as delinquency, academic underachievement, sexual risk behaviors, sexually transmitted diseases, experiencing violence, injuries, and mental health conditions (Clayton et al., 2019; CDC, 2023b; DuPont et al., 2018; Nelson et al., 2017; Steinberg, 2007). Although adolescent substance use rates have stayed level or even decreased nationally (Miech et al., 2023), surveillance data show that substance use remains common among adolescents (CDC, 2023b). Among high school students, approximately 23% reported current alcohol use, 16% reported current marijuana use, and 12% reported lifetime prescription opioid misuse in 2021 (CDC, 2023b). Initiating substance use during adolescence could increase the risk of substance use later in adulthood and increase the risk of a substance use disorder (SUD) (Grant & Dawson, 1998; Kehinde et al., 2019; Luciana & Ewing, 2015).

Although prior research has examined patterns in substance use among specific adolescent populations (e.g., secondary or high school students, adolescents aged 12–17 years, students at risk of dropping out of school, and street-living, homeless adolescents in SUD treatment) including analyses by demographic factors (Rainone, 1993; Smart & Ogborne, 1994; Jones et al., 2020; SAMHSA, 2022a; Miech et al., 2023; Hoots et al., 2023), little research has focused on recent substance use patterns including IMF among adolescents assessed for SUD treatment in the United States. Assessment of adolescents’ substance use to facilitate early intervention and access to evidence-based SUD treatment such as buprenorphine is a comprehensive public health approach to delivering care and could reduce their risk of overdose and overdose death (Thoele et al., 2021; Terranella et al., 2024). Although prior research used validated screening instruments for adolescent SUD treatment planning (Sterling et al., 2015; Levy et al., 2016; Thoele et al., 2021; NIDA, 2023), these instruments did not capture specific substances or medications beyond a drug class due to the intentional brevity of screening. To improve the understanding of substance use patterns and characteristics among adolescents assessed for SUD treatment reporting lifetime substance use, particularly IMF, this study focused on real world data derived from the National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO) Comprehensive Health Assessment for Teens (CHAT) between September 2017 and December 2021 and aimed to examine (1) patterns in lifetime substance use by substance overall and by demographic characteristics, (2) frequency of overdoses or hospital visits due to drug/alcohol use, (3) frequency of substances reported as causing the most problems, (4) frequency of substances reported as preferred substances, and (5) patterns in past 30-day substance use and substance use combinations.

Results below are organized by the study’s research questions.

This cross-sectional study examined the substance use patterns, demographic characteristics, and past-year and past 30-day overdoses or hospital visits due to substance use using real world data from a convenience sample of US adolescents aged 10–18 years assessed for SUD treatment from 2017 through 2021. Findings showed that marijuana was the most commonly reported substance used during the lifetime (68.0%), followed by alcohol (54.2%), misuse of prescription opioids (13.6%), and misuse of prescription sedatives or tranquilizers (12.6%). Our results, derived from a convenience sample of adolescents aged 10–18 years assessed for SUD treatment, are higher than those derived from the nationally representative data focusing on US secondary or high school students, or adolescents aged 12–17 years in 2021 (Miech et al., 2022; Hoots et al., 2023; SAMHSA, 2022b). For example, the Monitoring the Future (MTF) survey estimated that lifetime prevalence use of alcohol and marijuana among US students in 8^th, 10^th, and 12^th grades was 36.3% and 23.1% in 2021, respectively^¶¶¶ (Miech et al., 2022). The Youth Risk Behavior Survey (YRBS) estimated that alcohol (47.4%), marijuana (27.8%), and prescription opioid misuse (12.2%) were the most commonly reported lifetime substances used by US high school students in 2021 (Hoots et al., 2023). Additionally, the 2021 National Survey on Drug Use and Health (NSDUH) data estimated that 22.9% and 13.2% adolescents aged 12–17 years used alcohol and marijuana in the lifetime, respectively**** (SAMHSA, 2022b). Differences in results among these studies are likely due to different adolescent populations, data collection processes, or outcomes measured. Adolescents assessed for SUD treatment in the CHAT are likely to have more severe substance use than the general population of secondary and high school students or adolescents aged 12–17 years in the United States.

In this study, approximately one in four assessments reported the use of multiple substances over the past 30 days, with alcohol and marijuana being the most commonly reported combination (35.6%). Notably, most substance use combinations involved either marijuana or alcohol or both. This result is similar to the findings derived from the 2021 YRBS, which found that alcohol and marijuana were the most commonly past 30-day co-used substances among those who reported past 30-day alcohol use, marijuana use, or prescription opioid misuse, with 30.2% reporting co-use (Hoots et al., 2023). High rates of alcohol and marijuana use among adolescents are concerning. An abundance of research has shown that marijuana and alcohol are associated with an increased risk of other substance use, mental health conditions, the development of a SUD later in life, and other negative consequences (CDC, 2021a; DuPont et al., 2018; NIDA, 2021a; Olfson et al., 2018). These findings emphasize the importance of comprehensive prevention strategies that focus on reducing risk factors and strengthening protective factors related to adolescent substance use (Hawkins et al., 1992; Hawkins et al., 2016). For instance, promoting programs that prevent adverse childhood experiences has the potential to reduce adolescent substance use (CDC, 2019; Tanz et al., 2022a). CDC, through the Drug-Free Communities Program, is providing funding and support to community coalitions in their work to prevent and reduce adolescent substance use (CDC, 2022a). In addition, school‐based programs integrating social competence and social influence approaches have shown protective effects in preventing marijuana and other substances use (Faggiano et al., 2014). Moreover, education about the safe storage of marijuana and safe storage and disposal of prescription drugs may reduce substance-related morbidity among adolescents (Achana et al., 2015; de la Cruz et al., 2017; Roehler et al., 2022; Thomas et al., 2019). Further, evidence-based prevention policies such as increased alcohol taxes and prescription drug monitoring programs have been shown to reduce adolescent alcohol use and overdose deaths involving prescription opioids (Dowell et al., 2016; Elder et al., 2010; Esser et al., 2022; Pardo, 2017). More research is needed to evaluate whether policies used to reduce alcohol use among adolescents are effective in reducing adolescent marijuana use.

Our study only represents adolescents who reported knowingly using IMF. Tanz et al found that approximately 84% of overdose deaths involved IMF among persons aged 10–19 years between July 2019–December 2021 (Tanz et al., 2022a), our result that IMF was the least reported substance used among adolescents, with 2.3% of all assessments reporting lifetime use, thus is likely underestimated. Notably, only 0.3% of all assessments reported IMF as their preferred substance, and 0.6% thought that IMF caused them the most problems. Nevertheless, with the high potency of IMF, increased availability of counterfeit pills resembling prescription drugs containing IMF, and frequent contamination of some illicit drugs with IMF (e.g., heroin, cocaine), adolescents exposed to substances with IMF are at high risk for fatal overdose (Joynt & Wang, 2021; NIDA, 2021b; Tanz et al., 2022a). In fact, consistent with earlier research focusing on adults assessed for SUD treatment (Jiang et al., 2021), our study indicated that a higher percentage of assessments completed by adolescents assessed for SUD treatment that reported IMF use over the lifetime also included past-year/past 30-day overdose or hospital visits due to drug/alcohol use compared to assessments with other categories of lifetime substances reported. Additionally, our study indicated that 10–14% of assessments reported misusing prescription opioids, prescription sedatives/tranquilizers, and prescription stimulants over the lifetime. The most common sources of those prescription drugs among adolescents aged 10–18 years could be from family/friends, dealers, or others (Jiang et al., 2024). It is unclear how many of those prescription drugs are counterfeit pills that could contain IMF or other illicit drugs. Counterfeit pills are easy to purchase through social media and e-commerce platforms, which poses a severe danger to adolescents (DEA, 2022b; Tanz et al., 2022a). Given the missed opportunities for interventions within the health systems (Follman et al., 2019; Schoenfeld et al., 2020; Tanz et al., 2022b; Wilson et al., 2018), continued overdose prevention, treatment, and response strategies are needed to address rising rates of IMF-involved overdose among adolescents. Education in schools on IMF and counterfeit pills and improving adolescents’ awareness about their risk is important (Tanz et al., 2022a; DEA, 2023). Naloxone distribution expansion, robust overdose education, linkage to evidence-based treatment for SUD, and harm reduction services such as use of fentanyl test strips and syringe services programs are also needed (CDC, 2022b; Hadland, 2019; Peiper et al., 2019).

Another notable finding was the high percentages of substance use reported among adolescents either living with friends, a partner or spouse, or living alone, and those not currently enrolled in school. Previous research has stressed the importance of family environment, peer influence, and school attachment on an adolescent’s life (Moore et al., 2018; Saladino et al., 2020; Schuler et al., 2019; Valkov, 2018). Research suggests it is important that substance use prevention efforts that seek to address peer influence begin prior to middle school and are sustained throughout high school (Schuler et al., 2019). In addition, early school disengagement assessment and prevention may play an important role in preventing school dropout and substance use among adolescents (Henry et al., 2012; Valkov, 2018; Rainone, 1993). Further, our study found high percentages of substance use among adolescents with a history of criminal justice involvement. This finding aligns with a robust set of research which has shown a correlation between adolescents’ criminal justice system involvement and substance use (Christeson et al., 2008; Maynard et al., 2015; Salcedo et al., 2021). This finding underscores the importance of evidence-based interventions (e.g., family counseling in the early stages of delinquency), and importance of building partnerships through multiple public health and public safety collaborations to strengthen and improve efforts to reduce drug overdoses (Young et al., 2007; CDC, 2021b). Taken together, these findings highlight the complex nature of substance use among adolescents, and the interplay between substance use, families, peers, schools, and the criminal justice system. More research is warranted to help develop tailored prevention messages and interventions at different layers of environmental influence (Moore et al., 2018).

This study also identified noteworthy patient-level characteristics and patterns in substance use among adolescents. Specifically, almost one in three adolescent assessments had a past 30-day moderate to extreme severity in the emotional/psychological health content area. These adolescent assessments reported a higher percentage of use of all substances compared with those with less severity in the emotional/psychological health content area. This is consistent with previous research documenting that mental health conditions and substance use are tightly linked among adolescents (CMI, 2019; NIDA, 2020). Additionally, we found that only 24.1% of adolescent assessments reported receiving counseling or treatment for their alcohol or drug use. Stigma concerning SUD treatment could partially explain the low engagement in care (Bagley et al., 2022; CMI, 2019). Potential intervention opportunities such as decreasing stigma, screening for co-occurring mental health conditions and SUD, and treating mental health conditions concomitantly with SUD treatment in integrated care (i.e., combining primary care, mental health, and substance use services) can help to improve care (Bagley et al., 2022; CMI, 2019; Zhang et al., 2022). Moreover, we found heterogeneity in most substances use by sex, race/ethnicity, location of the assessment site, and route of administration. Notably, although nearly one-third of the females did not report any lifetime substance used among all assessments, 3–11% of them reported substantially higher lifetime use of IMF, heroin, methamphetamine, and cocaine compared to males. In our study, lifetime substance use patterns by sex differed from those identified in MTF, YRBS, and NSDUH (Miech et al., 2022; Hoots et al., 2023; SAMHSA, 2022b). For example, these surveys revealed a higher prevalence of lifetime marijuana use among adolescent females compared to adolescent males in 2021 (Miech et al., 2022; Hoots et al., 2023; SAMHSA, 2022b). This pattern, highlighted by MTF, is considered unusual since, in past years, more adolescent males reported lifetime marijuana use (Miech et al., 2022). Together with our findings, these findings underscore the importance of designing tailored prevention strategies to address substance use and related harms among different adolescent populations (Simon et al., 2022).

Finally, many of the validated screening instruments, including CHAT, allow for identification of adolescents’ risky behaviors and substance use (Sterling et al., 2015; Levy et al., 2016; Thoele et al., 2021; NIDA, 2023). These instruments can facilitate the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model among adolescents (Sterling et al., 2015; Levy et al., 2016; Thoele et al., 2021; NIDA, 2023). However, due to the intentional brevity of screening instruments, none capture specific substances or medications beyond a drug class, nor do they measure related conditions such as current living situation, school, psychiatric/medical history, justice system involvement, and peer/familial relationships among adolescents. These additional measures are collected in CHAT which lead to the clinician’s ability to develop wholistic treatment plans and research opportunity to better understand the needs of adolescents.

Our findings are subject to at least seven limitations. First, CHAT data are self-reported and thus subject to reporting bias and recall error. Nearly one-quarter of the assessments completed by adolescents reported no lifetime substance use, which may have impacted the results. Second, our study only represents adolescents who reported knowingly using IMF. CHAT data did not collect information on whether the respondent deliberately sought out IMF, nor if they believed they were usually sold/given IMF or whether they confirmed IMF with fentanyl test strips (Ciccarone, 2017; Jiang et al., 2021; Morales et al., 2019). Third, CHAT data did not collect the main reason why adolescents were at the assessment sites and being administered the CHAT assessment. Fourth, as CHAT data are a convenience sample and are not nationally representative, our results may not be generalizable to all US adolescents being assessed for SUD treatment or to US adolescents who use substances but are not assessed for SUD treatment. Fifth, we analyzed the study at the assessment-level rather than individual-level. Nevertheless, our sensitivity analysis at the individual-level is consistent with the main analysis because of the low percentage of repeated assessments (i.e., 3.5% of all assessments were completed by adolescents who had already completed one assessment during the study period). Results from the sensitivity analysis, derived from a convenience sample of adolescents aged 10–18 years assessed for SUD treatment, are still higher than those from the 2021 nationally representative data focusing on US secondary or high school students or adolescents aged 12–17 years (Miech et al., 2022; Hoots et al., 2023; SAMHSA, 2022b). Sixth, our study period included the COVID-19 pandemic which may impact adolescent substance use patterns. More research is needed to understand how adolescent substance use changed during the COVID-19 pandemic. Finally, CHAT did not collect information about specific drug-related overdose or hospital visit; thus, we are not able to differentiate whether adolescents experienced a specific drug overdose, visited the hospital for a drug-related health problem, or visited the hospital for an alcohol-related health problem.

This study highlights the substance use patterns and characteristics using real world data from US adolescents assessed for SUD treatment and informs opportunities to address substance use among adolescents. Tailored strategies such as preventing adverse childhood experiences, promoting school-based substance use prevention programs, expanding evidence-based prevention policies, and screening for and treating co-occurring mental health conditions and SUDs are needed to reduce harms related to adolescent substance use.

This study also provides new insights into adolescents who report IMF use. In the context of increasing IMF-involved overdose deaths among adolescents cited in other studies, continued overdose prevention and response strategies such as evidence-based education on IMF and counterfeit pills, use of fentanyl test strips, naloxone distribution, and evidence-based SUD treatment expansion are needed to address rising rates of IMF-involved overdose among adolescents.