Despite recent decreases in rates of substance use in adolescents, substance use remains common and most teens in need of treatment do not access it largely due to not feeling they need treatment. Adolescent substance use is associated with physical, mental, and social harms, and providers should expand beyond screening for use or use disorders to better understand risks. Harm reduction practices (e.g. naloxone, not using alone, drug test strips, sterile supplies, etc.) can help providers decrease risks while working to enhance adolescent motivation and treatment engagement. Providers can recommend treatment, reduction in use, and abstinence while providing harm reduction.