The risks of teen drinking and the role of family medicine physicians

Teen alcohol use is far more common, and far more consequential, than many family practitioners realize. According to recent surveys, nearly one in three high school students report drinking alcohol and over 13% report binge drinking within the past month. Yet, conversations about alcohol are often missing from the exam room.

That silence is a missed opportunity. Adolescents who drink face serious short- and long-term risks — not just social or disciplinary consequences. Teenage drinking leads to measurable changes in brain development, academic performance, mental health and future addiction risk. And unlike other conditions, alcohol use often presents subtly at first, making early identification and intervention even more critical.

Family medicine providers are positioned to detect those early signs and guide teens and their families. But doing so requires a clear understanding of how alcohol affects the adolescent brain, what warning signs to watch for and how to talk to teens in a way that’s effective, not alienating.

Why alcohol hits the teen brain so hard

The human brain continues developing well into the mid-20s, making adolescents especially sensitive to alcohol’s effects. Three distinct regions of the brain still undergoing critical development are especially prone to disruption.

First is the prefrontal cortex, which is responsible for impulse control and decision-making. It is the last brain region to fully mature. Alcohol interferes with its development, contributing to increased impulsivity and poor judgment.

The second is the hippocampus, a part of the brain responsible for memory and learning. Studies indicate that adolescents who drink heavily have smaller hippocampi. A decrease in brain volume during adolescence can impair the cognitive abilities to remember facts, maintain focus in class and meet academic demands. These deficits may seem subtle at first but often accumulate, leading to declining grades, reduced confidence and lasting setbacks in academic performance.

The third area of interest is the brain’s reward system. Young people have a more sensitive response to pleasurable stimuli, including alcohol. That intense euphoria may feel good in the moment, but it increases the risk of developing an addiction long term. Teens who start drinking before age 15 are nearly four times more likely to develop alcohol dependence in adulthood than those who wait until age 21.

Short-term risks with long-term impact

The consequences of teen drinking extend beyond the brain to impact both psychosocial development and overall well-being. Hangovers, though often dismissed as minor, can impair concentration, energy and mood, leading to declining academic performance, reduced motivation and strained relationships with teachers, peers and family.

Alcohol also lowers inhibitions, making teens more likely to engage in risky behaviors such as unplanned or unprotected sexual activity. These encounters can lead to unintended pregnancies, sexually transmitted infections and lasting emotional consequences. Alcohol can also intensify negative emotions, heightening the risk of aggression, bullying and intimate partner violence. Research shows that alcohol raises the risk of both perpetrating and being a victim of aggression during adolescence.

For teens already experiencing anxiety or depression, alcohol can worsen mental health symptoms. While alcohol may provide short-term relief, the rebound effect often leads to deeper emotional lows, increasing the risk of self-harm or suicidal thoughts.

Finally, alcohol poisoning remains a serious and under-recognized threat. Many teens misjudge their limits, and when inexperience combines with peer pressure and binge drinking culture, the result can lead to acute medical emergencies.

Red flags: What to watch for

Teen drinking can be difficult to identify and track, with subtle pattern shifts potentially noteworthy. Parents and providers alike should look for new or different behaviors, such as shifts in friend groups, secrecy, lying about whereabouts, suddenly turning off location sharing, slipping grades or mood swings.

A family history of substance or alcohol use disorder is another potential risk factor, especially when teens report feeling euphoric after drinking. While alcohol typically causes drowsiness in most people, those with a genetic predisposition may experience heightened stimulation and euphoria instead, which can signal increased vulnerability to addiction. Even brief patterns of impaired control, such as intending to have one drink but ending up having several, should be seen as early warning signs. These are the moments when clinicians need to step in. Preventing addiction is far easier and more effective than treating it once fully developed.

Communicating with teens about alcohol use

Information is only one component of successfully addressing teen alcohol use. Teens are more likely to engage in open dialogue when they don’t feel judged or threatened. That’s where the BRENDA approach comes in.

BRENDA is a structured method for engaging teenagers in discussions about alcohol use.

B — Biopsychosocial evaluation: Gather information about the teen’s biological, psychological and social functioning, including alcohol use, physical health, mental health and peer relationships.

R — Report findings: Share what you’ve learned in a clear, factual and nonjudgmental way.

E — Empathize: Acknowledge and validate the teen’s feelings and experiences, showing that you understand their feelings.

N — Needs: Help the teen identify what matters to them — such as improved focus in school, healthier friendships or managing anxiety.

D — Direct advice: Offer guidance tailored to their goals, explaining how certain choices (like reducing drinking) support those outcomes.

A — Assess response to advice: Check how the teen reacts. Are they ready to make changes? Did the changes work? Then, adjust your approach as needed and support them in making realistic next steps.

In practice, BRENDA fosters a calm and respectful conversation, emphasizing support and clear guidelines. The clinician listens actively, recognizes both the appeal and the risks of drinking, and helps the teen reflect on how alcohol fits — or doesn’t fit — with their personal goals. When teens feel heard, they are more likely to internalize the risks of drinking and make healthier decisions moving forward.

This same approach can be adapted for conversations with parents. It’s important to prepare families for the reality that teens may experiment with alcohol and that reacting with anger or panic isn’t the way to go. Instead, parents may be coached to approach their teens with curiosity, clarity and calm, using data and open dialogue to guide decisions.

Takeaways for family medicine providers

Primary care remains one of the most consistent points of contact for adolescents, placing physicians, nurse practitioners or physician assistants with family medicine specializations in a unique position to identify early alcohol use and intervene before it leads to lasting harm.

This starts with normalizing alcohol use screening as part of routine adolescent care. Brief tools like the Alcohol Use Disorders Identification Test-Concise, a screening instrument to identify hazardous drinking, can uncover early risk patterns and open the door to important conversations. Health care providers should stay alert to subtle signs, like impaired control, changes in social behavior, secrecy or unusually positive responses to alcohol, particularly in teens with a known family history of addiction.

When alcohol use does come up, engaging teens with empathy is essential. Using structured approaches, such as motivational interviewing or the BRENDA framework, helps build trust and foster open dialogue, giving teens space to reflect on their choices relative to long-term goals. Parents should also be looped in and coached on how to respond calmly and constructively.

Above all, health care providers must remember that prevention is a form of treatment. Intervening before behavior crosses into dependence, whether through conversation, counseling or even early pharmacological support, can alter the course of a young person’s life for the better.

Joseph R. Volpicelli, MD, PhD, is a scientist-clinician with over 40 years of experience specializing in addiction psychiatry. He is executive director of the Institute of Addiction Medicine. His early work led to the approval of naltrexone to treat alcohol dependence; it was the first new medication to be FDA approved for this condition in nearly 50 years.