Few pediatric practice-based drug and alcohol surveys have been conducted with adolescent patients. This study reports on similarities and differences in adolescent drug and alcohol use between urban (95% black) pediatric practices and a suburban (89% white) pediatric practice. While there were greater similarities between patient substance use and reported problems than differences, a number of significant differences emerged. White suburban youth were heavier users of tobacco products, alcohol, and inhalants, and experienced more difficulties with blackouts, family conflict, school absence, suicidal ideation, and loss of peer relationships. Other racial/ethnic and practice site differences are discussed. This study highlights characteristics of youth drug abuse in the private pediatric practice setting and implications for the pediatrician in caring for adolescents.