Recovery 2019: The Year in Review

From the Recovery Advocacy Update blog of the Hazelden Betty Ford Foundation originally posted on January 7, 2020.

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As Americans reflect on the past decade, the much more defining story, of course, was the opioid crisis, which fueled an unprecedented overdose epidemic that has barely begun to abate. Drug overdoses claimed a mind-boggling half-million lives in the 2010s and devastated countless others, while exposing the inadequacy of our nation’s overall approach and commitment to preventing and treating addiction, and supporting long-term recovery.

Amid the tragedy, we saw the beginning of positive change in addiction-related public attitudes, perceptions, policies, practices and systems. Hazelden Betty Ford has helped lead the way with many changes of its own. They began using opioid-addiction-treatment medications in 2012, and became a strong advocate for comprehensive care that includes medication options, psychosocial therapies and peer support. They emerged as a leading voice for breaking down barriers between the medical and Twelve Step communities.

Hazelden Betty Ford also transitioned to an insurance model so more people could access care; evolved away from the 28-day residential standard to a more individualized approach that enables people to stay engaged longer over multiple levels of care; launched a new era of aggressive collaboration with the broader healthcare field; made the evidence-based therapy “motivational interviewing” core to a more patient-centered clinical approach; initiated a new, innovative system for capturing and acting upon patient feedback throughout the treatment experience; developed new recovery coaching options; and much more. In addition, the foundation spoke up vigorously about the need for ethical and quality standards in recovery, and continued to support related industry reform efforts. It was a decade of big change for them, and they will likely evolve a great deal more in the 2020s, as they have consistently done since 1949.

Broader changes to the many systems that affect people with addiction are coming more slowly, but things seem to be pointed in the direction of progress. Indeed, most addiction specialists want addiction prevented and treated, rather than stigmatized and criminalized. The question arises, though: Does that mean it is wise to fully legalize and commercialize more addictive substances? Or are there policies and approaches in between that promote public health better than either extreme?

In the new decade, marijuana will be a case study and likely a defining story. The experiment with full legalization looks troubling so far. State-level data from the National Survey on Drug Use and Health finds that marijuana use in “legal” states among youth, young adults, and the general population continued its multi-year upward trend in several categories. New data and studies come in weekly, it seems—consistently showing cause for greater public health concerns. One of the foundation’s 2020 resolutions is to help ensure the facts about marijuana and the risks of expanded use get more attention.

One big concern, for example, is that marijuana vaping by teens surged in 2019, signaling that more adolescents are using the drug and consuming highly potent vape oils, according to new government data and drug-use researchers. Federal regulators are paying attention. They shut down 44 websites advertising illicit THC vaping cartridges, part of a crackdown on suppliers amid a nationwide spate of lung injuries tied to black-market cannabis vaping products.

The outbreak of severe lung injuries may have peaked, but cases are still surfacing, and the agency is urging doctors to monitor people closely after hospitalization, due to the risk of continued vaping. One Harvard graduate student writes, “I nearly died from vaping THC, and you could too.” Marijuana and vaping are both among the issues coming up on the campaign trail, and recent polling released by the National Council for Behavioral Health shows strong bipartisan agreement among registered voters in New Hampshire that the federal government is not doing enough to address mental health and addiction in America. Mental Health for US, a coalition trying to raise more awareness in the campaign, held a recent forum in New Hampshire. Watch the livestream replay here.

In Washington, the White House hosted a summit of its own on efforts to deliver mental health treatment to people experiencing homelessness, violence and substance use disorder. Watch Part 1 of the event, Part 2, and the President’s remarks. The Administration also issued its long-awaited vaping policy last week, with the FDA banning fruit, mint and dessert-flavored vaping cartridges but continuing to allow menthol- and tobacco-flavored cartridges as well as all flavored e-cigarette liquids. Many worry the guidelines don’t go far enough.

Since the foundation’s last update, the President also signed a $1.4 trillion spending package passed by Congress, averting a government shutdown. The package maintains funding levels for most areas relevant to the field of addiction counseling, with modest increases in a few SAMHSA grants as well as at the CDC and at the National Institutes of Health. Most notably, the legislation gives states more flexibility in spending State Opioid Response (SOR) grant funds; specifically, they’ll now be able to use the money to also address the growing problems associated with addiction to meth, cocaine and other stimulants. Here’s a thorough overview from our friends at the National Association of State Alcohol and Drug Abuse Directors.

If you are interested in more information about these topics or the Hazelden Betty Ford Foundation, please visit their website by clicking here.

If you or someone you know is struggling with substance use disorder and want more information or help quitting, please contact your local AA or NA chapter, or click here to visit the National Institute on Drug Abuse official website. You can also scroll back to the top of this post and click on the COMMENT bar to open an dialog with me. I will be glad to speak with you any time.

2019 Monitoring the Future Survey Raises Worries about Teen Marijuana Vaping

From the monthly blog of Dr. Lora Volkow,
Executive Director
National Institute on on Drug Abuse

Originally posted December 18, 2019

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For the second year in a row, rapid rises in vaping among adolescents are the top story from the Monitoring the Future survey of drug use and attitudes among the country’s 8th, 10th, and 12th graders. What became evident in 2018 was that vaping devices, which have exploded in popularity over the past several years, are now exposing a new generation to nicotine. Those trends continued in 2019, but with the additional concern of a rapid rise in the vaping of marijuana, as well as increases in daily marijuana use in 10th graders.

More than one fifth of high school seniors (20.8 %) reported having vaped marijuana in the past year, as did nearly that same proportion of 10th graders (19.4 %). From 2018 to 2019, the percentage of seniors vaping marijuana in the past month increased from 7.5 percent to 14 percent—the second largest one-year increase in any drug use that has ever been recorded in the 45-year history of the MTF survey. (The first largest increase was nicotine vaping from 2017 to 2018 reported last year.) Among 10th graders, past-month use was 12.6 percent.

Overall, marijuana use has held relatively steady over the past several years despite wider availability and diminished perception of the drug’s harms by this age group (and by the U.S. population more generally). But the increases in vaping of THC, the active ingredient in marijuana, are alarming for a number of reasons. For one thing, we don’t yet know if THC’s effects differ when vaped versus when smoked in a traditional fashion or whether the amount of THC that youth are being exposed to differs with these methods.

Also, the students took the survey in January of this year, which was before the alarming news this summer about serious lung illness and a number of deaths (48, as of this writing) in people using vaping devices. Most of the illnesses occurred in people who had vaped THC. It is not known whether the cause may have been contamination in certain black market vape fluids, or some other factor. The CDC has named vitamin E acetate as a chemical of concern in vape fluids, but it is too soon to rule out other chemicals or device attributes that may also contribute to the illnesses.

At this point, we know very little about the health and safety effects of administering THC at high concentrations, and this applies not only to vaping but also to smoking of concentrated THC products and new edible products and beverages coming on the market in states that have legalized marijuana for adult use. Research is urgently needed to answer these questions. However, marijuana is federally classified as a Schedule 1 substance. Scientists face administrative hurdles when studying Schedule 1 substances, and currently there are no provisions allowing federally funded researchers to study marijuana products coming from the black market or even from dispensaries in states where they are permitted to operate. Resolving these research barriers is an urgent priority.

Daily marijuana use has remained steady among 12th graders, at 6.4 percent, but this number conceals a very significant gender difference. Eight percent of male seniors report using marijuana daily, whereas 4.6 percent of females do. This suggests that a disproportionate percentage of male students may not be performing to their potential because of daily impairment by that drug.

Increased daily marijuana use by younger teens is another worrying trend in this year’s survey results. This year, 4.8 percent of 10th graders reported daily marijuana use, as did 1.3 percent of 8th graders. The brain is very much a work in progress throughout adolescence, and this is especially true at younger ages, so there is increased risk of long-term harms as well as addiction when 8th and 10th graders use any substance, including marijuana.

The continued increase in nicotine vaping by adolescents is also concerning. A quarter of 12th graders reported past-month vaping of nicotine, as did nearly 20 percent of 10th graders and nearly 10 percent of 8th graders. It is not yet leading to increased cigarette use in this age group—one of the many bright spots in this year’s survey is continued downward trends in smoking—but many public health experts worry that vaping will lead to nicotine addiction in many users of these devices.

The number of 12th graders who vape because they say they are “hooked” more than doubled between 2018 and 2019, from 3.6 percent to 8.1 percent. Addiction to nicotine could lead some users to switch to conventional cigarettes—a trajectory already found in some studies. Another noteworthy statistic in the MTF findings is that teens’ second most cited reason for vaping was liking the taste—a strong argument in favor of limiting the flavorings in vape products as a way of limiting these products’ tremendous appeal.

Apart from the real concerns linked to marijuana and nicotine vaping, the general picture painted by the MTF survey continues to be largely encouraging, however. Most illicit drug use continues to decline or hold steady at low levels. Cocaine and methamphetamine use are as low as they have ever been despite increases seen in adults. Nonmedical use of prescription opioids, which had raised worries several years ago in this survey, is also way down. And thankfully, the crisis of heroin use that continues unabated in U.S. adults also does not seem to be affecting high school students—heroin use continues to be very rare among teens surveyed, with past year use among high-school seniors at 0.4 percent. The fact that MTF is a survey of students in school is important to remember, however. It necessarily does not sample from those who have dropped out of school, and thus misses capturing a segment of the youth population for whom drug use is likely more prevalent.

See all the findings of the 2019 MTF survey, our press release, fact sheet and two infographics on vaping and other drug categories. For more information on the increases in marijuana vaping and what they mean, read the research letter published today in JAMA.

The MTF survey is a valuable indicator of substance use trends in the segment of the population most vulnerable to the short- and long-term effects of drug exposure. It is also the most “real-time” survey of drug use patterns: Every January, 42,531 students in 396 public and private schools across the nation take an hour or so to complete the MTF questionnaire—increasingly, on tablets rather than on paper—and the results are tabulated and analyzed by the end of that same year. It gives the NIDA-funded researchers at the University of Michigan, currently led by Richard A. Miech, an unprecedented ability to track substance use in real time.

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.

U.S. Surgeon General’s Advisory: Marijuana Use and the Developing Brain

Steven Barto, B.S., Psych.

I am reposting this information from a link to the U.S. Department of Health and Human Services (HHS.gov) provided by the National Institute on Drug Abuse (NIDA) website.

I, Surgeon General Jerome Adams, am emphasizing the importance of protecting our Nation from the health risks of marijuana use in adolescence and during pregnancy. Recent increases in access to marijuana and in its potency, along with misperceptions of safety of marijuana endanger our most precious resource, our nation’s youth.

Background

Marijuana, or cannabis, is the most commonly used illicit drug in the United States. It acts by binding to cannabinoid receptors in the brain to produce a variety of effects, including euphoria, intoxication, and memory and motor impairments. These same cannabinoid receptors are also critical for brain development. They are part of the endocannabinoid system, which impacts the formation of brain circuits important for decision making, mood and responding to stress.

Marijuana and its related products are widely available in multiple forms. These products can be eaten, drunk, smoked, and vaped. Marijuana contains varying levels of delta-9-tetrahydrocannabinol (THC), the component responsible for euphoria and intoxication, and cannabidiol (CBD). While CBD is not intoxicating and does not lead to addiction, its long-term effects are largely unknown, and most CBD products are untested and of uncertain purity.

Marijuana has changed over time. The marijuana available today is much stronger than previous versions. The THC concentration in commonly cultivated marijuana plants has increased three-fold between 1995 and 2014 (4% and 12% respectively). Marijuana available in dispensaries in some states has average concentrations of THC between 17.7% and 23.2%. Concentrated products, commonly known as dabs or waxes, are far more widely available to recreational users today and may contain between 23.7% and 75.9% THC.

The risks of physical dependence, addiction, and other negative consequences increase with exposure to high concentrations of THC and the younger the age of initiation. Higher doses of THC are more likely to produce anxiety, agitation, paranoia, and psychosis. Edible marijuana takes time to absorb and to produce its effects, increasing the risk of unintentional overdose, as well as accidental ingestion by children and adolescents. In addition, chronic users of marijuana with a high THC content are at risk for developing a condition known as cannabinoid hyperemesis syndrome, which is marked by severe cycles of nausea and vomiting.

This advisory is intended to raise awareness of the known and potential harms to developing brains, posed by the increasing availability of highly potent marijuana in multiple, concentrated forms. These harms are costly to individuals and to our society, impacting mental health and educational achievement and raising the risks of addiction and misuse of other substances.  Additionally, marijuana use remains illegal for youth under state law in all states; normalization of its use raises the potential for criminal consequences in this population. In addition to the health risks posed by marijuana use, sale or possession of marijuana remains illegal under federal law notwithstanding some state laws to the contrary.

Marijuana Use during Pregnancy

Pregnant women use marijuana more than any other illicit drug. In a national survey, marijuana use in the past month among pregnant women doubled (3.4% to 7%) between 2002 and 2017. In a study conducted in a large health system, marijuana use rose by 69% (4.2% to 7.1%) between 2009 and 2016 among pregnant women. Alarmingly, many retail dispensaries recommend marijuana to pregnant women for morning sickness.

Marijuana use during pregnancy can affect the developing fetus.

  • THC can enter the fetal brain from the mother’s bloodstream.
  • It may disrupt the endocannabinoid system, which is important for a healthy pregnancy and fetal brain development.
  • Studies have shown that marijuana use in pregnancy is associated with adverse outcomes, including lower birth weight.
  • The Colorado Pregnancy Risk Assessment Monitoring System reported that maternal marijuana use was associated with a 50% increased risk of low birth weight regardless of maternal age, race, ethnicity, education, and tobacco use.

The American College of Obstetricians and Gynecologists holds that “[w]omen who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use. Women reporting marijuana use should be counseled about concerns regarding potential adverse health consequences of continued use during pregnancy”. In 2018, the American Academy of Pediatrics recommended that “…it is important to advise all adolescents and young women that if they become pregnant, marijuana should not be used during pregnancy.”

Maternal marijuana use may still be dangerous to the baby after birth. THC has been found in breast milk for up to six days after the last recorded use. It may affect the newborn’s brain development and result in hyperactivity, poor cognitive function, and other long-term consequences. Additionally, marijuana smoke contains many of the same harmful components as tobacco smoke. No one should smoke marijuana or tobacco around a baby.

Marijuana Use during Adolescence

Marijuana is also commonly used by adolescents, second only to alcohol. In 2017, approximately 9.2 million youth aged 12 to 25 reported marijuana use in the past month and 29% more young adults aged 18-25 started using marijuana. In addition, high school students’ perception of the harm from regular marijuana use has been steadily declining over the last decade. During this same period, a number of states have legalized adult use of marijuana for medicinal or recreational purposes, while it remains illegal under federal law. The legalization movement may be impacting youth perception of harm from marijuana. 

The human brain continues to develop from before birth into the mid-20s and is vulnerable to the effects of addictive substances. Frequent marijuana use during adolescence is associated with:

  • Changes in the areas of the brain involved in attention, memory, decision-making, and motivation. Deficits in attention and memory have been detected in marijuana-using teens even after a month of abstinence.
  • Impaired learning in adolescents. Chronic use is linked to declines in IQ, school performance that jeopardizes professional and social achievements, and life satisfaction.
  • Increased rates of school absence and drop-out, as well as suicide attempts.

Risk for and early onset of psychotic disorders, such as schizophrenia. The risk for psychotic disorders increases with frequency of use, potency of the marijuana product, and as the age at first use decreases. 

  • Other substance use. In 2017, teens 12-17 reporting frequent use of marijuana showed a 130% greater likelihood of misusing opioids.

Marijuana’s increasingly widespread availability in multiple and highly potent forms, coupled with a false and dangerous perception of safety among youth, merits a nationwide call to action. 

You Can Take Action

No amount of marijuana use during pregnancy or adolescence is known to be safe. Until and unless more is known about the long-term impact, the safest choice for pregnant women and adolescents is not to use marijuana.  Pregnant women and youth–and those who love them–need the facts and resources to support healthy decisions. It is critical to educate women and youth, as well as family members, school officials, state and local leaders, and health professionals, about the risks of marijuana, particularly as more states contemplate legalization.

Science-based messaging campaigns and targeted prevention programming are urgently needed to ensure that risks are clearly communicated and amplified by local, state, and national organizations. Clinicians can help by asking about marijuana use, informing mothers-to-be, new mothers, young people, and those vulnerable to psychotic disorders, of the risks. Clinicians can also prescribe safe, effective, and FDA-approved treatments for nausea, depression, and pain during pregnancy. Further research is needed to understand all the impacts of THC on the developing brain, but we know enough now to warrant concern and action. Everyone has a role in protecting our young people from the risks of marijuana.