The youth mental health crisis has dominated the news in recent years, but American educators and healthcare professionals have also remained vigilant about the risks of substance use and abuse in adolescents and about the connection between these two troubling behavioral health problems. Research has demonstrated that several mental health concerns – including severe anxiety, mood disorders, trauma, neurocognitive challenges like ADHD, and borderline personality disorder – increase an individual’s vulnerability to substance use problems. At the same time, there are numerous biological and environmental factors affecting teens that put them at risk.

Although we currently face both poor mental health and loneliness epidemics in this country, interestingly the news on the substance use front is not all bad. Rates of use among teens have dropped steadily in recent years, and newer approaches to youth awareness campaigns and treatment hold much promise. At the same time, since the onset of the pandemic, youth drug overdose deaths have more than doubled, largely due to the contamination of the drug supply with the synthetic opioid fentanyl and to the increased availability of stronger substances. In addition, a growing body of neuroscience research highlights the dangers of exposing developing brains to alcohol and drugs. In short, the picture is complicated and at times confusing.

Substance Use and Abuse in Adolescents – A Current Snapshot

The Youth Risk Behavior Surveillance System (YRBSS) conducted by the Centers for Disease Control (CDC) showed declines in adolescent use of several substances from 2011 to 2021: “current alcohol use” decreased from 39% to 23%; “current marijuana use” declined from 23% to 16%; and “ever used illicit drugs” declined from 19% to 13%. Similarly, the 2023 Monitoring the Future survey, a National Institute of Health (NIH)-funded initiative that began collecting data on teen substance use in the 1970s, also shows that teen alcohol use continues to decrease. The number of 12^th graders who reported ever having used alcohol was 93% in 1978. By 1993 the number had decreased to 80%, and by 2023 the number had further decreased to 53%. In addition, the number of 12^th graders who reported abstaining completely from any alcohol, drug, or nicotine use rose to a high of 37.5%, while 54.4% of 10^th graders and 70% of 8^th graders also reported total abstinence.

Despite these promising overall numbers, findings about pandemic related substance use among teens are mixed. Some research shows that substance use decreased in 2021 among adolescents and held steady in 2022, possibly because substance use often occurs in the presence of peers and the pandemic greatly affected social habits. Other studies, however, found that among high school students who used substances prior to the pandemic, nearly a third reported increased use in 2021. This number may relate to the finding that young people who start using substances frequently at earlier ages face a higher risk of developing a substance use disorder that persists into adulthood.

Although alcohol use is declining, it continues to be the most abused substance by teens. At the same time, rates of nicotine vaping and prescription medication use are increasing. Some common prescription drugs that teens may misuse include stimulants used to treat ADHD, such as Adderall, and medications known as benzodiazepines, e.g. Xanax, that are used to treat anxiety. While alcohol and cocaine are less popular than in the past, a 2021 study by the National Institute on Drug Abuse (NIDA) found that the use of cannabis and hallucinogens was higher than ever in young adults aged 19-30. This fact, combined with the ongoing opioid crisis and the finding that from 2016 to 2021 the U.S. death rate from alcoholism had increased by 29% (as reported by the CDC, 500 people per day die of alcohol related issues!) paints a rather grim picture of substance use and abuse in this country.

Factors That Contribute to Substance Use and Abuse in Adolescents

Adolescence is a time of transition that is characterized by a search for identity – who am I and where do I fit in? – and a striving for individuation and independence. Experimentation of all kinds goes with the territory as young people “try on for size” different looks, friends, attitudes, beliefs, and behaviors. Within this context, the use of substances becomes a way to experiment with different feeling states and coping strategies, and a way to “be cool” and fit in with peers. Most teens who experiment with substances in high school and college grow out of this phase and do not go on to develop a substance use disorder. There are, however, numerous factors that contribute to a continuing pattern of problematic use.

One factor of course is biology and brain structure – it is well known that some individuals are genetically predisposed to alcoholism and other forms of addiction. Adding to this predisposition can be the effect of modeling. If one grows up in a family in which substances play a major role in the ability to cope and self-regulate, and more healthy coping methods are not taught or modeled, a young person may learn to use substances as the default method for managing emotions and life’s challenges.

As reported in a fall 2023 issue of Psychology Today, “One notable aspect of adolescent development is the delayed maturation of the prefrontal cortex—the brain’s decision-making and impulse control center. This delay contributes to teenagers’ susceptibility to engaging in risky behaviors, including experimenting with drugs and alcohol, primarily driven by the attraction of short-term rewards.” Teens are more emotionally reactive and “experience higher activation in response to rewards than adults, which makes them more susceptible to the pleasurable effects of substances like drugs. Repeated drug exposure can disrupt dopamine levels, leading to a reliance on drugs for pleasure and motivation, eventually resulting in addiction.”

In February 2024 the Washington Post reported that according to a recent CDC study “Most teens who use drugs are searching for calm and hoping to relieve stress”. Seventy-three percent of adolescents in the study “reported using drugs and alcohol to ‘feel mellow, calm, or relaxed.’ Half said they did so ‘to have fun or experiment.’ But 44 percent reported using drugs to stop worrying about a problem or forget bad memories, and 40 percent said they used to help with depression or anxiety.” Alcohol and nonprescription drugs were used more often for fun or experimentation while marijuana was used most often for relaxation. These findings directly link the state of teen mental health to the potential for drug use and abuse and suggest that expanding mental health services can further decrease adolescent substance use and reduce the alarming number of overdose deaths.

In addition to the factors discussed above, several other aspects of teen life are connected to substance use:

1. Family dynamics, including parental attitudes toward and use of substances, and a lack of close supervision.
2. A history of trauma, including physical or sexual abuse and exposure to other Adverse Childhood Events (ACES).
3. The legalization of marijuana in many states that to teens may suggest that since it is legal it is also “safe”.
4. Real or perceived pressures to perform academically.
5. Low self-esteem.
6. The increased availability and access to substances.
7. Stress related to change of any kind, such as the need to adapt during transitional periods (e.g., starting middle school, a move to a new neighborhood, entering puberty, etc.).

The Risks Associated with Teen Substance Use

Substance use during adolescence is particularly dangerous because psychoactive substances, including nicotine, cannabis, and alcohol, can interfere with healthy brain development, a process that continues until approximately age 25. Substance use can change brain structure and negatively affect brain functions like concentration, memory, the processing of emotions, and decision-making capacities, and can impair muscular coordination.

Alcohol use is associated with several dangerous behaviors, such as car accidents, increased violence, an increased vulnerability to sexual assault, blackouts, and a greater likelihood of engaging in unprotected sex. Bingeing on alcohol can cause serious illness such as alcohol poisoning and can even lead to death. Marijuana use can also lead to risky behaviors, impair concentration, worsen mental health, interfere with prescription medications, and negatively affect lung health. Because of its legalization, therapeutic uses, and wide availability, cannabis is often thought of as being “not as bad” as other drugs, but it has many of the same risks that are associated with alcohol use, and with extensive use can undermine motivation and the ability to be goal-directed. Furthermore, although mental health problems often underlie substance use, it works in reverse as well – substance use can destabilize an individual or unleash a latent mental health vulnerability. Substance use decreases judgement and can lower the threshold for suicidal impulses and behaviors. And one’s physical health can be compromised as well: adolescents who abuse substances are at higher risk for health problems as adults including heart disease, high blood pressure, liver disease, cancer, stroke, and sleep disorders.

We have learned from the responses of young people when asked about why they use substances that they are often trying to escape the moment. Needless to say, one’s physical presence in a classroom is not enough for learning – when mentally and emotionally detached from the moment youngsters are not fully available for academic pursuits. When frequently under the influence of substances teens are disconnected from other necessary learning opportunities as well, such as the development of social and basic life skills.

Warning Signs and Red Flags

Educators and parents often seek advice about the behavioral, physical, and psychological signs that might suggest potential substance abuse in teenagers. It is important to note that many of these items can also be signs of mental health or other teen struggles, so it is important to talk with teens and remain open to all possible scenarios.

Concerned adults should be on the lookout for:

• Drug paraphernalia, including mirrors with white powder residue, razorblades, straws, rolled dollar bills or rolling paper, crack pipes and spoons, needles and syringes, or bongs;
• Personality changes, such as increased irritability and/or aggression, paranoia, mood swings, or a lack of interest in activities that were previously enjoyed;
• Sleep changes, either more or less;
• A decline in academic performance and/or avoiding school;
• Odd or inappropriate behaviors (e.g., laughing inappropriately);
• Social isolation, avoiding eye contact, staying out late without explanation, acting secretive;
• Abandoning old friend groups and hanging out with a new group;
• Poor hygiene;
• Stealing or lying behaviors;
• Physical signs that are not otherwise explained, including: red eyes or dilated pupils, a persistent cough, hoarseness, frequent nosebleeds or runny nose, changes in energy level, changes in appetite and/or weight;
• Memory problems.

Besides maintaining an awareness of these possible signs, school professionals and parents ideally should have access to updated information about professional referrals. Depending on the signs that are noticed, an assessment by a pediatrician, mental health practitioner, or substance abuse specialist should be scheduled as soon as a pattern is suspected. For more information on how to talk to teens, current approaches to drug awareness and available treatments, stay tuned for Part 2 of this series.

Resources:

https://www.kff.org/mental-health/issue-brief/recent-trends-in-mental-health-and-substance-use-concerns-among-adolescents/

https://www.verywellhealth.com/teenage-drug-addiction-5213002

https://www.huffpost.com/entry/underage-drinking-survey-trends_l_657c7201e4b08e9b410a1b37