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Adolescent Substance Use: America’s #1 Public Health Problem


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These slides accompany the CASAColumbia report, Adolescent Substance Use: America's #1 Public Health Problem (, which reveals that adolescence is the critical period for the initiation of substance use and its consequences. The CASA report finds 1 in 4 Americans who began using any addictive substance before age 18 are addicted, compared to 1 in 25 Americans who started using at age 21 or older.

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Adolescent Substance Use: America’s #1 Public Health Problem

  2. 2. Funders • The Conrad N. Hilton Foundation • The American Legacy Foundation • The Carnegie Corporation of New York © CASAColumbia 2013 2
  3. 3. 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 • • • • Charles E. Irwin, MD, Director, Division of Adolescent Medicine, University of California, San Francisco Peter Mitchell, Chairman and Chief Creative Officer, SalterMitchell © CASAColumbia 2013 Hon. Lucille Roybal-Allard, U.S. House of Representatives (D-CA) • Ralph Hingson, ScD, MPH, Director, Division of Epidemiology and Prevention Research, NIAAA Anthony Mullen, 2009 National Teacher of the Year • Barbara J. Guthrie, PhD, RN, FAAN, Associate Professor and Associate Dean for Academic Affairs, Yale University School of Nursing • 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 3
  4. 4. 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) © CASAColumbia 2013 4
  5. 5. 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 © CASAColumbia 2013 5
  6. 6. 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 © CASAColumbia 2013 6
  7. 7. Earlier Use Equals Greater Risk Percent of Population 12 and Older with a Substance Use Disorder by Age of First Use of Any Substance 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. © CASAColumbia 2013 7
  8. 8. 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 © CASAColumbia 2013 8
  9. 9. High School Student Substance Use, 2009 Percent of High School Students Who Have Used Cigarettes, Alcohol, Marijuana or Cocaine 75.6 46.1 Lifetime Use Current Use Source: CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009. © CASAColumbia 2013 9
  10. 10. High School Student Substance Use, 2009 Percent Using Top 3 Addictive Substances 72.5 46.3 41.8 36.8 20.8 19.5 Alcohol Cigarettes Ever Used Marijuana Current Use Source: CASA analysis of the Youth Risk Behavior Survey (YRBS), 2009. © CASAColumbia 2013 10
  11. 11. Trends in High School Student Substance Use Percent Ever Used Cigarettes, Alcohol, Marijuana or Cocaine, by Gender 83.0 80.5 76.9 76.6 82.5 77.4 1999 77.0 74.9 2001 76.9 2003 Female 76.9 73.9 2005 2007 74.3 2009 Male Source: CASA analysis of Youth Risk Behavior Survey (YRBS), 2009. © CASAColumbia 2013 11
  12. 12. Trends in High School Student Substance Use Percent Ever Used Cigarettes, Alcohol, Marijuana or Cocaine, by Race 90 85 80 75 70 65 1999 White 2001 2003 Black 2005 2007 Hispanic 2009 Other Source: CASA analysis of Youth Risk Behavior Survey (YRBS), 2009. © CASAColumbia 2013 12
  13. 13. High School Student Substance Use Percent Who Have Used Controlled Prescription and Illicit Drugs Inhalants 11.7 Ecstasy 6.7 Cocaine 6.4 Methamphetamine 4.1 Over-the-Counter Medicine 3.3 Heroin 2.5 © CASAColumbia 2013 13
  14. 14. 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 © CASAColumbia 2013 14
  15. 15. 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 © CASAColumbia 2013 15
  16. 16. Substance Use Disorders Among High School Students Percent by Substance Any Substance Use Disorder 11.9 Alcohol Use Disorder 7.1 Marijuana Use Disorder 4.9 Nicotine Dependence 2.9 Prescription Drug Use Disorder 1.3 Other Illicit Drug Use Disorder 1.2 More Than One Substance Use Disorder 3.7 Source: CASA analysis of the National Household Survey on Drug Use and Health (NSDUH), 2009. © CASAColumbia 2013 16
  17. 17. Substance Use Disorders Among High School Students, Dropouts, Juveniles in the Justice System Percent with Substance Use Disorders 52.4 44.0 34.8 11.9 High School Students High School Dropouts Juveniles in the Juvenile Justice System Juveniles in the Adult 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. © CASAColumbia 2013 17
  18. 18. Referrals to Treatment Typically Occur When Teens Are Deeply in Trouble Percent of Treatment Referrals by Source 48.2 16.5 12.0 11.2 4.7 Criminal Self Referral Justice System Other Community Referral School Health Care Provider Source: CASA analysis of the Treatment Episode Data Set (TEDS), 2008. © CASAColumbia 2013 18
  19. 19. 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 © CASAColumbia 2013 19
  20. 20. 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 © CASAColumbia 2013 20
  21. 21. 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 © CASAColumbia 2013 21
  22. 22. 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 © CASAColumbia 2013 22
  23. 23. 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 © CASAColumbia 2013 23
  24. 24. School Responses Often Punitive Percent of Teachers Reporting How Their Schools Respond to Student Substance Use 82.5 59.3 47.3 34.0 14.1 13.2 17.3 20.3 11.0 Suspends Calls Law Suggests Requires Student Enforcement Counseling Counseling Smoking 4.9 Expels Student 4.7 10.2 Refers to Health Care Provider Alcohol or Other Drugs Source: CASA National Survey of High School Students, Parents of High School Students, and High School Personnel, 2010. © CASAColumbia 2013 24
  25. 25. 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 Advertisements like this one for Jose Cuervo tequila glamorize substance use © CASAColumbia 2013 25
  26. 26. 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 © CASAColumbia 2013 26
  27. 27. 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 © CASAColumbia 2013 27
  28. 28. Disconnect in Teen Perceptions Percent of High School Students Who Say the Following Are Very/Somewhat Cool Getting Good Grades 71 Being Substance Free 10 Drinking Alcohol Smoking Cigarettes Misusing Prescription Drugs 31 54 7 Getting Drunk or High Using Marijuana 88 48 48 6 43 4 36 4 What "I" Think Is Cool 28 What Most Teens Think Is Cool Source: CASA National Survey of High School Students, Parents of High School Students, and School Personnel, 2010. © CASAColumbia 2013 28
  29. 29. 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 © CASAColumbia 2013 29
  30. 30. 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 © CASAColumbia 2013 30
  31. 31. 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. © CASAColumbia 2013 31
  32. 32. 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 © CASAColumbia 2013 32
  33. 33. 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 © CASAColumbia 2013 33
  34. 34. 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 © CASAColumbia 2013 34
  35. 35. 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 © CASAColumbia 2013 35
  36. 36. Ending Addiction Changes Everything © CASAColumbia 2013
  37. 37. Speaker Notes 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. © CASAColumbia 2013 37
  38. 38. Speaker Notes 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. © CASAColumbia 2013 38
  39. 39. Speaker Notes 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. © CASAColumbia 2013 39
  40. 40. Speaker Notes 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. © CASAColumbia 2013 40
  41. 41. Speaker Notes 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. © CASAColumbia 2013 41
  42. 42. 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. © CASAColumbia 2013 42
  43. 43. Speaker Notes 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. © CASAColumbia 2013 43
  44. 44. Speaker Notes 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. © CASAColumbia 2013 44
  45. 45. Speaker Notes 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. © CASAColumbia 2013 45
  46. 46. Speaker Notes 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. © CASAColumbia 2013 46
  47. 47. Speaker Notes 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. © CASAColumbia 2013 47
  48. 48. Speaker Notes 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. © CASAColumbia 2013 48
  49. 49. Speaker Notes 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. © CASAColumbia 2013 49
  50. 50. Speaker Notes 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. © CASAColumbia 2013 50
  51. 51. Speaker Notes 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. © CASAColumbia 2013 51
  52. 52. Speaker Notes 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. © CASAColumbia 2013 52