Many Questions Remain About Youth Substance Use Trends

December 15, 2020

The following is from the web blog of Dr. Nora Volkow, Executive Director of NIDA.

The results of the 2020 Monitoring the Future (MTF) survey of drug use and attitudes in middle and high school students were released today, with the encouraging news that the alarming rises in teen vaping both of nicotine and marijuana seen in prior years had leveled off, although use remained high. But as with so many other efforts in 2020, the MTF survey was impacted by the COVID-19 pandemic. And we are left at the end of this tumultuous year with many questions about how circumstances have affected youth, their substance use, and their mental health more generally.

The MTF survey is ordinarily conducted from February until May, with the results released later the same year. This year, schools closed in mid-March before the majority of the students could be surveyed, leaving the University of Michigan researchers who conduct the survey with a smaller-than-usual sample—11,821 students in 112 schools. Although only a quarter the size of the usual sample, it remained nationally representative and contained much valuable data.

Generally, the 2020 MTF showed continued low levels of most forms of substance use among teens, including very low levels of opioid use despite the devastating effects opioids have had on all older age groups including young adults. However, there are other indications that the evolving addiction and overdose crisis is directly affecting youth. For example, a study by CDC researchers just published in the Journal of Pediatrics shows increases in suspected nonfatal overdoses involving stimulants (a category that includes prescription stimulants, cocaine, and methamphetamine) in children and teens between 2016 and 2019. MTF shows decreases in use of prescription stimulants in 10th and 12th graders but a trend toward increased use among 8th graders. It will be important to closely monitor adolescent stimulant use in future MTF surveys.

The MTF data collected at the beginning of this year reflect a certain point of relative normality before the COVID-19 pandemic threw all our lives into upheaval, including the lives of teens. As we seek to understand adolescent substance use in this new reality, we look to research to answer many important questions on how the stresses of the pandemic may have affected substance use by teens. For example, it is important to investigate the consequences of social distancing and virtual classes on adolescent drug experimentation and use, since those are strongly influenced by peer pressure and group dynamics. NIDA has issued supplemental funds to existing grantees to help study the impact of the pandemic on adolescents’ risk of substance use; their access to prevention and treatment services; and the pandemic’s effects on families. Future research, including the results of next year’s MTF survey, can help us understand how school closures and lockdowns affected adolescent substance use.  

Although research has suggested that the pandemic’s stresses have increased many forms of substance use in adults, it remains to be seen whether reduced ability to interact with peers or other sources of drugs may be a mitigating factor in youth. There is already evidence that reduced commercial availability of vape products during the pandemic may be affecting teen vaping. Researchers at Stanford and University of California San Francisco captured self-reported vaping habits of 2,167 teen and young-adult e-cigarette users in May, two months after the national emergency was declared and after MTF stopped gathering data for the 2020 survey. Over half of the respondents reported changing their use of vaping products, with 68 percent of those reporting that they had reduced their use or quit. Inability to purchase the products was one reason cited.

2020 has posed many urgent questions for science. Finding out the different ways the pandemic and other stresses of the year have affected young people is a high priority. Adolescence is an important period of social and emotional development, and the pandemic has disrupted many of the processes that impact that development. NIDA research has pivoted to ensure we address this unique time in history as we pursue scientific solutions to the impacts of drug use and addiction across the lifespan.

Addressing the Stigma that Surrounds Addiction

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From the Monthly Blog of Dr. Nora Volkow, Exec. Dir.
NATIONAL INSTITUTE ON DRUG ABUSE

Original Date April 22, 2020

Untreated drug and alcohol use contribute to tens of thousands of deaths every year and impact the lives of many more. Healthcare already has effective tools including medications for opioid and alcohol use disorder that could prevent many of these deaths, but they are not being utilized widely enough, and many people who could benefit do not even seek them out. One important reason is the stigma that surrounds people with addiction.

Man sitting alone in streetlight at night

Stigma is a problem with health conditions ranging from cancer and HIV to many mental illnesses. Some gains have been made in reducing stigma around certain conditions; public education and widespread use of effective medications has demystified depression, for instance, making it somewhat less taboo now than it was in past generations. But little progress has been made in removing the stigma around substance use disorders. People with addiction continue to be blamed for their disease. Even though medicine long ago reached a consensus that addiction is a complex brain disorder with behavioral components, the public and even many in healthcare and the justice system continue to view it as a result of moral weakness and flawed character.

Stigma on the part of healthcare providers who tacitly see a patient’s drug or alcohol problem as their own fault leads to substandard care or even to rejecting individuals seeking treatment. People showing signs of acute intoxication or withdrawal symptoms are sometimes expelled from emergency rooms by staff fearful of their behavior or assuming they are only seeking drugs. People with addiction internalize this stigma, feeling shame and refusing to seek treatment as a result.

In a Perspective published recently in The New England Journal of Medicine, Dr. Volkow tells the story about a man she met who was injecting heroin in his leg at a “shooting gallery”—a makeshift injection site—in San Juan, Puerto Rico, during a visit to that country several years ago. His leg was severely infected, and Dr. Volkow urged him to visit an emergency room—but he refused. He had been treated horribly on previous occasions, so preferred risking his life, or probable amputation, to the prospect of repeating his humiliation. This highlights a dimension of stigma that has been less remarked on in the literature and that is uniquely important for people with substance use disorders: Beyond just impeding the provision or seeking of care, stigma may actually enhance or reinstate drug use, playing a key part in the vicious cycle that drives addicted people to continue using drugs.

Previously on her montly blog Dr. Volkow highlighted research by Marco Venniro at NIDA’s Intramural Research Program, showing that rodents dependent on heroin or methamphetamine still choose social interaction over drug self-administration, given a choice; but when the social choice is punished, the animals revert to the drug. It is a profound finding, very likely applicable to humans, since we are highly social beings. Some of us respond to social as well as physical punishments by turning to substances to alleviate our pain. The humiliating rejection experienced by people who are stigmatized for their drug use acts as a powerful social punishment, driving them to continue and perhaps intensify their drug-taking.

The stigmatization of people with substance use disorders may be even more problematic in the current COVID-19 crisis. In addition to their greater risk through homelessness and drug use itself, the legitimate fear around contagion may mean that bystanders or even first responders will be reluctant to administer naloxone to people who have overdosed. And there is a danger that overtaxed hospitals will preferentially pass over those with obvious drug problems when making difficult decisions about where to direct lifesaving personnel and resources.

Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. Even people in healthcare, if they do not have training in caring for people with substance use disorders, may be at a loss as to how to interact with someone acting threateningly because of withdrawal or some drugs’ effects (e.g., PCP). It is crucial that people across healthcare, from staff in emergency departments to physicians, nurses, and physician assistants, be trained in caring compassionately and competently for people with substance use disorders. Treating patients with dignity and compassion is the first step.

There must be wider recognition that susceptibility to the brain changes in addiction are substantially influenced by factors outside an individual’s control, such as genetics or the environment in which one is born and raised, and that medical care is often necessary to facilitate recovery as well as avert the worst outcomes like overdose. When people with addiction are stigmatized and rejected, especially by those within healthcare, it only contributes to the vicious cycle that entrenches their disease.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1(800) 273-TALK. Or click on: www.suicidepreventionlifeline.org.

You can also find help through Narcotics Anonymous at 844-335-2408.

COVID-19: Potential Implications for Individuals with Substance Use Disorders

From National Institute on Drug Abuse
March 24, 2020

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As people across the U.S. and the rest of the world contend with coronavirus disease 2019 (COVID-19), the research community should be alert to the possibility that it could hit some populations with substance use disorders (SUDs) particularly hard. Because it attacks the lungs, the coronavirus that causes COVID-19 could be an especially serious threat to those who smoke tobacco or marijuana or who vape. People with opioid use disorder (OUD) and methamphetamine use disorder may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health. Additionally, individuals with a substance use disorder are more likely to experience homelessness or incarceration than those in the general population, and these circumstances pose unique challenges regarding transmission of the virus that causes COVID-19. All these possibilities should be a focus of active surveillance as we work to understand this emerging health threat.

SARS-CoV-2, the virus that causes COVID-19 is believed to have jumped species from other mammals (likely bats) to first infect humans in Wuhan, capital of China’s Hubei province, in late 2019. It attacks the respiratory tract and appears to have a higher fatality rate than seasonal influenza. The exact fatality rate is still unknown, since it depends on the number of undiagnosed and asymptomatic cases, and further analyses are needed to determine those figures. Thus far, deaths and serious illness from COVID-19 seem concentrated among those who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19.

Co-occurring conditions including COPD, cardiovascular disease, and other respiratory diseases have been found to worsen prognosis in patients with other coronaviruses that affect the respiratory system, such as those that cause SARS and MERS. According to a case series published in JAMA based on data from the Chinese Center for Disease Control and Prevention (China CDC), the case fatality rate (CFR) for COVID-19 was 6.3 percent for those with chronic respiratory disease, compared to a CFR of 2.3 percent overall. In China, 52.9 percent of men smoke, in contrast to just 2.4 percent of women; further analysis of the emerging COVID-19 data from China could help determine if this disparity is contributing to the higher mortality observed in men compared to women, as reported by China CDC. While data thus far are preliminary, they do highlight the need for further research to clarify the role of underlying illness and other factors in susceptibility to COVID-19 and its clinical course.

Vaping, like smoking, may also harm lung health. Whether it can lead to COPD is still unknown, but emerging evidence suggests that exposure to aerosols from e-cigarettes harms the cells of the lung and diminishes the ability to respond to infection. In one NIH-supported study, for instance, influenza virus-infected mice exposed to these aerosols had enhanced tissue damage and inflammation.

People who use opioids at high doses medically or who have Opioid Use Disorder (OUD) face separate challenges to their respiratory health. Since opioids act in the brainstem to slow breathing, their use not only puts the user at risk of life-threatening or fatal overdose, it may also cause a harmful decrease in oxygen in the blood (hypoxemia). Lack of oxygen can be especially damaging to the brain; while brain cells can withstand short periods of low oxygen, they can suffer damage when this state persists. Chronic respiratory disease is already known to increase overdose mortality risk among people taking opioids, and thus diminished lung capacity from COVID-19 could similarly endanger this population.

A history of methamphetamine use may also put people at risk. Methamphetamine constricts the blood vessels, which is one of the properties that contributes to pulmonary damage and pulmonary hypertension in people who use it. Clinicians should be prepared to monitor the possible adverse effects of methamphetamine use, the prevalence of which is increasing in our country, when treating those with COVID-19.

Other risks for people with substance use disorders include decreased access to health care, housing insecurity, and greater likelihood for incarceration. Limited access to health care places people with addiction at greater risk for many illnesses, but if hospitals and clinics are pushed to their capacity, it could be that people with addiction—who are already stigmatized and underserved by the healthcare system—will experience even greater barriers to treatment for COVID-19. Homelessness or incarceration can expose people to environments where they are in close contact with others who might also be at higher risk for infections. The prospect of self-quarantine and other public health measures may also disrupt access to syringe services, medications, and other support needed by people with OUD.

We know very little right now about COVID-19 and even less about its intersection with substance use disorders. But we can make educated guesses based on past experience that people with compromised health due to smoking or vaping and people with opioid, methamphetamine, cannabis, and other substance use disorders could find themselves at increased risk of COVID-19 and its more serious complications—for multiple physiological and social/environmental reasons. The research community should thus be alert to associations between COVID-19 case severity/mortality and substance use, smoking or vaping history, and smoking- or vaping-related lung disease. We must also ensure that patients with substance use disorders are not discriminated against if a rise in COVID-19 cases places added burden on our healthcare system.

As we strive to confront the major health challenges of opioid and other drug overdoses—and now the rising infections with COVID-19—NIDA encourages researchers to request supplements that will allow them to obtain data on the risks for COVID-19 in individuals experiencing substance use disorders.

Vulnerable Populations

The most vulnerable to Covid-19 among substance abuses is going to be the crack-smoking homeless. The homeless are vulnerable just by being homeless, but add to that the lung damage from smoking crack and the risk is compounded. As Dr. Volkow points out, tobacco and marijuana smoking are also more prevalent among those who are homeless. This is going to be an important area of research.