ASA8285 - SECTION 3: ADOLESCENT ALCOHOL AND OTHER DRUG (AOD) USE
Patterns of Adolescent Alcohol and Other Drug Use
The most frequent risk-taking behavior by adolescents is the use of alcohol and other drugs (AOD). The National Institute on Drug Abuse’s Monitoring the Future reports that more than half of American young people have tried cigarettes by the 12th grade, and more than a quarter of 12th graders are current smokers (Johnston, O’Malley, & Bachman, 2003). They report that nearly four out of every five young people have consumed alcohol by the end of high school, and nearly half have done so by the 8th grade.
In fact, almost two-thirds of the 12th graders and a fifth of the 8th graders report having been drunk at least once in their life. They report that over one-half of American young people have tried an illicit drug by the time they finish high school. If inhalant use is included in the definition of an illicit drug, nearly a third of adolescents have done so as early as 8th grade. Three out of ten have used some illicit drug other than marijuana by the end of the 12th grade, and two of those three have done so in just the 12 months prior to the survey.
Looking at the trends for the past ten years shows that illicit drug use reached its recent peak among teens in 1996 or 1997, depending upon the grade. Since then, only the eighth-graders have exhibited a gradual, ongoing decline. Use in the upper grades held fairly constant until 2002, when all three grades finally began to show some decline.
That decline continued into 2003, with statistically significant drops observed in annual prevalence in eighth- and 10th- grades and nearly significant drop in 12th-grade. Because marijuana is by far the most widely of the illicit drugs, trends in its use tend to drive the index of any illicit drug use. In 2003, marijuana use exhibited its second year of decline in the upper grades and its seventh year of decline among eighth-graders. Its use has now fallen by three-tenths among eighth-graders since their peak in 1996 and by about two-tenths and one-tenth, respectively, among the 10th and 12th-graders since their recent peaks in 1997.
In 2003, 13 percent, 28 percent, and 35 percent of the eighth-, 10th- and 12th-graders indicated having smoked marijuana in the prior 12 months. The proportions of students using any illicit drug other than marijuana also declined in 2003 among 10th-grade students and 12th-grade students. However, use among the eighth-graders, which had fallen by a third in earlier years from the recent peak in 1996, showed no further decline in 2003 (www.monitoringthefuture.org).
Alcohol use among youth has showed fairly steady declines since the early 1990s, though the rate has remained relatively steady in the last few years with only binge drinking showing slight decreases in frequency. Smoking by adolescents has also showed steady declines. Cocaine use has also declined and current levels of heroin use are half of what they were at their recent peaks in the mid-1990s.
There were also decreases in the use of LSD and ecstasy (fallen by more than half since 2001), amphetamine use, tranquilizers, inhalants, and sedatives. Drugs such as the so-called club drugs (Rohypnol, GHB, and ketamine) and hallucinogens other than LDS have showed some declines in recent years, but the use of the drug OxyContin showed some increases (though the overall rates of use are low—1.7 percent, 3.6 percent, and 4.5 percent for eighth-, 10th-, and 12th-grade students).
Of concern is evidence that the age of initiating AOD use is decreasing, particularly for marijuana and alcohol. Males are more likely than females to use illicit drugs frequently and engage in heavy drinking, however, females are as likely as males to smoke. The northeast and west have the highest proportions of students using any illicit drug, whereas the south has the lowest, and the south and the west continue to have slightly lower rates of drinking among youth.
In addition, substance use is somewhat more prevalent in rural than metropolitan areas. Across all age groups, African-American youth have substantially lower rates of substance use than Whites for alcohol, cigarettes, and any illicit drug. Hispanics’ rates of use tend to fall between the two groups. Only for crack and ecstasy did Hispanics' use exceed that of whites and African-Americans.
For heroin, Hispanic use is equivalent to rates of white teens. Data on Native American substance abuse indicate alcohol use equivalent to whites. In addition, differences in use by socioeconomic status are small, with declines in use occurring among students from more educated families.
While the use of individual drugs (other than marijuana) may fluctuate widely, the proportion of adolescents using any of them fluctuates much less. In other words, the proportion of students prone to using drugs changes more gradually. The usage rates for each individual drug, on the other hand, reflects many, more rapidly changing determinants specific to that drug, including how widely its psychoactive potential is recognized, how favorable the reports of its supposed benefits are, how risky the use of it is seen to be, how acceptable it is in the peer group, and how accessible it is (Rapp-Paglicci, Dulmus, & Wodarski, 2004).
Patterns of AOD use among adolescents differ from those of adults in several important ways including: 1) they engage in more episodic or binge alcohol drinking and other substance use, 2) adolescence rarely experience the AOD-related problems that are usually associated with the chronic conditions of adult AOD dependence (such as withdrawal and other health related symptoms), and 3) adolescents usually experience different types of negative consequences as a result of their use that those experienced by adults (Trapold, 1998).
AOD use is particularly dangerous because adolescence is a critical developmental period. AOD use is associated with the three highest causes of mortality among young people: physical injury, suicide, and homicide (Dennis, 2004; Kaminer, 2004).
The research shows that chronic AOD use by adolescents is often associated with other physiological, psychological, and social problems, including co-morbid psychiatric disorders (particularly conduct disorder, affective disorders, and ADHD); poor school and work performance, high-risk health and sexual behavior; and poor peer, family, and community relations (Bukstein, 1995; 2001).
Most adolescents who are identified as problem AOD users become identified because they are in some type of trouble that is directly or indirectly associated with their AOD use. Despite the evidence of widespread problem use, it is estimated that only one in ten adolescents receive any type of formal help for their AOD problems as compared to one in five adults (Drug Strategies, 2003).
Types of Adolescent Alcohol and Other Drug Use and Users
Two dimensions distinguish types of drug use: legal status and goal or purpose of use (Goode, 1999). With respect to legal status, the use, the possession, and sale of some drugs are criminal acts. The legal status of a drugs use is determined by factors such as age (i.e., 18 years of age for alcohol consumption), source of the drugs (i.e., prescription from a doctor), and place of use (i.e., driving while under the influence of drugs).
With respect to goal or purpose, the same drug can be used for a variety of different reasons by different users and even the same person may use the same drug for different reasons at different times and in different situations. It is also useful to distinguish between instrumental use (using a drug as a means to an end, for example, to stay alert) and recreational use (using a drug to achieve a pleasurable effect, for example, to get high).
Each of these types of drug use will attract different users whose patterns and frequencies are significantly different.
1. Legal Instrumental use: taking prescribed drugs and over-the-counter (OTC) drugs to relieve or treat mental or physical symptoms
2. Legal recreational use: using such licit drugs as tobacco, alcohol, and caffeine to achieve a certain pleasurable mental or psychic state (i.e., to get high)
3. Illegal instrumental use: taking drugs without a prescription or using illicit drugs to accomplish a society approved task or goal (i.e., taking nonprescription amphetamines to drive through the night or relying excessively on barbiturates to get through the day)
4. Illegal recreational use: taking illicit drugs to achieve a certain pleasurable mental or psychic state (i.e., to get high)
It can be difficult to distinguish between adolescents who are using AOD as part of a relatively normal developmental stage of learning how to handle these substances through experimentation and adolescents who have more serious substance use problems.
Generally, there are two developmental paths for adolescents and AOD use: 1) various patterns of AOD use begin in adolescence and decline substantially - with the transition to young adulthood suggesting that some adolescent AOD use patterns are a normal part of adolescent exploration of adult behaviors, and 2) some adolescents continue their AOD abuse into young adulthood. These problems that are maintained can usually be predicted by adolescent problem behavior and not necessarily by the patterns of AOD use during adolescence.
Most adolescents who use AOD do not develop serious problems associated with their use. A small percentage of adolescents will develop some serious AOD problems and a smaller percentage (less than 10%) of adolescents will continue their AOD problems into adulthood. Adolescent AOD use and abuse is best conceptualized as lying along a continuum ranging from nonuse to substance dependent (Steinberg & Levine, 1990).
It is possible to identify a sequence of AOD use that can lead to AOD dependence:
- Nonusers do not use AOD for a wide range of reasons including religious or moral reasons; fear of social, legal, and/or personal consequences; and lack of easy assess to AOD.
- Experimenters try substances (usually alcohol or marijuana) a few times. Some of these adolescents will decide they do not like the effects enough to warrant the risks, while other adolescents will progress to more regular use.
- Recreational users use AOD largely because of peer pressure and curiosity, they are usually able to set limits on when these substances are taken, and they usually confine their use to recreational and social settings with the event usually the primary focus, not the AOD use.
- Regular users begin to use AOD on a regular, somewhat frequent basis. These adolescents generally still care about their reputations with their parents and non-AOD using friends, but they increasingly tend to prefer friends and activities associated with AOD use.
- Abusers devote considerable time and energy to getting and using AOD; generally lose interest in non-AOD related activities and people who do not share their pattern of AOD use; usually engage in other risk-taking behaviors; and they begin to evidence problems in areas such as school and job performance, relationships with family members and friends, problems in the community, and, possibly, problems with the legal system.
- Substance dependent abuser’s lifestyle involves daily use of typically more than one drug on a heavy and regular basis; obsession with finding, paying for, and using drugs; isolation from non-AOD using friends and family; some physical and psychological deterioration; and increased problems at home, school, work, in the community, and, possibly, with the legal system.
Factors Influencing Adolescent Alcohol and Other Drug Use
The decision to begin using a particular drug by adolescents usually involves weighing the perceived benefits and the perceived risks that come to be associated with each drug (Smith & Anderson, 2001). The problem is that for most adolescents, word of the supposed benefits of using a particular drug usually spread much faster than information about any adverse consequences.
What often happens with adolescents is when they begin their AOD use they will tend to focus on the positive consequences of their use and if they experience some negative consequences, they usually will try to ignore or minimize the problems. If they see a problem at all, they tend to see it as a management problem in terms of trying to stay out of trouble as a result of their AOD use.
Most adolescents have a particular problem in projecting any negative consequences for their AOD use in the future (Berkowitz, Begun, Zweben et al., 1995). Most AOD using adolescents also tend to overestimate the number of their peers who are using AOD (Nucci, Guerra, & Lee, 1991).
For most adolescents, this weighing of the positive and negative consequences is drug specific - meaning that knowledge of the adverse consequences of one drug does not necessarily generalize to the use of other drugs. Thus when a new drug or a “rediscovered” old drug comes onto the scene, it often has a considerable grace period before its adverse consequences become readily known and acknowledged among adolescents (Bukstein, 1995).
The initial use of AOD, their continuance and possible abuse are typically the result of a complex interaction of genetic or biological vulnerabilities, including 1) psychiatric disorders and different pharmacological responses, 2) psychological vulnerability to the effects or the perceived effects of AOD use, 3) parental and peer influences, 4) life events, and 5) other sociocultural and environmental factors.
Most adolescents who develop AOD problems “mature out” of their problem use as they transition into adulthood. We know that fewer than 10% of people who experiment with AOD will become drug dependent. We also know that some of the factors that influence whether a person will become drug dependent are independent of the factors that influence whether the person will initiate AOD use.
It remains generally true that people who do not abuse drugs during the decisive years before age 25 are unlikely ever to develop a serious drug problem (Hanson, Venturelli, & Fleckenstein, 2004; Lawson & Lawson, 1992; School Campus Partnership, 2004).
A common progression of adolescents who become AOD abusers includes some experimentation followed by opportunistic use of tobacco and alcohol, primary with friends at parties and other common places, followed by weekly or more use of marijuana, with continued use of tobacco and alcohol, and increasing experimentation with other substances. While some adolescents will progress from experimentation to dependence, the progression is not inevitable for most adolescents.
There is one practical way to tell if adolescents have serious AOD use problems. When parents or other adults try to control their AOD use and associated problem behaviors, adolescents who have some degree of control over their AOD use will tend to initially resist, but their behaviors will quickly improve and they will generally be able to stop or accept limits on their use. Adolescents who will not, or cannot, control their AOD use will continue to use despite continued negative consequences. In fact, their use may escalate. Most of these adolescents will need some type of formal treatment.
Risk-Factors for Adolescent Alcohol and Other Drug Use
Among the most important recent developments in the prevention and treatment of adolescent risk-taking behavior, including AOD use, has been a focus on risk and protective factors (Weinberg & Glantz, 1999). Risk and protective factors are the individual factors and social or environmental conditions that research has found to be related to the development of AOD use and abuse.
A large body of research has documented the risk factors for AOD use and abuse among adolescents (Bell & Bell, 1993; Hawkins, Catalano, & Miller, 1992; Weinberg, 2001; Weinberg & Glantz, 1999). Petraitis, Flay, and Miller (1995), in a thorough review of the research, state that the causes of adolescent AOD use can be meaningfully classified along two dimensions: 1) types of influence and 2) levels of influence (proximal, distal, and ultimate influences). They identify three distinct types of influence that underlie existing theories of adolescent AOD use.
1. Social and interpersonal influences include inadequate parental warmth, supervision, control and reinforcement; negative evaluations from parents; home strain; and parental divorce and separation
2. Cultural and attitudinal influences include not being committed to conventional society, religion, school, or people who hold negative views of AOD use; seeing AOD use as a symbolic rejection of conventional standards; feeling socially alienated; being oriented toward short-term goals and hedonic gratifications; being rebellious; having little interest in success or achievement; desiring independence from parents; and holding tolerant or positive attitudes toward other deviant behaviors
3. Intrapersonal influences include impaired cognitive functions; pharmacological sensitivity to the use of substances; personality characteristics including temperamental personalities, impulsiveness, aggressiveness, emotional distress (e.g., neuroticism, anxiety, or depression), extraversion, and sociability; tendencies toward risk-taking and thrill seeking; external locus of control and low self-esteem; poor coping skills and deficient social interaction skills (e.g., being shy, impolite, or uncompromising); inadequate academic skills; and substance-specific self-efficacy (e.g., refusal skills, refusal self-efficacy, and use of self-efficacy)
Risk factors may be different for AOD use versus AOD abuse or addiction (Petraitis, Flay, & Miller, 1995). For example, we have learned that risk factors for AOD use appear to lie more in the social and environmental realms, whereas those individuals who initial AOD use progresses to an abuse or dependence syndrome appear to be influenced more by biological and psychological factors.
In general, the more risk factors a child or adolescent experiences, the more likely it is that he or she will experience AOD use and related problems in adolescence and youth adulthood. Researchers have also found that the more risk factors in a child’s life that can be reduced - such as effectively treating mental health disorders, improving parents’ family management skills, improving the school environment, and stepping up enforcement of laws regarding sales of illicit and licit drugs to minors, and improvements in reducing drinking and driving - the less vulnerable that child will be to subsequent health and social problems (Rapp-Paglicci, Dulmus, & Wodarski, 2004).
The research has also demonstrated that exposure to even a substantial number of risk factors in a child’s life does not mean that AOD abuse or other problem behaviors will inevitably follow. Many children and youth who grow up with high-risk behaviors and who are raised in high-risk environments emerge relatively problem-free.
One of the reasons is the presence of certain “protective” or “resilience” factors that are able to reduce the likelihood that an AOD abuse disorder will develop. These protective factors appear to balance and buffer the negative impact of risk factors. From a prevention perspective, protective factors function as mediating variables that can be targeted to prevent, postpone, or reduce the impact of AOD use.
While the influence of some risk and protective factors can be effectively reduced, not all risk and protective factors are susceptible to change (i.e., race/ethnicity, gender, poverty, high crime environment). However, the research does demonstrate that the influence of these risk and preventive factors can often be reduced or enhanced.
The research has shown that factors contributing to resilience include: a strong relationship with a parent or caring adult; feelings of success and mastery; strong internal (i.e., health, self-esteem) and external resources (supportive network of family and friends); good social and problem-solving skills; a sense of hope; and a history of successfully surviving previous stressful situations (Hazelden Foundation, 1996).
Neuroscience and AOD Use
An expanding body of research suggests that there may be differences in the brains of persons who are susceptible to addiction. There may be particular vulnerabilities with genetic origins that cause some brains to respond differently when mind altering substances are introduced. While the science has not reached the point where we have specific tests or brain scans that can accurately determine which adolescents will be most at risk for problems with addiction, it is possible to envision a day when this will be possible.
Along with an increasing understanding about the role of genetics in the differences in brain development and functioning, an entirely new field is emerging related to epigenetics. This is concerned with how genes are altered in their interaction with the environment. It is generally understood that there is a complex relationship between a person's genetic make-up and his/her interaction with an equally complex environment. Certain genes can be "switched on" or "switched off" through interactions with the environment. This means that environmental effects can create alterations in the DNA of a person so that the environmental effects can be passed on to future generations.
At the heart of addiction, there appear to be a few areas of the brain that respond differently to chemicals that activate the release of dopamine. An area of the brain called the Anterior Cingulate Cortex appears to be hypoactive in people with addictions. This is an area of the brain that is crucial to making good decisions related to reward versus punishment choices. People with these brain differences have an easier time being motivated to act based upon the rewards from the dopamine elevation that accompanies substance use, and less motivated to consider the possible negative consequences related to substance use.
This motivational dysfunction is one of the reasons that the treatment of addiction has shifted in recent years, and why Motivational Interviewing has been such an important addition to the tools used to treat substance use disorders.
It must also be remembered that adolescent brains already have some difficulties with making good decisions with regard to evaluating reward versus punishment choices. Assessment of whether there are genetic and/or epigenetic considerations driving the addiction process forward must take into consideration the development components of this motivational equipment.
The science at the heart of the genetic and epigenetic contributions to substance abuse is likely to become clearer and more useful over the course of the next several decades. For now, we must still gather information through the use of a family history and try to infer what the influences are with relation to the increased risk of problems with substance use.