adolescent substance use: america’s #1 public health problem

A Report by

CASAColumbia®

June 29, 2011

ADOLESCENT SUBSTANCE

USE: AMERICA’S #1 PUBLIC

HEALTH PROBLEM

© CASAColumbia 2013

Funders

• The Conrad N. Hilton Foundation

• The American Legacy Foundation

• The Carnegie Corporation of New York

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National Advisory Commission

• Hon. Jim Ramstad (Chair), Former U.S. House of Representatives (R-MN)

• Robert Bazell, Chief Health and Science Correspondent, NBC News

• Hon. Jeb Bush, Former Governor (R-FL)

• Enrique A. Carranza, Parent/Activist

• Barbara J. Guthrie, PhD, RN, FAAN, Associate Professor and Associate Dean for Academic Affairs, Yale University School of Nursing

• Ralph Hingson, ScD, MPH, Director, Division of Epidemiology and Prevention Research, NIAAA

• Charles E. Irwin, MD, Director, Division of Adolescent Medicine, University of California, San Francisco

• Peter Mitchell, Chairman and Chief Creative Officer, SalterMitchell

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• Anthony Mullen, 2009 National Teacher of the Year

• Hon. Lucille Roybal-Allard, U.S. House of Representatives (D-CA)

• Laurence Steinberg, PhD, Distinguished University Professor and Laura H. Carnell Professor of Psychology, Temple University

• Hon. Linda Tucci Teodosio, Judge, Summit County Juvenile Court

• Darrell Thompson, Former NFL Running Back, Green Bay Packers and Executive Director, Bolder Options

• Hon. Leticia Van de Putte, RPh, Texas State Senate (D-26th District)

• David Walsh, PhD, Former President and Chief Executive Officer, National Institute on Media and the Family


Study Methodology

• Reviewed 2,000 publications

• Analyzed 7 national data sets

• Interviewed approximately 50 experts and professionals

• Focus groups with students, parents and school personnel

• CASAColumbia national surveys of:

High school students (1,000)

Parents of high school students (~1,000; 75% from same household as students)

School personnel—teachers, principals, social workers/counselors, coaches (~500)

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Risky Substance Use:

A Public Health Problem

Risky Substance Use Leads to Negative Health

Outcomes Including:

• Addiction

• 70+ diseases requiring hospitalization

• Mental health problems

• Accidents, injuries, fatalities

• Sexually transmitted diseases and unplanned pregnancies

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Early Use Increases Risk

9 in 10 People with Substance Use Disorder Begin

Smoking, Drinking or Using Other Drugs before Age 18

• 91.4% of those addicted to nicotine

• 91.6% of those addicted to alcohol

• 96.1% of those addicted to illicit or controlled prescription drugs

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Earlier Use Equals Greater Risk

7

28.1

18.6

7.4

4.3

Before 15 15 to 17 18 to 20 21+

Source: CASA analysis of the National Household Survey on Drug Use and Health (NSDUH), 2009.

Percent of Population 12 and Older with a Substance Use Disorder

by Age of First Use of Any Substance


Adolescence Is

The Critical Period

For the Onset of Substance Use and Its Consequences

• Teen brain is more prone to risk taking, including substance use

• Teen brain is more vulnerable to damage from substances,

including addiction

8


High School Student

Substance Use, 2009

9

75.6

46.1

Lifetime Use Current Use

Source: CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009.

Percent of High School Students Who Have Used Cigarettes, Alcohol, Marijuana or Cocaine


High School Student

Substance Use, 2009

10

72.5

46.336.8

41.8

19.5 20.8

Alcohol Cigarettes Marijuana

Percent Using Top 3 Addictive Substances

Ever Used Current Use

Source: CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009.


Trends in High School Student

Substance Use

11

82.5

77.476.9

73.976.9

77.0

83.0

80.576.6

74.9

76.9

74.3

1999 2001 2003 2005 2007 2009

Female Male

Percent Ever Used Cigarettes, Alcohol,

Marijuana or Cocaine, by Gender

Source: CASA analysis of Youth Risk Behavior Survey (YRBS), 2009.


Trends in High School Student

Substance Use

12

65

70

75

80

85

90

1999 2001 2003 2005 2007 2009

White Black Hispanic Other

Percent Ever Used Cigarettes, Alcohol,

Marijuana or Cocaine, by Race

Source: CASA analysis of Youth Risk Behavior Survey (YRBS), 2009.


High School Student

Substance Use

13

Percent Who Have Used

Controlled Prescription and Illicit Drugs

Inhalants

Ecstasy

Cocaine

Methamphetamine

Over-the-Counter Medicine

Heroin

11.7

6.7

6.4

4.1

3.3

2.5


Consequences of Teen

Substance Use

• Academic: lower grades and academic attainment, higher

unemployment

• Health: traffic accidents, risky sex, chronic health problems, brain

damage, addiction, fatal health conditions, unintentional injuries,

homicides, suicides

• Crime: juvenile and adult property, violent and substance-related

offenses

14


Substance Use Disorders

Among High School Students

• 11.9% (1.6 million) of all high school students

• 19.4% of those who have ever tried any substance

• 33.3% of current substance users

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Among High School Students

16

3.7

1.2

1.3

2.9

4.9

7.1

11.9

More Than One Substance UseDisorder

Other Illicit Drug Use Disorder

Prescription Drug Use Disorder

Nicotine Dependence

Marijuana Use Disorder

Alcohol Use Disorder

Any Substance Use Disorder

Source: CASA analysis of the National Household Survey on Drug Use and Health (NSDUH), 2009.

Percent by Substance



17

11.9

34.8

44.052.4

High SchoolStudents

High SchoolDropouts

Juveniles in theJuvenile Justice

System

Juveniles in theAdult Corrections

System

Source: CASA analysis of the National Survey on Drug Use and Health(NSDUH), 2009; CASA Criminal Neglect: Substance Abuse, Juvenile

Justice and The Children Left Behind, 2004.

Among High School Students, Dropouts, Juveniles in the Justice System

Percent with Substance Use Disorders


Referrals to Treatment

18

48.2

16.512.0 11.2

4.7

CriminalJustice System

Self Referral OtherCommunity

Referral

School Health CareProvider

Source: CASA analysis of the Treatment Episode Data Set (TEDS), 2008.

Typically Occur When Teens Are Deeply in Trouble

Percent of Treatment Referrals by Source


Few Teens Receive

Quality Treatment

• 1.6 million high school students meet medical criteria for a

substance use disorder involving alcohol or other drugs

• Only 6.4% of them (99,913) received treatment in past year

• Only 28% of treatment facilities offer specialized care for

adolescents; most offer substandard care

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Staggering Costs to Society

Costs of Teen Use:

• $68 billion/year for underage drinking ($2,280/year for every adolescent in the U.S.)

• $14.4 billion/year for juvenile justice

Teen Use Drives Lifetime Costs:

• $467.7 billion/year in government spending on substance use/addiction ($1,500/year for every person in the U.S.)

• 96 cents of every $1 goes to cope with the consequences; only 2 cents for prevention and treatment

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American Culture

Drives Teen Use

Messages in American Culture Promote or Condone

Teen Substance Use

• Parental substance use and attitudes

• School influences

• Advertising

• Entertainment media

• Availability

• Peer norms

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Mixed Messages from Families

• 46.1% of children under 18 (34.4 million) live with

risky substance user

• 20.8% of parents of high school students think

marijuana is a harmless drug

• Home/family is most common source of addictive

substances, after friends

• Most parents don't see addiction to nicotine

(61.2%), alcohol (54.9%) or Rx/illicit drugs (53.8%)

as genetic, physical or mental health problems

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Schools Miss the Mark

• Only 27% of high school teachers say their schools train staff to

identify and respond to student substance use

• Less than 40% of high school teachers think their school’s

prevention efforts are effective

• Three-quarters of high school teachers were unable to name a

professional who is available to help students with substance use

problems

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School Responses

Often Punitive

24

59.3

14.1 13.2 11.04.9 4.7

82.5

47.3

17.3

34.0

20.310.2

SuspendsStudent

Calls LawEnforcement

SuggestsCounseling

RequiresCounseling

ExpelsStudent

Refers toHealth Care

Provider

Source: CASA National Survey of High School Students, Parents of High School Students, and High School Personnel, 2010.

Smoking Alcohol or Other Drugs

Percent of Teachers Reporting How Their

Schools Respond to Student Substance Use


Advertising/Media Glamorize

Substance Use

• Odds of becoming a tobacco user increase with exposure to tobacco

marketing

• Exposure to TV and movie portrayals of drinking linked to teen

drinking

77% of the most popular TV shows among teens and adults

mention or depict drinking

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Advertisements like this one

for Jose Cuervo tequila

glamorize substance use


Easy Availability Promotes Use

• Easy access = Increased risk of using

• 10th graders who say it’s easy to get:

Cigarettes (76.1%)

Alcohol (80.9%)

Marijuana (69.3%)

• Increased alcohol outlet density linked to increased use

• Key sources for teens are friends and family/home

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Teens’ Expectations Drive Use

• Teens are 2x likelier to initiate alcohol use if they believe that their

peers approve of their doing so

• Teens more likely to use if:

Low perception of risk/high perception of benefits

Friends’ use

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Disconnect in Teen Perceptions

28

28

36

43

48

54

31

48

4

4

6

7

10

71

88

Misusing Prescription Drugs

Smoking Cigarettes

Using Marijuana

Getting Drunk or High

Drinking Alcohol

Being Substance Free

Getting Good Grades

What "I" Think Is Cool What Most Teens Think Is Cool

Source: CASA National Survey of High School Students, Parents of High

School Students, and School Personnel, 2010.

Percent of High School Students Who Say the

Following Are Very/Somewhat Cool


Compounding the Risk

• Genetic predisposition or family history of substance use disorders

• Adverse childhood events (e.g., abuse or neglect)

• Co-occurring mental health or behavioral problems

• Peer victimization or bullying

• Other risky behaviors

• Subgroups at risk: child welfare, juvenile offenders, dropouts, minority sexual identity

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Factors that Mitigate Risk

• Positive family environment

• Positive adult role models

• Strong school/community attachment, extracurricular activity participation, goals for the future

• Sense of spirituality, religious involvement

• High self-esteem, impulse control

30


Public Health Approach

to Prevention

1. Help the public understand the risks of teen substance use, the nature of addiction and its origins in adolescence.

2. Prevent or delay the onset of substance use for as long as possible through the implementation of effective public health measures.

3. Identify teens at risk for substance use through routine screenings, as we do for other public health problems.

4. Intervene early with teens who are using to prevent further use and its consequences.

5. Provide appropriate treatment to teens identified as having a substance use or co-occurring disorder.

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Help the Public Understand

• Conduct public awareness campaigns to educate the public about:

Nature of addiction

Consequences of teen substance use

Facts about why teens use addictive substances

Link between early use and increased risk of addiction

How to prevent and respond

• Promote campaigns that are proven to be effective

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Prevent or Delay Initiation

• Reduce access

$1 increase in cigarette tax/pack would reduce teen smoking by

2.7% to 5.9%

10% increase in alcohol price associated with ~5% reduction in

drinking

• Regulate advertising

• Prevention programs

• Engage parents

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Identify Teens at Risk

and Intervene Early

• Health care practice:

Target teens in primary care and emergency settings

~15% of teens screened in primary care settings test positive

• Schools, justice and child welfare programs:

78.4% of juvenile offenders are substance involved

Teens in child welfare system at high risk due to parental substance use

and trauma

34


Provide Appropriate Treatment

• Addiction is a complex brain disease driven by genetics,

psychological and environmental factors

Chronic substance use can produce alterations in brain systems and structures, dramatically altering behavior and disrupting normal human processes

35


Ending Addiction

Changes Everything

www.casacolumbia.org


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Slide 1: • Addiction is a complex brain disease.

• What this report shows is:

• That this disease, in almost all cases, has its roots in adolescence,

• That it is the number one preventable and most costly health problem we face,

• And that our culture, broadly defined, actually increases the risk that teens will smoke, drink or

use other drugs--and suffer the consequences.

Slide 6: • The epidemiological evidence demonstrates a clear link between using addictive substances

during the teen years and developing the disease of addiction.

• Teens who use any addictive substance--including tobacco/nicotine--before the age of 18 have a 1

in 4 chance of having a substance use disorder; for those who wait until age 21 to before using any

addictive substance, their chance goes down to 1 in 25.

• Because of the link between adolescence substance use and lifetime occurrence of substance use

disorders, addiction is considered a developmental disorder.

Speaker Notes


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Slide 7: • The earlier teens use nicotine, alcohol or other drugs, the greater the likelihood that they will suffer

from a substance use disorder. The converse is also true, every year that first use is delayed, the

risk of addiction goes down.

Slide 8: • Adolescence is the critical period of risk for both using substances and for suffering from the

associated consequences, including addiction.

• The reason why teens are more vulnerable to substance use and its consequences is that the

parts of the brain responsible for judgment, decision making and controlling impulses develop

during adolescence and through the mid-20s.

• This developmental period creates a perfect storm for teens. When compared with adults:

• Teens are more likely to take risks, like experimenting with tobacco, alcohol and other drugs;

• The adolescent brain is more easily damaged by these addictive substances; and

• Teens are more likely to become addicted when they use them.

Speaker Notes


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Slide 9: • 3 out of 4 high school students in America have smoked cigarettes, drunk alcohol, smoked

marijuana or used cocaine at least once.

• Almost ½ of high school students are current users of 1 or more of these substances, meaning,

they have used them in the past month.

• While substance use is often intertwined with other problems, by itself, it is more prevalent than

anxiety, depression, obesity, and bullying.

Side Note: About 2/3 (65.1%) of students who have ever used any addictive substance have used

more than 1; among high school students who currently use any addictive substance, 46.9 %--just

under ½ currently use more than 1. Of those who have smoked cigarettes, 92% have used another

drug, as have 96% of those who have used marijuana.

Slide 10: • Alcohol is, by far, the most commonly used substance, followed by cigarettes and marijuana.

Among high schools students who use these substances, the average age of initiation is between

the ages of 13 and 14.

Side Note: For cigarettes-13.6 years old; alcohol-14.0 years old; marijuana-14.3 years old.

Speaker Notes


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Slide 11: • The good news is that over the past decade, the percent of high school students who are lifetime

substance users has dropped.

• The bad news is that these rates are still unacceptably high and declines in current use appear to

have stalled.

• Here you can see the trend in lifetime substance use over the past decade by gender.

Slide 12: • Since 2007, use has increased among Hispanic students, stayed roughly the same among black

students, and fallen among white students and students of other races/ethnicities.

Speaker Notes


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Slide 13: • The 4th most commonly used type of drug among high school students is controlled prescription

drugs, with 14.8% of teens reporting lifetime use (not comparable data with that previously

presented as it comes from a different data source).

• To put these numbers in perspective, a typical high school class comprised of 30 students:

• 21 or 22 will have used alcohol

• 13 or 14 will have smoked a cigarette

• 11 will have used marijuana

• 4 or 5 will have misused controlled prescription drugs

• 3 or 4 will have used inhalants

• 2 will have tried ecstasy and cocaine, and

• 1 student will have used methamphetamine, over-the-counter drugs or heroin.

Speaker Notes


Speaker Notes

Slide 14: • Teen substance use can have serious academic consequences, including lower grades, higher

drop-out rates, reduced likelihood of earning a college degree, and higher rates of unemployment

in adulthood.

• Teen substance use also is associated with a range of health and mental health problems,

including depression, anxiety disorders and suicidal thoughts.

• It use also contributes to the 3 leading causes of death among adolescents: accidents, suicides

and homicides.

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Slide 15: • Use of addictive substances during adolescence dramatically increases the lifetime risk of

addiction. For many students, the disease of addiction manifests at an early age.

• 1 in 8 students has already developed a substance use disorder before graduating from high

school.

• Among current substance users, 1 in 3 meet the clinical criteria for a substance use disorder.

Side Note: all high school students, ages 18 and younger, who met the DSM-IV criteria for alcohol or

drug abuse/ dependence in the past year, or the Nicotine Dependence Syndrome Scale (NDSS)

criteria for nicotine dependence in the past month

Slide 16: • Here you see the prevalence of substance use disorders broken out by substance.

Speaker Notes


44

Slide 17: • The rates of substance use disorders among particular adolescent populations such as high

school dropouts and those involved in the justice system are even higher.

Slide 18: • Typically, referrals to treatment come late in the game, when teens are already deeply in trouble.

• The vast majority of referrals come from the justice system.

Slide 19: • An unconscionably few teens who need treatment receive it, and those who do often receive

substandard care.

Slide 20: • Adolescent substance use results in both immediate and long term costs for tax payers.

• Because addiction is a developmental disorder that typically originates in the teen years, the long

term costs of addiction can extend over a lifetime.

• For every $1 we spend on this problem, only 2 cents are spent on prevention and treatment.

Speaker Notes


45

Slide 21: • American culture is rife with messages that encourage adolescents to smoke, drink and use other

drugs.

• These messages help drive this problem and they are created, in large part, by adults.

Slide 22: • Parents are sending mixed messages through their own substance-related attitudes and

behaviors.

• For example, CASAColumbia’s analysis found that almost ½ (46.5%) of parents are engaging in

risky substance use themselves; meaning they currently smoke, drink excessively or binge drink,

misuse controlled prescription drugs or use illicit drugs.

• In our survey of parents, 1 in 5 say that they see marijuana as a harmless drug and most don't

see addiction as a genetic, physical or mental health problem

• Sending a clear no use message is important: High school students report that the main reason

their peers do not drink or use other drugs is because their parents would disapprove.

• Other research confirms that greater perceived parental disapproval of teen substance use is

linked to lower likelihood of teen use.

Speaker Notes


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Slide 23: • Lack of funding, lack of evidence-based prevention programs for teens and failure to treat this as

a health problem have led schools to miss an important opportunity for prevention and

intervention.

Slide 24: • Too often schools take a punitive approach to students with substance use problems, which can

exacerbate the problem cutting off those in need of help from the institutions and services that

could benefit them.

Slide 25: • The media’s frequent presentation of substance use as glamorous, fun and stress-relieving,

coupled with limited regulation of alcohol and tobacco advertising, contribute to the pro-substance

use messages that bombard teens every day.

• These messages are not benign: Tobacco and alcohol advertising and promotions have been

linked to increased risk of adolescent tobacco and alcohol use, as have images of smoking and

drinking on television and in the movies.

Speaker Notes


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Slide 26: • Once the desire for addictive substances is primed in them, high school-age teens have little

problem accessing these products.

• High school students who report that cigarettes, alcohol and marijuana are easy to obtain are

more likely to use them.

• Adolescents in communities that are densely populated by alcohol outlets are more likely to drink,

and lower prices of these substances contribute to greater access and use.

• For the most part, however teens report getting their cigarettes, alcohol and other drugs from their

friends or family, which includes the family medicine or liquor cabinet.

Slide 27: • The mixed messages teens receive from the larger culture shape teens’ perceptions, attitudes and

expectations about smoking, drinking and using other drugs, which in turn influence their use.

• For example, teens tend to overestimate the percent of their peers who are using substances and

the extent to which their peers are accepting of use.

• Teens who believe their peers are using, or that their peers think substance use is cool, are more

likely to use.

Speaker Notes


48

Slide 28: • As you can see, there is a vast discrepancy between teens own views and their perception of the

views of their peers. This is important because we know that as teens age, they look increasingly

towards their peers to define social norms.

Slide 29: • Some teens have particular characteristics that make them more inclined to use addictive

substances and that hike the risk of progression from substance use to addiction.

• A large body of research confirms that teens who are at increased risk include those who:

• Have a genetic predisposition or a family history of substance use disorders

• Have suffered from trauma in childhood

• Have a mental health or behavioral problem or have been victims of bullying; and those who

• Engage in other risky behaviors, like unhealthy weight control practices or risky sexual activity.

• Certain sub-groups of adolescents--such as those who drop out of high school, are involved with

the criminal justice system, have a minority sexual identity or are involved in athletics--also are at

elevated risk.

Speaker Notes


49

Slide 30: • Researchers have documented a range of factors that mitigate the risk of adolescent substance

use, here are a few important examples:

• Living with parents who model healthy behavior, create a nurturing family environment, play an

active role in their teen’s lives, communicate openly and honestly about substance use, and set

and enforce clear rules;

• Having positive adult role models;

• Forging strong attachments to schools or communities,

• Having a sense of spirituality or being involved in religion; and

• High self-esteem and the ability to control one’s impulses.

Slide 31: • Parents may be the number one influence on a child’s decision to smoke, drink or use other

drugs, but there is mounting evidence that public health measures designed to address both the

cultural and individual factors that drive teen substance use can prevent such use and its

consequences.

• Yet, current approaches frequently are not supported by scientific evidence and the effective

strategies that are available are not widely employed.

Speaker Notes


50

Slide 32: • One public health measure that can help prevent adolescent substance use is conducting public

awareness campaigns to help the public understand the nature of addiction and its origins in

adolescence.

• CASAColumbia’s research has found that more than ½ of parents do not identify addiction as

primarily a health problem.

• A public awareness campaign would educate the public about what addiction is, what the

consequences of teen substance use are, the factors that drive use, what to look for and how to

respond.

• Although some public awareness campaigns around this issue are based in the research, most

have been implemented without evidence supporting their effectiveness.

• In fact, some public awareness campaigns that target teens have been shown to increase use.

Speaker Notes


51

Slide 33: • Public policies designed to limit access to tobacco and alcohol are some of the most effective

strategies available for preventing or delaying the onset of adolescent substance use.

• Raising cigarette and alcohol taxes, implementing smoking bans, and raising the minimum

drinking age to 21 have all been proven effective at reducing teen access and use. Over ½ of the

parents in CASAColumbia’s survey support raising tobacco and alcohol taxes to reduce

adolescent substance use.

• In addition, smaller studies suggest that:

• Limiting teens’ exposure to advertising

• Implementing comprehensive school and community based programs; and

• Targeting high-risk teens with specially designed interventions are all promising approaches.

Slide 34: • It is important to identify substance use early and intervene to reduce risk and prevent the

progression from use to addiction.

• Screenings and brief interventions are effective public health tools that work well in health care

settings, including primary care and ER visits, but can also work in many other settings where

teens receive services, such as schools, juvenile justice facilities and child welfare programs.

• Although research shows that screening and brief intervention techniques are effective among

high school-age adolescents, they are currently not routine practice in any of these settings.

Speaker Notes


52

Slide 35: • Addiction is a complex brain disease characterized by structural and functional changes that

disrupt normal brain processes.

• Addiction is a serious medical condition but it can be treated effectively. Psychosocial therapies

such as cognitive behavioral therapy and family-based therapies--often in combination--are

effective treatments for adolescents with substance use disorders. Pharmacotherapy is another

treatment option but not widely practiced in adolescent populations.

• We also need to expand access to care--by increasing the number of trained health care providers

who can provide treatment, facilities to provide it, and health insurance coverage for treatment.

Speaker Notes

adolescent substance use: america’s #1 public health problem

Health & Medicine