IBH President's Letter on Fentanyl Published in The Washington Post

In response to The Washington Post’s series on fentanyl, IBH President Robert L. DuPont, MD authored a letter to the editor, published on December 16, 2022:

The Cartel Rx series is an important contribution, recognizing the immensity of the U.S. fentanyl overdose problem and the inadequacy of efforts to turn back the devastating tide over the past two decades; however, three essential realities were overlooked.

First, there are virtually no drug overdose deaths where fentanyl is the only drug present. The “fentanyl” problem is 100 percent a polydrug problem. The United States has a five-decades-long history of demonizing one drug at a time (i.e., heroin, cocaine, methamphetamine, prescription opioids), yet these were, and still are, polydrug problems.

Second, the only way to meaningfully reduce the supply of fentanyl and other nonmedical drugs is to take away the $150 billion spent by Americans who use them. Leave that on the table, and there is no end to the supply by drug-trafficking organizations eager to collect money. There is nothing unique to either Mexico or China regarding fentanyl. It is easily synthesized anywhere in the world.

Third, though each overdose death is a tragedy for the individuals, their families and friends, most who use illicit drugs are well aware of the deadly risk of fentanyl and other drugs. The series noted more than 9 million opioid users in the country and more than 107,000 deaths; that is about 1 in 100 illegal opioid users dying of an overdose each year.

Robert L. DuPont, Chevy Chase

The writer, the first director of the U.S. National Institute on Drug Abuse and the second White House drug czar, is president of the Institute for Behavior and Health.

See the coverage on The Washington Post.

Dr. DuPont Featured on the High Truths on Drugs and Addiction Podcast

Is drug use inevitable among teens and young adults? Listen to Dr. Robert DuPont’s discussion on High Truths on Drugs and Addiction, Episode # 13. Dr. DuPont gets right to the data in challenging the myth that “everyone uses.”

Dr. Roneet Lev of High Truths Podcast

Addressing "America's Ambivalence About Youth and Alcohol" with One Choice

An article in Psychology Today by Stephen Gray Wallace, President and Director of the Center for Adolescent Research & Education (CARE), addresses the nation’s ambivalence about youth alcohol use. He highlights the “profound lack of awareness of the costs of underage drinking and the physical, social, and emotional toll it can take” and notes IBH’s research findings that for youth, the use of alcohol is closely connected to the use of cigarettes (nicotine), marijuana, and other drugs. One solution to the ambivalence to youth substance use is the clear health standard offered by IBH’s One Choice prevention message: no use of any alcohol, nicotine, marijuana, or other drugs by those under age 21 for reasons of health.

“Focused on adolescent health and rooted in the unique vulnerability of the developing brain, the One Choice message supports all other prevention messages and can be integrated into another prevention programming.”

Read the full article in Psychology Today.

A Call for a ‘Peace Plan’ to Properly Treat Opioid Use Disorder

At the 2021 Rx Drug Abuse and Heroin Virtual Summit, IBH President Robert L. DuPont, MD presented a session entitled. “Combining Medications With 12-Step Model Treatment” that he co-presented with Marvin D. Seppala, MD, of the Hazelden Betty Ford Foundation, Center City, Minnesota. In a follow-up interview for the Rx Summit Newsroom, Dr. DuPont focuses on the need for a “peace plan” between substance use disorder treatment models that use and do not use medications.

Video Interview Part 1

Dr. DuPont discusses the 12‑step‑oriented model of addiction treatment and the need for it to “add medication as a fully respected, long-term option for patients with opioid use disorder”. He also discusses his goal to help the 2 treatment camps “stop fighting with each other” and his hopes that both can” work together in mutual respect”.

Video Interview Part 2

One Choice for Health

**Click here to view or print a PDF copy of this commentary.***

One Choice for Health: A Data-Informed, Youth-Driven Prevention Message

The understanding of substance use disorder (SUD) or “addiction” as a chronic relapsing brain disease has improved over many decades and continues to evolve with science of evidence-based treatment and directly learning from individuals in long-term recovery. We know SUDs are most often pediatric-onset diseases: 9 in 10 adults with SUDs began drinking, smoking or using other substances before the age of 18.¹ Thanks to advances in brain imaging, we also know that the human brain is not fully developed until about age 25,² making adolescents uniquely vulnerable to substance use.^3-4 As the nation looks to improve public health and reduce the astounding toll of overdose deaths and addiction, now is the time for a renewed focus on primary prevention – and when early substance use is initiated, provide effective intervention.

New Context to Youth Prevention Messaging

Youth substance use prevention efforts are often focused on individual substances, specific settings (e.g., impaired driving), and even specific amounts (e.g., binge drinking). While specific prevention messages are useful, they lack the context of the common patterns of substance use reported by youth. Nationally representative data from the National Survey on Drug Use and Health show that for young people, all substance use (and non-use) is closely related: among youth aged 12-17, the use of any one substance – alcohol, cigarettes, or marijuana – significantly increases the likelihood of using the other two substances and other illicit drugs.⁵ Similarly, not using any one substance significantly reduces the likelihood of using any other substances.

Figure 1 compares youth aged 12-17 who reported no use of alcohol in the past month (on the left) to those who reported various levels of past month alcohol use (on the right). Compared to their peers who did not use any alcohol in the past month, those who reported some alcohol use in the past month were 5.8 times more likely to have used marijuana, 3.8 times more likely to have used cigarettes and 4.8 times more likely to have used other illicit drugs. Youth who reported binge drinking (i.e., consuming 5+ drinks in one sitting) or heavy alcohol use (i.e., binge drinking 5+ times in the past month) were even more likely to have used marijuana, cigarettes, and other drugs.

Figure 1. Past Month Alcohol Use is Associated with Higher Use of Other Drugs Among Youth Aged 12-17

Source: National Survey on Drug Use and Health; DuPont, R. L., Han, B., Shea, C. L., & Madras, B. K. (2018). Drug use among youth: national survey data support a common liability of all drug use. Preventive Medicine, 113, 68-73.

The correlation of use holds true for other substances as shown in Figures 2 and 3. These data provide evidence for a generalized risk of substance use. Rooted in the science of the vulnerable developing brain, the goal of youth prevention can be reframed as, One Choice: no use of any alcohol, nicotine, marijuana. or other drugs by youth under age 21 for reasons of health.

 Figure 2. Past Month Marijuana Use is Associated with Higher Use of Other Drugs Among Youth Aged 12-17

Source: National Survey on Drug Use and Health; DuPont, R. L., Han, B., Shea, C. L., & Madras, B. K. (2018). Drug use among youth: national survey data support a common liability of all drug use. Preventive Medicine, 113, 68-73.

Figure 3. Past Month Cigarette Use is Associated with Higher Use of Other Drugs Among Youth Aged 12-17

Source: National Survey on Drug Use and Health; DuPont, R. L., Han, B., Shea, C. L., & Madras, B. K. (2018). Drug use among youth: national survey data support a common liability of all drug use. Preventive Medicine, 113, 68-73.

Is Making One Choice of No Use a Realistic Goal?

Parents and other adults may view adolescent substance use as inevitable or a rite of passage – but many American teens are already making One Choice today, and that number is growing.⁶ As shown in Figure 4, for decades, the percentage of American high school seniors who have not used any alcohol, cigarettes, marijuana, or other drugs in their lifetime has increased dramatically. The most recent Monitoring the Future data shows that in 2019, over 31% of high school seniors did not use any substances in their lifetime, and nearly 59% did not use any substances in the past month. These trends are also seen among 10th and 8th grade students.⁷

Figure 4. No Use of Alcohol, Cigarettes, Marijuana and Other Illicit Drugs by US High School Seniors, 1976-2019

Source: Monitoring the Future, 2019; Levy, S., Campbell, M. C., Shea, C. L., DuPont, C. M., & DuPont, R. L. (2020). Trends in substance nonuse by high school seniors: 1975–2018. Pediatrics, 146(6), e2020007187.

A New Health Standard for Youth

Just as the nation has embraced other health standards to support teen health – use a seat belt, wear a bicycle helmet, eat a healthy diet, avoid sugary drinks, and exercise regularly – together we can make no use of alcohol, nicotine, marijuana, or other drugs a new health standard for young people under age 21. This is not a reincarnation of the famous “Just Say No” campaign which focused on marijuana use. These data shows that alcohol, nicotine, and marijuana all dominate youth substance use and that the use of any of these three drugs is closely related to the use of all others.

Youth substance use is a health issue, not a moral issue. The One Choice goal is based on the science of the developing brain; highlights the long and strong youth-led trend in more young people refraining from substance use; follows legal age limits; and supports all other drug prevention efforts, including those that focus on single drugs and use in specific settings and specific amounts.

Teens are biologically driven to seek new and exciting behaviors which can put them at increased risk for substance use. Although use of alcohol, nicotine, marijuana, and other drugs is illegal for anyone under age 21 in the US, there are several factors that can make these substances more attractive to this age group including increased availability, normalization of use, and a decrease in perceived harm from use. As such, it is important to recognize the impact of Commercialized Recreational Pharmacology, defined as the super-stimulation of brain reward for profit.⁸ It is driven by the exploitation of people who use both legal and illegal substances and profits most off heaviest users. The US has a long and troubled history with the legal alcohol and tobacco industries related to youth, and now faces powerful, growing legal vaping and recreational cannabis (marijuana) industries that promote and profit from addiction to their products.

Take Action to Promote Adolescent Health and to Reduce the Toll of Future Addiction

Addiction is a preventable pediatric-onset disease; reducing the future prevalence of substance use disorders can begin with improving youth prevention. In this effort there are essential roles for parents, families, school and community leaders, health care providers and addiction professionals. What can caring adults do?

• Articulate the One Choice goal as a health standard for young people. Talk early and often about expectations of no use before the age of 21 of any substances including alcohol, nicotine, and marijuana and its foundation of the science of the developing brain. Fit the One Choice goal into your family’s and community’s vision for youth health and wellness.

• Identify substance use and intervene early. The American Academy of Pediatrics (AAP) provides guidelines for screening young patients for substance use, noting the importance of normalizing no use and of offering strong, supportive comments when no use is reported.⁹ When substance use is reported, brief interventions and, when needed, referral to treatment can make a positive difference in the health and wellness trajectory of a young person.

• Amplify youth voices. Each year, more young Americans are making the decision to not use any alcohol, nicotine, marijuana, or other drugs. Give this growing group opportunities to share the reasons why they make One Choice and how that decision is working out for them.

• Join the One Choice Community. The nation is searching for policies to reduce the burden of addiction on our nation’s families, communities, and health care, as well as how to save lives from opioid and other drug overdoses. We must begin this important work by promoting strong, clear public health prevention efforts based on the steady, sound, and clear support for no use of any alcohol, nicotine, marijuana, or other drugs for youth under age 21 for reasons of health.

We invite you to learn more about One Choice and how prevention groups are integrating the message and supporting data into prevention initiatives at www.OneChoicePrevention.org.

Robert L. DuPont, MD, IBH President

Caroline DuPont, MD, IBH Vice President

Corinne Shea, MA, IBH Director of Programs and Communications

References:

¹ The National Center on Addiction and Substance Abuse at Columbia University. (2011). Adolescent Substance Use: America’s #1 Public Health Problem. New York, NY: Author. Available: https://drugfree.org/reports/adolescent-substance-use-americas-1-public-health-problem/

² Gogtay, N., Giedd, J. N., Lusk, L., Hayashi, K. M., Greenstein, K., Vaituzis, A. C., Nugent III, T. F., Herman, D. H., Clasen, L. S., Toga, A. W., Rapoport, J. L., & Thompson, P. M. (2014). Dynamic mapping of human cortical development during childhood through early adulthood. PNAS, 101(21), 8174-8179. https://www.pnas.org/content/101/21/8174.full

³ DuPont, R. L. & Lieberman, J. A. (2014, May 9). Young brains on drugs [Editorial]. Science, 344(6184), 557. https://doi.org/10.1126/science.1254989

⁴ Volkow, N. D., Han, B., Einstein, E. B., & Compton, W. M. (2021). Prevalence of substance use disorders by time since first substance use among young people in the US. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2020.6981

⁵ DuPont, R. L., Han, B., Shea, C. L., & Madras, B. K. (2018). Drug use among youth: national survey data support a common liability of all drug use. Preventive Medicine, 113, 68-73. https://doi.org/10.1016/j.ypmed.2018.05.015

⁶ Levy, S., Campbell, M. C., Shea, C. L., DuPont, C. M., & DuPont, R. L. (2020). Trends in substance nonuse by high school seniors: 1975–2018. Pediatrics, 146(6), e2020007187. https://doi.org/10.1542/peds.2020-007187

⁷ Levy, S., Campbell, M. C., Shea, C. L., & DuPont, R. L. (2018). Trends in abstaining from substance use in adolescents: 1975-2014. Pediatrics, 142(2), e20173498. https://doi.org/10.1542/peds.2017-3498

⁸ DuPont, R. L., & Levy, S. (2020). The nation’s drug problem is commercial recreational pharmacology [From the Field]. Alcoholism & Drug Abuse Weekly, 32(35), 3-7. https://doi.org/10.1002/adaw.32827

⁹ Levy, S. J., Williams, J. F., & Committee on Substance Use and Prevention. (2016). Substance Use Screening, Brief Intervention, and Referral to Treatment. Pediatrics, 138(1), e20161211. https://doi.org/10.1542/peds.2016-1211

Polysubstance use in the U.S. Opioid Crisis

A new article co-authored by IBH President Robert L. DuPont, MD and Wilson M. Compton, MD, MPE and Rita J. Valentino of the National Institute on Drug Abuse (NIDA) urges new research on the prevalence and reasons for polysubstance use to inform and improve both the prevention and treatment of opioid use disorders. The current approach to substance use disorders (i.e., addiction) is substance-specific which neglects to address the common issue of polysubstance use.

Published in Molecular Psychiatry, authors highlight the overlap of substances used by American adults across the lifetime, noting, “as a general principal, the more widely a drug is used, the higher the percentage of users who do not use other drugs; and, the less widely used, the more likely a drug is to be used with other drugs.”

Fig. 1: Overlap of substances used across the lifetime. Weighted lifetime prevalence of substance use and mean number of other substances ever used by adults age 18 and older in the United States (n = 51,000; Source: 2018 U.S. National Survey on Drug Use and Health [adapted from Eric Wish, University of Maryland, Center for Substance Abuse Research]).

Abstract: Interventions to address the U.S. opioid crisis primarily target opioid use, misuse, and addiction, but because the opioid crisis includes multiple substances, the opioid specificity of interventions may limit their ability to address the broader problem of polysubstance use. Overlap of opioids with other substances ranges from shifts among the substances used across the lifespan to simultaneous co-use of substances that span similar and disparate pharmacological categories. Evidence suggests that nonmedical opioid users quite commonly use other drugs, and this polysubstance use contributes to increasing morbidity and mortality. Reasons for adding other substances to opioids include enhancement of the high (additive or synergistic reward), compensation for undesired effects of one drug by taking another, compensation for negative internal states, or a common predisposition that is related to all substance consumption. But consumption of multiple substances may itself have unique effects. To achieve the maximum benefit, addressing the overlap of opioids with multiple other substances is needed across the spectrum of prevention and treatment interventions, overdose reversal, public health surveillance, and research. By addressing the multiple patterns of consumption and the reasons that people mix opioids with other substances, interventions and research may be enhanced.

Compton, W.M., Valentino, R.J. & DuPont, R.L. (2021). Polysubstance use in the U.S. opioid crisis. Molecular Psychiatry, 26, 41–50. https://doi.org/10.1038/s41380-020-00949-3

Federal Judicial Center's The Opioid Crisis Series Features Robert L. DuPont, MD

The Federal Judicial Center, the research and education agency of the judicial branch of the US government, published The Opioid Crisis, a series of interviews related to the opioid misuse epidemic. The goal of this series is to provide federal judges and court personnel with information they can use in addressing one of the most destructive public health crises in our nation’s history.

Among the speakers features in the series is IBH President Robert L. DuPont, MD who shared insights from his 50+ years of experience on dealing with the issue.

The full series can be viewed online at the FJC website.

Dealing with the Addiction Crisis During the Nightmare of COVID-19

How do we deal with an addiction crisis during the nightmare of COVID? Individuals that suffer from substance use disorder (SUD) are facing even more challenges during COVID-19 as a vulnerable population that is experiencing isolation, loss of support, employment, food security, housing, transportation and safety issues. This stress and isolation have contributed to rising overdose deaths, up by as much as 42% compared to last year. Our addiction crisis is worsening during these unprecedented times and the impact to mental health is taking a toll on this population.

On November 17, 2020, the National Association of Drug Court Professionals (NADCP) and Averhealth sponsored a webinar to discuss the SUD epidemic prior to the pandemic, the current landscape, and offer solutions for how we can address these issues of social isolation, economic hardships and loss of support for those suffering with SUD.

IBH President Robert L. DuPont, MD presented alongside General Barry R. McCaffrey, U.S. Army (Retired) and Bertha Madras, PhD.

The recorded webinar can be watched online via Averhealth.

In Celebration of Recovery Month

In celebration of Recovery Month this September, IBH President Robert L. DuPont, MD participated in a recovery webinar hosted by the World Federation Against Drugs. Dr. DuPont reflected on his years working in the field of addiction medicine and the many lessons learned from individuals in recovery from substance use disorders. 

The webinar, moderated by Mulka Nišić of Celebrate Recovery in Bosnia and Herzegovina, also featured a presentation by Huseyin Djemil, Director of Towards Recovery CIC and Green Apple Consulting Ltd in the UK. 

Robert L. DuPont, MD

Photo credit: Christoffer Bergström

Huseyin Djemil

Mulka Nišić

In concluding remarks, WFAD President Amy Ronshausen noted, "Let us make every month recovery month. Let us celebrate recovery and inspire others every day. Let us engage the recovery community in policy reform. Do not let your stories of hope end this month, continue to spread that message and be the light in a world that for many seem very dark at times. Remind them that recovery is real and attainable."

California should ban marijuana advertising to protect children and teens

A guest op-ed in The Sacrament Bee by Marvin Seppala, MD, Chief Medical Officer of Hazelden Betty Ford Foundation, describes the need for preventing youth marijuana use, beginning with banning advertising:

It’s one thing to decriminalize cannabis, but it’s another to encourage use with marketing and advertising that reaches kids.

And that’s the problem: Almost all commercial advertising makes its way to the eyes and ears of children. If we care about public health, we should ban all cannabis ads.

Dr. Seppala continues:

The entire point of advertising is to motivate people to want, and then purchase, a product, and to shape public perceptions about the product. We also know companies that market addictive substances benefit from reaching young people. The younger that people begin using, the more they purchase over a lifetime, the more profits they generate, and — unfortunately — the greater their risk for developing addiction.

Read more at The Sacramento Bee.