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

Health Care Professionals and Families Must Focus on Youth Substance Use Prevention

The peer-reviewed journal JAMA Network Open asked Robert L. DuPont, MD and Caroline DuPont, MD, President and Vice President, respectively, of IBH, to respond to a new research study by Bertha K. Madras, et al., "Associations of parental marijuana use with offspring marijuana, tobacco, and alcohol use and opioid misuse."

In their commentary, Drs. DuPont note that this study showed that when parents used marijuana, their children had increased risk of using marijuana too. "This underscores the need for engagement by both parents and health care professionals in youth substance use prevention and parental substance use disorder treatment." Drs. DuPont then connect the findings to IBH's own youth prevention work:

The association of parent use of marijuana with offspring use of marijuana and tobacco complements a recent finding suggesting that there is a common liability for substance use among adolescents. Among young people aged 12 to 17 years, the use of one substance is positively associated with the use of others, and nonuse of any one substance is positively associated with non-use of others. There is also evidence that there is a large and steadily increasing number of American youth who do not use any substances, including alcohol, tobacco, or marijuana. More than half (52%) of high school seniors have not used any substance in the past month and more than one-quarter (26%) have not used any substance in their lifetime, up from lows in 1982 of 16% and 3%, respectively. Together, these facts can empower parents when they are educated about their own substance use choices affecting the risks of their children using substances. They can also inform health care professionals that no use of alcohol, nicotine, marijuana, or other drugs is not only the health standard for youth but that nonuse by young patients is common and achievable.

This commentary extends the work of IBH to set a new health standard for youth prevention of One Choice: no use of any alcohol, nicotine, marijuana or other drugs by youth under age 21.

OP-ED: WE CANNOT LET E-CIGARETTES BECOME AN ON-RAMP FOR TEENAGE ADDICTION

An op-ed in The Washington Post from Alex M. Azar, Secretary of Health and Human Services (HHS) and Scott Gottlieb, Commissioner of the Food and Drug Administration (FDA), brings much-needed attention to the growing problem of youth use of nicotine through e-cigarettes: In one year fom 2017 to 2018, “the number of high-school-age children reporting use of e-cigarettes rose by more than 75 percent. Use among middle-schoolers also increased nearly 50 percent. That is an epidemic… The surge in e-cigarette use by teenagers is alarming because nicotine is highly addictive and can harm brain development, which continues into young adulthood. Worse, kids who start on e-cigarettes are actually more likely than non-user peers to migrate to smoking tobacco…” Read more.

IBH promotes the prevention goal for youth under age 21 as One Choice: no use of any alcohol, nicotine, marijuana or other drugs for reasons of health. Read more about One Choice Prevention.

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

TEENS CAN MAKE ONE CHOICE FOR A BETTER FUTURE

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For a Healthy Brain Teens Make “One Choice”

One Choice is a consistent, clear social messaging concept designed to encourage young people under 21 not to use any alcohol, tobacco, marijuana or other drugs to protect their health, especially the health of their brains. At present, prevention efforts tend to focus on a single substance or circumstance, e.g., only marijuana, only alcohol or binge drinking, or not drinking and driving. One Choice cuts through these details and centers in on the single decision that teens face every day: whether or not to use any substance at all. Rather than a series of substance-specific decisions, teens make one overarching, day-by-day decision on whether or not to use any substance, including alcohol, tobacco, marijuana and other drugs. Data from the National Survey on Drug Use and Health (NSDUH) from the Substance Abuse and Mental Health Services Administration (SAMHSA) show that the use by teens age 12 to 17 of any one of the three gateway drugs – alcohol, cigarettes or marijuana – dramatically increases the likelihood of use of the other two substances and other illicit drugs. Similarly, non-use of any one of these substances significantly reduces the likelihood of using the other two or other illicit drugs. This is the basis for One Choice. Adolescents, regardless of past substance use, have the choice today and the choice every day to not use any substance to maintain a healthy brain.

Addiction is rooted in adolescence: 90 percent of adults with substance use disorders begin using in the teenage years. The good news is that a growing percentage of teens in the US are making the choice not to use any substance. Nationally representative data from the National Institute on Drug Abuse (NIDA)-funded Monitoring the Future (MTF) survey show that over the course of the last four decades a steadily increasing percentage of high school seniors report having never used any alcohol, cigarettes, marijuana or other illicit drugs.

In 2014, over one quarter (25.5%) of high school seniors had never used any alcohol, cigarettes, marijuana or other drugs in their lifetimes.  Half (50%) of high school seniors had not used any substance in the past 30 days.  It is possible for every teen to make the choice not to use any substances.  More and more teens are making that One Choice.

 To learn more about One Choice to maintain a healthy brain, visit the IBH website, www.PreventTeenDrugUse.org.  

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

Going Beyond the Surgeon General’s Report: Redefining the Goals of Prevention, Treatment and Recovery

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Going Beyond the Surgeon General’s Report: Redefining the Goals of Prevention, Treatment and Recovery

The close of 2016 saw the release of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, providing sorely needed direction to a nation grappling with a serious drug epidemic. [1] We at the Institute for Behavior and Health, Inc. (IBH) are particularly interested in how close this landmark Report comes to our recommendations about the fundamental goals of youth substance abuse prevention and treatment for substance use disorders. For young people under the age of 21, IBH defines the goal of substance abuse prevention as no use of any alcohol, tobacco, marijuana or other drugs for reasons of health. Similarly, IBH defines the goal of substance abuse treatment as sustained recovery with a standard outcome measure of treatment of no use of such substances for at least five years.

We recall that the impact of the 1964 Surgeon General’s Report, Smoking and Health, was profound. It resulted in a slow cascade over several decades of legal sanctions on the advertising, sale and place of consumer use of tobacco products and an impressive multifaceted and multitargeted public education campaign that conveyed scientific knowledge about the severe negative health consequences of tobacco (nicotine) use. The result was a sustained decline in the use of all tobacco products coupled with a temporarily robust smoking cessation and treatment movement. Today we take for granted that Americans of all ages, even the very young, know that tobacco use is unhealthy and that its use is actively discouraged. Why do we not do the same with other substances of abuse such as alcohol and marijuana, the two most widely used drugs that are typically precursors to other drug use including nonmedical use of prescription opioids and heroin? This Commentary discusses these important issues.

The Surgeon General’s Report on Prevention

We commend the Office of the US Surgeon General for its clear message that substance use disorders are preventable.

The substance abuse prevention programs described in the Report for ages 0-10 concentrate on reducing risk factors by strengthening parent-child relationships, improving parenting skills and encouraging children’s problem solving skills. The expectation is that such programs reduce substance use later in life. No information is provided about the health implications of substance use and no recommendation is made that youth refrain from any substance use for their health.

For substance abuse prevention for ages 10-18 the Report focuses on providing adolescents with “life skills” and “substance refusal skills”. It cites The Botvin LifeSkills Program which covers topics such as managing and reducing stress and anger and building healthy relationships as well as learning about the consequences of drug use and risk taking. However, the Report states that this program has little effect on marijuana and other drug use, though it may reduce drinking and polydrug use. The Report also mentions results of similar programs in rural settings that show little effect on substance use.

Many of the adolescent substance abuse prevention programs described in the Report focus on high-risk populations including youth with impulse control issues, aggressive behavior, and those from lower socio-economic backgrounds.

In considering substance abuse prevention programs for young adults over the age of 18, the Report focuses on preventing the progression of substance use to substance misuse or “problematic use”. These prevention programs include the use of screening, brief intervention and referral to treatment (SBIRT) in school and primary care settings.

The IBH Prevention Message

IBH defines the fundamental goal of substance abuse prevention as no use of any alcohol, tobacco, marijuana or other drugs for reasons of health. Today’s prevention efforts must go further than simply reducing risk factors and increasing protective factors, though these are both important. The key facts that most substance use disorders can be traced to early initiation of substance use [2] and that the vulnerable brain is still developing until about age 25 [3] place additional emphasis on the need for more specific and effective prevention. Prevention should provide brief, clear, age-appropriate messaging that any youth substance use is unhealthy as well as illegal. In fact it is specifically illegal for the young, because it is unhealthy. Consistent messaging should come from many sources including schools, communities, religious groups, physicians and other health care providers as well as the media. All have a stake in and responsibility for the healthy development of our nation’s youth. At present the prevention messaging to youth and their parents from these various sources is unclear, inconsistent or in some cases non-existent. The acknowledgement is almost non-existent that any substance use by youth is unhealthy.

While the Surgeon General’s Report considers high-risk youth as a specific target population, we contend that today’s substance use and resulting problems including addiction are “equal opportunity”. The modern drug epidemic is not isolated within populations traditionally viewed as high-risk nor is it concentrated in inner city disadvantaged communities. Communities across the country are struggling to reduce the terrible toll of substance abuse. The US Centers for Disease Control and Prevention (CDC) reports national increases in heroin use and related deaths for all demographic groups, particularly among non-Hispanic whites. [4][5] Armed with the knowledge that youth use of the purportedly “safer” drugs of alcohol, tobacco (nicotine) and marijuana are highly correlated with one another as well as the use of other illicit drugs [6], we emphasize that for youth the decision to use any one substance opens the door to the use of other substances. For that reason we contend that young people should make one decision not to use at all for reasons of health.

With broad cultural exposure to substances of abuse – from legal alcohol to the shifting legal status of marijuana to legal prescription medications – as well as possible exposure in the home by parents, siblings, friends and the media, educating parents early about preventing all substance use by their children is crucial. Both parents and their children’s health care professionals need to understand that the use of any substance is unhealthy and all of these adults are in important positions to advise youth explicitly to not to use any alcohol, tobacco, marijuana or other drugs for their health. Substance use prevention is healthy brain protection.

In a clinical report [7] and related policy statement [8] on screening, brief intervention and referral to treatment (SBIRT), the American Academy of Pediatrics emphasizes that no use is the ultimate health goal for young patients and encourages pediatricians to support the choices made by their patients to refrain from any use and when youth already are using substances to encourage them to stop using. At present, such action by physicians is uncommon.

School-based substance abuse prevention programs also have important roles to play in empowering youth to make the healthy choice to refrain from substance use. Already in some areas of the country prevention curricula are directed at 4th and 5th graders based on the premise that teaching young people about healthy decisions in the early school years is protective.

Consistent, age-appropriate substance abuse prevention messaging focused on the fundamental goal for youth of no use of alcohol, tobacco, marijuana or other drugs must be both available and easily located on websites frequently accessed by the public seeking scientific information about the health consequences of substance use. At present finding this health-focused goal on such website resources is difficult or impossible. Media campaigns using population cohort targeted platforms also should support this no-use for health prevention messaging.

From an early age and throughout adolescence young people should be educated about the importance of avoiding substance use so they are well-prepared before they have to make the choice whether or not to use.

There is a tendency on the part of some of even the most knowledgeable people to shrug off substance abuse prevention efforts as useless because “all kids experiment”. Anecdotal stories abound about educators and medical practitioners who sanction such “trivial” substance use behavior. It is important that parents and other adults, including prevention professionals, not assume either that most young people will try alcohol and other drugs or that a little use does not pose health risks.

Using data from the nationally representative Monitoring the Future survey, IBH has shown that over the past three decades an increasing number of American high school seniors have abstained from using any alcohol, cigarettes, marijuana and other illicit drugs.[9] Among American high school seniors in 2015, 26% never, not even once in their lives, used any alcohol, tobacco, marijuana or other drugs and fully 50% have not used any alcohol, tobacco, marijuana or other drugs in the past 30 days. These new data on the growing population of youth who do not use drugs need to be publicized widely. New prevention strategies need to be developed that empower young people who do not use any drugs to talk with their peers about their healthy choices. Adults need to acknowledge and support this growing cohort of young people who are abstaining. Just as healthy eating and regular exercise are encouraged in the interest of health, so too can be an alcohol- and drug-free lifestyle.

Substance use disorders are entirely preventable when young people make the single decision not to use any substances of abuse. We hope that many more young people will continue to make this choice armed with information through new prevention efforts about how substance use negatively impacts health, and in particular, how it harms the developing brain.

The Surgeon General’s Report on Treatment and Recovery

Laudably, the Report stresses the importance of making long-term recovery the goal of substance abuse treatment. This ideal is expressed in a “continuum of care”, defined as “an integrated system of care that guides and tracks a person over time through a comprehensive array of health services appropriate to the individual’s need.” The full continuum of care promises to integrate specialty substance abuse treatment into the larger health care system, rather than treating it as an orphan outsider. Ideally health care would extend from primary prevention of the use of any substance through diagnosis of a substance use disorder, intervention and treatment to post-treatment long-term monitoring and intervention in case of relapse. Such a continuum holds the promise of drastically reducing not only the initiation of the use of alcohol and other drugs, but also addiction and subsequent relapse.

The Surgeon General’s Report does not provide a single definition of recovery but instead suggests several. For example, one definition is from the Betty Ford Institute’s Consensus Panel: “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship”. This definition highlights sobriety – no use of alcohol, marijuana and other drugs – as an essential element of recovery. Recovery, however, is more than abstinence from the use of alcohol and other addicting drugs. Recovery also includes meaningful character development and citizenship.

A less specific definition of recovery is that of the Substance Abuse and Mental Health Services Administration (SAMHSA): “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential”. Of the two definitions presented in the Report, IBH favors that of the Betty Ford Center which matches the standard of 12-step fellowships including Alcoholics Anonymous and Narcotics Anonymous.

The IBH Standard of Treatment and Recovery

IBH defines the fundamental goal of substance abuse treatment as sustained recovery, with a standard outcome measure of treatment of no use of such substances for at least five years. It is unfortunate that the Surgeon General’s Report is not explicit about the long-term sustained sobriety that characterizes recovery, considering the high prevalence of relapse after entering treatment among individuals with substance use disorders. Such relapse is similar to rates for many other chronic illnesses like diabetes and hypertension. [10] Of particular concern is the risk of overdose and death that awaits individuals with opioid use disorders who cut back their use of heroin or other opioids. Cutting back results in a loss of tolerance to a certain level of previous use, and overdose results when use is resumed at the previous dose level.

For individuals with substance use disorders, any use, even low levels of alcohol and drug use, puts them in danger of a severe relapse. There are numerous elements that support recovery: substance abuse treatment, 12-Step fellowships or similar peer-based recovery support, or an individual decision to stop using. For many individuals in recovery, a “sobriety date”, the last date on which they used alcohol or other drugs, is a core identity feature. The vast majority of people who are in recovery define it in terms of abstinence. [11] While the road to recovery is varied, its destination clearly is long and sustained abstinence.

The recent emergence of the national recovery movement is one of the most positive changes in the nation’s long-term battle to overcome addiction. IBH encourages an open dialogue with people in recovery from substance use disorders to ask how they define “recovery” and how they achieved it. Stories of recovery often come in three parts: first, what life was like when a person was using; second, what happened to get the person to make the transformation into recovery; and third, what life is like in recovery. These are inspiring stories. The testimony of people in recovery is clear and convincing.

Conclusion

With the publication of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, the Office of the Surgeon General has catalyzed and challenged the nation to constructively confront the drug epidemic. We encourage national leaders and organizations that focus on substance abuse prevention and treatment to read the Report carefully and to consider our formulations of the fundamental goals of prevention and treatment and our related recommendations. Then we ask them to assess and redouble their commitment to prevention, treatment and recovery. Together we will heed and strengthen the Surgeon General’s most important messages: substance use is preventable and treatment leading to sustained recovery is possible.

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

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[1] U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS. Available: https://addiction.surgeongeneral.gov/

[2] E.g., Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2014, July 17). The TEDS Report: Age of Substance Use Initiation among Treatment Admissions Aged 18 to 30. Rockville, MD. Available: https://www.samhsa.gov/data/sites/default/files/WebFiles_TEDS_SR142_AgeatInit_07-10-14/TEDS-SR142-AgeatInit-2014.pdf

[3] E.g., National Institute of Mental Health. (2011). The Teen Brain: Still Under Construction. NIH Publication No. 11-4929. Available: https://www.nimh.nih.gov/health/publications/the-teen-brain-still-under-construction/index.shtml ; Johnson, S. B., Blum, R. W., & Giedd, J. N. (2009). Adolescent maturity and the brain: the promise and pitfalls of neuroscience research in adolescent health policy. Journal of Adolescent Health, 45(3), 216-221; Partnership for Drug-Free Kids. (2017). The teen brain. Available: http://www.drugfree.org/why-do-teens-act-this-way/adolescent-brain-development/

[4] Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016, December 30). Increases in drug and opioid-involved overdose deaths — United States, 2010–2015. Morbidity and Mortality Weekly Report, 65(50-51), 1445-1452. Available: https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm

[5] Jones, C. M., Logan, J., Gladden, R. M., & Bohm, M. K. (2015, July 10). Demographic and substance use trends among heroin users­ – United States, 2002-2013. Morbidity and Mortality Weekly Report, 64(26), 719-725. Available: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a3.htm

[6] Data from the 2014 National Household Survey on Drug Use and Health provided by the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality.

[7] Levy, S. J., Williams, J. F., & AAP Committee on Substance Use and Prevention. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1), e20161211. 

[8] AAP Committee on Substance Use and Prevention. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1), e20161210.

[9] DuPont, R. L. (2015, July 1). 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. Available: https://www.ibhinc.org/s/IBH_Commentary_Adolescents_No_Use_of_Substances_7-1-15.pdf

[10] McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcome evaluation. JAMA, 284(13), 1689-1695.

[11] White, W. L. (2015, May 15). Recent life-in-recovery surveys. William White Papers Blog . Available: http://www.williamwhitepapers.com/blog/2015/05/recent-life-in-recovery-surveys.html