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.

One Choice for Health

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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

Linked National Crises: Overdose in the Time of COVID-19

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Linked National Crises: Overdose in the Time of COVID-19

The global pandemic of COVID-19 threatens every nation, demanding urgent efforts to meet the changing health care needs of their populations. At the same time, the United States faces a concurrent epidemic of drug-related overdose deaths. The effects of COVID-19 are particularly severe for individuals and families facing substance use disorders. Considering substance use disorders and overdose deaths must be a part of the national response to COVID-19.

Prior to the COVID-19 pandemic, the number of overdose deaths in the US rose steadily from 1990 peaking in 2017 with over 70,000 overdose deaths. Largely because of an increase in overdose deaths and suicides, US life expectancy declined for three straight years, from 2015 to 2017– the first decline since 1918 when the nation faced the previously disastrous flu pandemic.¹ Overdoses were not a factor in the deaths recorded at that time. What is happening now is a new, and worrisome trend that threatens several years of focused national and local efforts to reduce overdose deaths. In 2018 the US experienced a modest decline in drug overdose deaths, with a drop to 68,557. New preliminary data from the Centers on Disease Control and Prevention shows that progress was lost. A new record in overdose deaths was set at 71,999 in 2019.^2,3 Data from the Overdose Detection Mapping Application Program (ODMAP) indicates that yet another new record will be set during the era of COVID-19.

ODMAP, which collects data on overdoses from communities across the country, reports that in 2020 all overdoses – both fatal and non-fatal – increased compared to the same months in 2019: an 18% increase in March, a 29% increase in April, and a 42% increase in May.^4,5,3 Other national indicators suggest that illicit drug use is increasing. Following the March 13, 2020 declaration of COVID-19 as a national emergency, urine drug testing positivity rates showed statistically significant increases for fentanyl, methamphetamine, and cocaine.⁶ The positivity rate for heroin also increased but did not reach statistical significance.

We are losing the limited but important progress previously made in the battle to curb the overdose epidemic for several reasons. First, the drug supply is lucrative, widespread, and adaptable to COVID-19 related changes in the marketplace. Second, the COVID-19 pandemic has hindered significantly and even closed many inpatient and outpatient substance use disorder treatment programs. Third, the pandemic has incapacitated many community-based recovery support networks including, but not limited to, Twelve Step fellowships of Alcoholics Anonymous and Narcotics Anonymous. Fourth, substance use is often social, but it is also solitary; the broad isolation the population faces during COVID-19 may increase substance use and subsequent risk of overdose. As warned by Nora Volkow, MD, Director of the National Institute on Drug Abuse (NIDA), “Social distancing will increase the likelihood of opioid overdoses happening when there are no observers who can administer naloxone to reverse them and thus when they are more likely to result in fatalities.”⁷ Perhaps not surprisingly, a comparison of overdoses reported to ODMAP during pre-stay-at-home orders and post-stay-at-home orders in 2020 showed a 17.5% increase in all fatal and non-fatal overdoses.⁵

What can be done about the national rise in overdose rates?

• Use discussions of COVID-19 to highlight the problem of addiction, which is often solitary and hidden. Encourage families and others to intervene strongly when their loved ones are actively engaged in substance use. Get them into treatment and engaged in recovery support.
• Recognize the added threats of relapse even among those in recovery from substance use disorders in the time of COVID-19.
• Use media outlets aggressively to educate the public about the health threat posed by substance use, the warning signs of overdoses, and how to access and use naloxone to reverse an opioid overdose.
• Fund substance use disorder treatment and support programs as they innovate care during the COVID-19 pandemic. The American Medical Association recently outlined several action steps⁸ for states to take, including adopting rules and guidance from the Substance Abuse and Mental Health Services Administration (SAMHSA)⁹ and Drug Enforcement Administration (DEA)¹⁰ for programs that treat individuals with opioid use disorders.

As the nation faces the linked crises of the COVID-19 pandemic and a resurgence in overdoses, we must identify, protect, and assist those who are the most vulnerable. This includes individuals with substance use problems.¹¹

Robert L. DuPont, MD, IBH President

Caroline DuPont, MD, IBH Vice President

Corinne Shea, MA, IBH Director of Programs and Communications

References

[1] Woolf, S. H., & Shoomaker, H. (2019, November 26). Life expectancy and mortality rates in the United States, 1959-2017. JAMA, 322(20), 1996-2016. doi:10.1001/jama.2019.16932

[2] Ahmad, F. B., Rossen, L. M. & Sutton, P. (2020). Provisional drug overdose death counts. National Center for Health Statistics, US Center for Disease Control and Prevention. Available: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

[3] Katz, J., Goodnough, A., & Sanger-Katz, M. (2020, July 15). In shadow of epidemic, U.S. drug overdose deaths resurge to record. The New York Times. Available: https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html

[4] Wan, W., & Long, H. (2020, July 1). ‘Cries for help’: drug overdoses are soaring during the coronavirus pandemic. The Washington Post. Available: https://www.washingtonpost.com/health/2020/07/01/coronavirus-drug-overdose/

[5] Alter, A., & Yeager, C. (2020, June). COVID-19 impacts on US national overdoses. Overdose Detection Mapping Application Program. Available: http://www.odmap.org/Content/docs/news/2020/ODMAP-Report-June-2020.pdf

[6] Millennium Health. (2020, July). COVID-19 Special Edition: Significant Changes in Drug Use During the Pandemic. Millennium Health Signals Report volume 2.1. Available: https://resource.millenniumhealth.com/signalsreportCOVID

[7] Volkow, N.D. (2020, April 2). Collision of the COVID-19 and addiction epidemics. Annals of Internal Medicine, 173(1), 61-62. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138334/

[8] American Medical Association. (2020, July 8). Issue brief: reports of increases in opioid-related overdose and other concerns during COVID pandemic. AMA Advocacy Resource Center. Available: https://www.ama-assn.org/system/files/2020-07/issue-brief-increases-in-opioid-related-overdose.pdf

[9] Substance Abuse and Mental Health Services Administration. (2020, March 19). Opioid treatment program (OTP) guidance. Available: https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf

[10] Drug Enforcement Administration. (2020, March 31). Prevoznik, Thomas W. Letter to DEA Qualifying Practitioners and DEA Qualifying Other Practitioners. Available: https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-022)(DEA068)%20DEA%20SAMHSA%20buprenorphine%20telemedicine%20%20(Final)%20+Esign.pdf

[11] Pfefferbaum, B., & North, C. S. (2020, April 13). Mental health and the Covid-19 pandemic. New England Journal of Medicine. Available: https://www.nejm.org/doi/full/10.1056/NEJMp2008017

World Drug Day 2020

IBH President Robert L. DuPont, MD represents North America as a Member of the Board of Directors of the World Federation Against Drugs (WFAD). At the request of WFAD he wrote the following statement to celebrate International Day Against Drug Abuse and Illicit Drug Trafficking, better known as World Drug Day on June 25, 2020.

Click here to download or print a PDF copy of this statement.

Although the challenges posed by the COVID-19 pandemic are dominating our lives, let us not forget the equally deadly pandemic that continues to rage across the globe: drug abuse. This modern scourge, started in the late 1960s, continues to enslave and kill people of all nations in ever-changing ways. In Sweden, one of the first places the drug use pandemic hit, psychiatrist and professor, Nils Bejerot worked with the Stockholm police to fight the rising tide of methamphetamine and heroin use. Dr. Bejerot saw that the government’s initial response of providing users with physician-prescribed opioids and stimulants was futile. Not only did this policy fail to reduce drug use, but many of those drugs were diverted by users and ended up being sold on the street, leading to increased levels of drug use overall. Based on his first-hand experience with hundreds of patients, Dr. Bejerot concluded that providing addicts with drugs only prolonged their addiction and encouraged the spread of drug use throughout Swedish society. He saw that the only way to free users from the grip of addiction was to insist that they remain abstinent from all drugs. The world owes a debt of gratitude to Dr. Bejerot. Thanks to the instrumentality of his efforts over 50 years ago, Sweden’s commitment to abstinence-based drug use prevention and treatment was born.

With such a history it comes as no surprise that in 2009 the World Federation Against Drugs was established in Stockholm to create a better drug policy vision for the world by building on the Swedish experience. This was a vision in stark contrast to the increasingly dominant view that the most appropriate public health response to addiction was “harm reduction.” That strategy sought to reduce some of the harm produced by addictive drug use while permitting and even sometimes encouraging continued drug use.

WFAD is not opposed to harm reduction programs as a part of the response to the modern drug epidemic—as part of a continuum of care ending in treatment. However, WFAD insists that these programs be evaluated on the basis of their ability to help addicts become drug-free. That means seeing harm reduction as a step toward eventual abstinence. Although facilitating drug use among addicts is better than allowing them to die from overdose, such use is not in their own long-term interest as it carries many serious risks to physical and mental health. Harm reduction without eventual recovery “enables” continued drug use and addiction. That is not in the interest of addicted people or the societies in which they live. WFAD supports the use of medication-assisted treatment (MAT) for people suffering from opioid use disorders. When medications such as buprenorphine and methadone are used as prescribed and there is no other recreational or illicit use of substances, MAT patients are considered to be drug-free.

The UN Treaty on the Rights of the Child, the only UN treaty to focus on youth drug use, calls on all nations to help protect children from drugs. WFAD has the same clear goal for youth prevention as the ideal outlined in the treaty: that children be able grow up drug-free. For youth, there is no safe or healthy recreational use of drugs, including alcohol, nicotine, or marijuana. This drug-free, no-use, goal is based on the recognition of the unique vulnerability of the developing adolescent brain to drug addiction.

WFAD celebrates and supports the growing Recovery Movement worldwide. The recent emergence of millions of people who have overcome their own drug addiction not only inspires a world confronted by epidemic levels of deadly drug use, but it also reinforces the notion that true recovery is drug-free. People in recovery are the pathfinders for modern drug policy; this large and rapidly growing population offers hope to all addicted people.

WFAD is a world leader in promoting drug-free solutions for health and well-being. Composed of a diverse global array of organizations and individuals working together to combat drug addiction, WFAD is the antidote to the modern drug epidemic.

REDUCING FUTURE RATES OF ADULT ADDICTION MUST BEGIN WITH YOUTH PREVENTION

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Reducing Future Rates of Adult Addiction Must Begin with Youth Prevention

The United States is confronting a public health crisis of rising adult drug addiction, most visibly documented by an unprecedented number of opioid overdose deaths.¹ Most of these overdose deaths are not from the use of a single substance – opioids – but rather are underreported polysubstance deaths.² This is happening in the context of a swelling national interest in legalizing marijuana use for recreational and/or medical use. As these two epic drug policy developments roil the nation, there is an opportunity to embrace a powerful initiative. Ninety percent of all adult substance use disorders trace back to origins in adolescence.^3,a New prevention efforts are needed that inform young people, the age group most at-risk for the onset of substance use problems, of the dangerous minefield of substance use that could have a profound negative impact on their future plans and dreams.

Moving Beyond a Substance-Specific Approach to Youth Prevention

The adolescent brain is uniquely vulnerable to developing substance use disorders because it is actively and rapidly developing until about age 25. This biological fact means that the earlier substance use is initiated the more likely an individual is to develop addiction. Preventing or delaying all adolescent substance use reduces the risk of developing later addiction.

Nationally representative data from the National Survey on Drug Use and Health shows that alcohol, tobacco and marijuana are by far the most widely used drugs among teens. This is no surprise because of the legal status of these entry level, or gateway, drugs for adults^b and because of their wide availability. Importantly, among American teens age 12 to 17, the use of any one of these three substances is highly correlated with the use of the other two and with the use of other illegal drugs. ⁴ Similarly for youth, not using any one substance is highly correlated with not using the other two or other illegal drugs.

For example, as shown in Figure 1, teen marijuana users compared to their non-marijuana using peers, are 8.9 times more likely to report smoking cigarettes, 5.6, 7.9 and 15.8 times more likely to report using alcohol, binge drink, and drink heavily, respectively, and 9.9 times more likely to report using other illicit drugs, including opioids. There are similar data for youth who use any alcohol or any cigarettes showing that youth who do not use those drugs are unlikely to use the other two drugs. Together, these data show how closely linked is the use by youth of all three of these commonly used drugs.

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^aAmong Americans age 12 and older who meet criteria for substance use disorders specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). ^bMarijuana remains illegal under federal law but is legal in some states for recreational use the legal age is 21, and in some states for medical use, the legal age is 18. Nationally the legal age for tobacco products is 18 and for alcohol it is 21.

Figure 1. Past Month Use of Other Drugs, if Marijuana is Used, Ages 12-17

These findings show that prevention messaging targeting youth must address all of these three substances specifically. Most current prevention efforts are specific to individual substances or kinds and amounts of use of individual drugs (e.g., cigarette smoking, binge drinking, drunk driving, etc.), all of which have value, but miss a vital broader prevention message. What is needed, based on these new data showing the linkage of all drug use by youth, is a comprehensive drug prevention message: One Choice: no use of any alcohol, nicotine, marijuana or other drugs for youth under age 21 for reasons of health. ^5,6,7 This no use prevention message provides clarity for young people, parents, physicians, educators, communities and for policymakers. It is not intended to replace public health prevention messages on specific substances, but enhances them with a clear focus on youth.

Some claim adolescent use of alcohol, cigarettes and marijuana is inevitable, a goal of no use of any drug as unrealistic and that the appropriate goal of youth prevention is to prevent the progression of experimentation to later heavy use or problem-generating use. These opinions are misleading and reflect a poor understanding of neurodevelopment that underpins drug use. Teens are driven to seek new and exciting behaviors which can include substance use if the culture makes them available and promotes them. This need not be the case. New data in Figure 2 show over the last four decades, the percentage of American high school seniors who do not use any alcohol, cigarettes, marijuana or other drugs has increased steadily. In 2014, 52% of high school seniors had not used any alcohol, cigarettes, marijuana or other drugs in the past month and 26% had not used any alcohol, cigarettes, marijuana or other drugs in their lifetimes.⁸ Clearly making the choice of no use of any substances is indeed possible – and growing.

Figure 2. Past Month Trends among High School Seniors in Abstaining from Alcohol, Cigarettes, Marijuana and Other Illicit Drugs

Key lessons for the future of youth prevention can be learned from the past. Substance use peaked among high school seniors in 1978 when 72% used alcohol, 37% used cigarettes, and 37% used marijuana in the past month.⁹ These figures have since dropped significantly (see Figure 3). In 2016, 33% of high school seniors used alcohol, 10% used cigarettes and 22% used marijuana in the past month. This impressive public health achievement is largely unrecognized.

Figure 3. Percentage of US High School Seniors Reporting Past Month Substance Use, 1975-2016

Although the use of all substances has declined over the last four decades, their use has not fallen uniformly. The prevalence of alcohol use, illicit drug use and marijuana use took similar trajectories, declining from 1978 to 1992. During this time a grassroots effort known as the Parents’ Movement changed the nation’s thinking about youth marijuana use¹⁰ with the result that youth drug use declined a remarkable 63%. Rates of adolescent alcohol use have continued to decline dramatically as have rates of adolescent cigarette use. Campaigns and corresponding policies focused on reducing alcohol use by teens seem to have made an impact on adolescent drinking behavior. The impressive decline in youth tobacco use has largely been influenced by the Tobacco Master Settlement Agreement which provided funding to anti-smoking advocacy groups and the highly-respected Truth media campaign. The good news from these long-term trends is that alcohol and tobacco use by adolescents now are at historic lows.

It is regrettable but understandable that youth marijuana use, as well as use of the other drugs, has risen since 1991 and now has plateaued. The divergence of marijuana trends from those for alcohol and cigarettes began around the time of the collapse of the Parents’ Movement and the birth of a massive, increasingly well-funded marijuana industry promoting marijuana use. Shifting national attitudes to favor legalizing marijuana sale and use for adults both for medical and for recreational use now are at their highest level¹¹ and contribute to the use by adolescents. Although overall the national rate of marijuana use for Americans age 12 and older has declined since the late seventies, a greater segment of marijuana users are heavy users (see Figure 4). Notably, from 1992 to 2014, the number of daily or near-daily marijuana uses increased 772%.¹² This trend is particularly ominous considering the breathtaking increase in the potency of today’s marijuana compared to the product consumed in earlier decades. ^13,14,15 These two factors – higher potency products and more daily use – plus the greater social tolerance of marijuana use make the current marijuana scene far more threatening than was the case four decades ago.

Figure 4. Millions of Americans Reporting Marijuana Use, by Number of Days of Use Reported in the Past Month

Through the Parents’ Movement, the nation united in its opposition to adolescent marijuana use, driving down the use of all youth drug use. Now is the time for a new movement backed by all concerned citizens to call for One Choice: no use of any alcohol, nicotine, marijuana or other drugs for youth under age 21 for reasons of health. This campaign would not be a second iteration of the earlier “Just Say No” campaign. This new no-use message focuses on all of the big three drugs together, not singly and only in certain circumstances such as driving.

We are at a bitterly contentious time in US drug policy, with front page headlines and back page articles about the impact of the rising death rate from opioids, the human impact of these deaths and the addiction itself.¹⁶ At the same time there are frequent heated debates about legalizing adult marijuana and other drug use. Opposing youth substance use as a separate issue is supported by new scientific evidence about the vulnerability of the adolescent brain and is noncontroversial. Even the Drug Policy Alliance, a leading pro-marijuana legalization organization, states “the safest path for teens is to avoid drugs, including alcohol, cigarettes, and prescription drugs outside of a doctor’s recommendations.” ¹⁷

This rare commonality of opinion in an otherwise perfect storm of disagreement provides an opportunity to protect adolescent health and thereby reduce future adult addiction. Young people who do not use substances in their teens are much less likely to use them or other drugs in later decades. The nation is searching for policies to reduce the burden of addiction on our nation’s families, communities and health systems, as well as how to save lives from opioid and other drug overdoses.¹⁸ Now is precisely the time to unite in developing strong, clear public health prevention efforts based on the steady, sound message of no use of any alcohol, nicotine, marijuana or other drugs for youth under age 21 for reasons of health.

Robert L. DuPont, MD, President, Institute for Behavior and Health, Inc.

www.PreventTeenDrugUse.org / www.OneChoicePrevention.org

[1] Hedegaard, M., Warner, M., & Minino, A. M. (2017, December). Overdose deaths in the United States, 1999-2016. NCHS Data Brief, 294. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Available: https://www.cdc.gov/nchs/data/databriefs/db294.pdf  

[2] Florida Drug-Related Outcomes Surveillance and Tracking System (FROST), University of Florida College of Medicine. http://frost.med.ufl.edu/frost/

[3] 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://www.centeronaddiction.org/addiction-research/reports/adolescent-substance-use-america%E2%80%99s-1-public-health-problem

[4] 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.

[5] DuPont, R. L. (2015).  It’s time to re-think prevention: increasing percentages of adolescents understand they should not use any addicting substances. Rockville, MD: Institute for Behavior and Health, Inc.

[6] DuPont, R. L. (2017, October 23). For a healthy brain teens make “One Choice”. Rockville, MD: Institute for Behavior and Health, Inc. Available: https://www.preventteendruguse.org/s/IBH_Commentary_One_Choice_10-23-17.pdf

[7] Chadi, N., & Levy, S. (2017). Understanding the highs and lows of adolescent marijuana use. Pediatrics, 140(6). Available: http://pediatrics.aappublications.org/content/pediatrics/early/2017/11/02/peds.2017-3164.full.pdf

[8] Levy, S., Campbell, M. C., Shea, C. L., & DuPont, R. L. (2018). Trends in abstaining from substance use in adolescents: 1975-2014. Pediatrics, doi: 10.1542/peds.2017-3498.

[9] Miech, R. A., Johnston, L. D., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2017). Monitoring the Future national survey results on drug use, 1975–2016: Volume I, Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan. Available at http://monitoringthefuture.org/pubs.html#monographs

[10] Dufton, E. (2017). Grass Roots: The Rise and Fall of Marijuana. New York, NY: Basic Books.  

[11] Geiger, A. (2018, January 5). About six-in-ten Americans support marijuana legalization. Washington, DC: Pew Research Center. Available: http://www.pewresearch.org/fact-tank/2018/01/05/americans-support-marijuana-legalization/

[12] Caulkins, J. (2017, November 7). Psychoactive drugs in light of libertarian principles. Law and Liberty. Available: http://www.libertylawsite.org/liberty-forum/psychoactive-drugs-in-light-of-libertarian-principles/

[13] ElSohly, M. A., Mehmedic, Z., Foster, S., Gon, C., Chandra, S., & Church, J. C. (2016). Changes in cannabis potency over the last 2 decades (1995-2014): Analysis of current data in the United States. Biological Psychiatry, 79(7), 613-619.

[14] World Health Organization. (2016). The Health and Social Effects of Nonmedical Cannabis Use. Geneva, Switzerland: Author. Available: http://www.who.int/substance_abuse/publications/cannabis/en/

[15] Rocky Mountain High Intensity Drug Trafficking Area. (2017, October). The Legalization of Marijuana in Colorado: The Impact, Volume 5. Denver, CO: Author. Available: https://rmhidta.org/files/D2DF/2017%20Legalization%20of%20Marijuana%20in%20Colorado%20The%20Impact2.pdf

[16] E.g., Sanger-Katz, M. (2018, August 16). Bleak new estimates in drug epidemic: a record 72,000 overdose deaths in 2017. The New York Times, p. A1. Available: https://www.nytimes.com/2018/08/15/upshot/opioids-overdose-deaths-rising-fentanyl.html; Seelve, K. Q. (2018, January 21). One son. Four overdoses. Six hours. A family’s anguish. New York Times, p. A1. Available: https://www.nytimes.com/2018/01/21/us/opioid-addiction-treatment-families.html

[17] Drug Policy Alliance. (2018). Real drug education. New York, NY: Author. Available: http://www.drugpolicy.org/issues/real-drug-education

[18] The President’s Commission on Combatting Drug Addiction and the Opioid Crisis. (2017). Final Draft Report. Available: https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-15-2017.pdf