Altered States: Alcohol and Substance Use and Abuse in Adolescents Jess P. Shatkin, MD, MPH Vice Chair for Education NYU Child Study Center Director of Undergraduate Studies Child & Adolescent Mental Health Studies (CAMS) New York University College of Arts & Science Associate Professor of Child & Adolescent Psychiatry & Pediatrics New York University School of Medicine
Outline • Defining Drug Use vs. Abuse • Who uses drugs – what do they use and when do they start? • The power of the press • Why drugs are addicting (and the Dopamine theory) • Negative health consequences of drug use • Risk/Protective factors • Monitoring & talking to kids about drugs • Guidelines for reasonable choices
When does use become abuse?What constitutes “normal” substance use?
The Universal Desire to Alter Consciousness • When does it start? • What does it look like? • What forms does it take?
What does it mean to be “addicted”? • Addiction: a cluster of cognitive, affective, behavioral, and physiologic signs that indicate compulsive use of a substance and inability to control intake despite negative consequences (e.g., medical illness, failure in life roles, interpersonal difficulties). • Dependence: upon cessation of drug, an individual experiences pathological signs and symptoms (e.g., tolerance and withdrawal).
Costs of Substance Abuse Economic Alcohol misuse: $167 billion Tobacco misuse: $138 billion Drug Abuse: $110 billion Healthcare Tobacco misuse: $80 billion Alcohol misuse: $23 billion Drug Abuse: $12 billion Costs disproportionately affect the 15-44 age group, in contrast to most other costly healthcare problems which are concentrated in the older population Source: RWJ foundation 2001 based on 1995 estimates
Consequences of Adolescent Substance Use Association with: • High-risk sexual behavior with increased risk of • Rape • STDs • Unintended pregnancy • Health Problems: short and long-term • Motor vehicle accidents • Suicide • Homicide
How Common is Addiction? • 10-20% of the population will at some point have an addiction • Approximately 10% of individuals with Substance Dependence (including alcohol) commit suicide (most often in the context of a mood disorder) • An estimated 22 million Americans in 2002 were classified with substance dependence or abuse (9.4 percent of the total population aged 12 or older). Of these, 3.2 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.9 million were dependent on or abused illicit drugs but not alcohol, and 14.9 million were dependent on or abused alcohol but not illicit drugs. • 2002; National Survey on Drug Use and Health
Epidemiology • About 9% of adolescents, aged 12 – 17 years, are classified as needing treatment for alcohol and substance abuse (SAMHSA, 2010) • Greater use in adolescence translates into greater use as an adult (e.g., the earlier you start, the more likely it is to persist into later life) • Gay, lesbian, and bisexual youth report more SUDS use than heterosexual youth • Females more likely than males among GLB youth to use and males more than females among heterosexual youth
Illicit Drug Use (2010) • An estimated 22.6 million Americans, or 8.9% of the population aged 12 or older, were illicit drug users • Marijuana was the most commonly used illicit drug with a rate of 6.9% (17.4 million) • 1.5 million people (0.6%) used cocaine, 25% of whom used crack • Hallucinogens were used by 1.2 million people (0.5%), over half of whom used Ecstasy • There were an estimated 166,000 current heroin users • An estimated 7 million people, or 2.7% of the population aged 12 or older, abused psychotherapeutic drugs
LifetimeAnnual 30-day MTF 1 2009
LifetimeAnnual 30-day MTF 2 2009
Epidemiology: Use Disorders • Nationwide diagnostic telephone interview (Kilpatrick 2000) • 4000 adolescents • Among 17 year olds • 10% alcohol abuse or dependence • 7% cannabis abuse or dependence • 2% ‘hard drug’ abuse or dependence • 12-17 • 4% alcohol abuse or dependence • 4% cannabis abuse or dependence • 1% ‘hard drug’ abuse or dependence
Past month tobacco use among youths age 12-17 from 2008 NSDUH
Current Alcohol use among persons aged 12-20 from 2008 NSDUH
And in Europe? • European School Survey Project on Alcohol and Other Drugs, 2007 • A large majority of European countries have higher intoxication rates and binge drinking (e.g., 5 or more drinks in a row) rates than the united states. • Data collected from 15 and 16 year-olds in 35 European countries showed that European adolescents drink more often, drink more heavily, and get drunk more often than American adolescents do. • In the US, 22% binge drank in the past 30 days; in Denmark, that figure was 60%; in Germany 57%; in Britain 54%; in Italy 34%; and in France 28%. • Intoxication rates for the last 30 days for US adolescents was 18%, compared with 61% in Denmark, 53% in Ireland, 48% in Austria, and 46% in Britain.
Influence of Early Use (Drugs) Dramatic relationship between age of first drug use and subsequent drug abuse/dependence (SAMHSA, 2007) Early first use (≤13) triples odds of drug dependence in adulthood compared to first use >21 Strongest predictor of drug use is prior drug use
Influence of Early Alcohol Use Dramatic relationship between age of first alcohol use and subsequent alcohol abuse/dependence Early first use (≤15) increases the rate of subsequent alcohol abuse/dependence by 6 fold compared to those who first ≥21 (SAMHSA, 2003) Each year drinking onset is delayed, risk of alcohol dependence is reduced by 14% CONCLUSION: If risk factors discovered and treated early and drug initiation delayed adolescent SUDS can be prevented!
Adolescent Behavioral Changes: Drug & Alcohol Use Percentages of Past Year Alcohol Dependence or Abuse among Adults Aged 21 or Older, by Age at First Use: NSDUH 2003
Hey, man, should you be driving? • In 2002, an estimated 11 million people reported driving under the influence of an illicit drug during the past year. This corresponds to 4.7 percent of the population aged 12 or older. The rate was 10 percent or greater for each age from 17 to 25, with 21 year olds reporting the highest rate of any age (18.0 percent). Among adults aged 26 or older, the rate was 3.0 percent. • About 1 in 7 Americans aged 12 or older in 2002 (14.2 percent, or 33.5 million persons) drove under the influence of alcohol at least once in the 12 months prior to the interview.
More About Driving • According to a report by the National Institute on Drug Abuse, in 2006 30% of high school seniors reported driving after drinking heavily or using drugs, or riding in a car whose driver had been drinking heavily or using drugs, at least once in the prior 2 weeks. • Males were more likely than females to drive after heavy drinking or marijuana use. • Only 20 percent of those students with an A or A- GPA exposed themselves to these situations as opposed to almost 39 percent with a GPA of B- or below.
Driving Under the Influence of Alcohol in the Past Year among Persons Aged 16 or Older, by Age: 2010
Marijuana • Marijuana is the most widely used illicit drug, and it is usually the first drug used by persons who use illicit drugs • The number of annual marijuana initiates increased from 1.5 million in 1991 to around 2.5 million from 1996. There has been no significant change in the number since 1996. An estimated 2.4 million persons used marijuana for the first time in 2000, the most recent estimate available.
Neurobiology of Specific Drugs of Abuse: Addictive Spectrum Percent who try a drug ever and become dependent: Nicotine: 32% Heroin: 23% Crack, IV cocaine: 23% Intranasal cocaine: 17% Alcohol: 15% Cannabis: 9% Sedative-Hypnotics: 9% Psychedelics 4.9% Inhalants: 3.7% Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol. 1994;2:244-268
Prescription Drugs • More teens abuse prescription drugs than any illicit drug except marijuana. • 13% of adolescents and 31% of young adults report non-medical use of Rx drugs (lifetime, SAMHSA 2007, NSDUG) • The majority of teens who abuse prescription drugs get them easily and for free, primarily from friends and relatives. • There has been a dramatic increase in the number of poisonings and even deaths associated with the abuse of prescription and OTC drugs. • The prescription drugs most commonly abused by teens are painkillers, prescribed to treat pain; sedative-hypnotics, such as sleeping pills or anti-anxiety drugs; and stimulants, mainly prescribed to treat attention-deficit hyperactivity disorder (ADHD).
Over the Counter Drugs • The cough suppressant dextromethorphan (DXM) is found in more than 140 over-the-counter (OTC) cough and cold medications. • Based on SAMHSA's National Survey on Drug Use and Health, in 2006 about 3.1 million persons aged 12 to 25 (5.3%) had ever abused an over-the-counter cough and cold medication to get high. • Among youths aged 12 to 17, females were more likely than males to have misused OTC cough and cold medications in the past year, but among young adults aged 18 to 25, males were more likely than females to have misused these medications. • Among persons aged 12 to 25 who had misused an OTC cough and cold medication in the past year, 30.5 percent misused a NyQuil® product, 18.1 percent misused a Coricidin® product, and 17.8 percent misused a Robitussin® product