National Drug Control Strategy

A Day in the Life of American Adolescents: Substance Use Facts UpdateBrad Nelson

Georgia Department of Behavioral HealthOffice of Prevention Services and ProgramsJunior Fellow, Drug Policy Institute, University of Florida

1OverviewSAMHSA, Center for Behavioral Health Statistics and Quality (CBHSQ) Report

Present facts about adolescent substance use, including initiation, past month and year use, emergency department visits, and receipt of treatment on an average day.

ObjectivesScience of the Adolescent Brain

Use Rates and TrendsAlcohol and MarijuanaProblem and Consequences

CBHSQ Typical Day FiguresMindset of an Adolescent How would you describe an adolescent aged 12-17?

AdjectivesDescribe the state of mind

The Science of an Adolescent BrainAdolescence is a critical period for brain development

The increasing control over our behavior as we become adults is due to the maturation of our brains. Adolescence is long because brain maturation takes a long time.The development takes 23-25 years.

In childhood, behavior is driven by needs and emotions.

Adult behavior is driven by rational thought.

REWARDMEMORY/LEARNING EXECUTIVEFUNCTION/ INHIBITORY CONTROL

Circuits Involved In Drug Abuse and Addiction

NAcc

VPREWARD Reward Circuit

Drugs of Abuse EngageSystems in the Motivation Pathwaysof the Brain7

Drugs of abuse increase DA in the Nucleus Accumbens, which is thought to trigger neuroadaptions that result in addiction.150

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1000 20 40 60 80MARIJUANA% of Basal Release010020030040050060070080090010001100012345 hrAMPHETAMINE% of Basal Release050100150200060120180Time (min)% of Basal ReleaseEmptyBoxFeedingDi Chiara et al.FOODTanda, et al, Science 1997.Natural and Drug Reinforces Increase Dopamine in NAc8

HippAmyg

MEMORY/LEARNING 2. Memory circuit People, Place and Things93.) Motivation & Executive Control Circuits

ACGOFCSCCINHIBITORY CONTROL

EXECUTIVEFUNCTIONPFCMOTIVATION/DRIVE Dopamine is also associated with motivation and executive function via regulation of frontal activity.10

ACGOFCSCCHippNAcc

VPAmyg

REWARDMEMORY/LEARNING PFCMOTIVATION/DRIVE The fine balance in connections that normally exists between brain areas active in reward, motivation, learning and memory, and inhibitory control EXECUTIVEFUNCTIONINHIBITORY CONTROL

11Control of Emotions Depends on Maturation of Prefrontal Cortex

What Actually Happens as the Brain Matures?

Development of Rational Decision-MakingAge 12 move from concrete here-and-now thinking to abstract thinkingVisualization of outcomesLogical cause and effect analysis

Age 15 make sound decisions about hypothetical situations as well as adults

Yet adolescents take silly risks whats that about?

Why Are Adolescents So Reckless?Teen Brains are VolatileIncreased estrogen and testosterone provoke brain maturationBut, they lead to emotional impulsivity.Risky Behavior stimulates the Reward CircuitCircuit is hot during adolescence

VTA (Ventral Tegmental Area) neurons release dopamine to the nucleus accumbens and prefrontal cortex.Adolescence: A Mismatch Between the Immediacy of Intense Emotion & the Effort of Rational Decision-Making

About The ClickersFirst, wait until the question is active.

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Who First Figured Out When the Brain is Fully Mature?NeuroscientistsDMVThe ArmyActuariesState Liquor Control Board

What percentage of high school seniors in Georgia had at least one drink of alcohol in the past 30 days?

20%25%30%35%40%25% of Georgia High School Seniors had at least one drink in the past 30 days.

How many drinks do adolescents have when they do drink?

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Average: 4.3 Drinks

In terms of quantity of drinking, the proportion of young drinkers who report drinking heavily is higher than for adults.United States Department of Justice, Office of Juvenile Justice and Delinquency Programs. Survey on Drug Use and HealthHow has drinking among U.S. 12th graders changed in the past 25 years?Increased SignificantlyIncreased Slightly Stayed the SameDecreased Slightly Decreased Significantly

Alcohol Use Among U.S. 12th GradersUniversity of Michigan, Monitoring the Future Study (Table 17, 18)

How has drinking and driving among High School Students changed in the past 20 years?Increased SignificantlyIncreased Slightly Stayed the SameDecreased Slightly Decreased Significantly

Drinking and Driving Among High School Students

Centers for Disease Control, Youth Risk Behavior SurveyWhich has the lowest drinking rate among 10th graders?

FranceGermanyItalyUnited KingdomUnited StatesBinge Drinking Among 10th Graders

What is the percentage of adolescents in Georgia, aged 12-17, who perceive that there is no great risk from having 5 or more drinks once or twice a week?20-30%30-40%40-50%50-60%60-70%70-80%17%17%17%17%17%17%

Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: Georgia 2013Georgia Student Health Survey:Comparison No Great Risk & Harmful

Interactive Activity78% of 11th graders and 75% of 12th graders perceive alcohol as harmful yet 57% of 12-17 year olds perceive that there is no great risk from having 5 or more drinks once or twice a week.

- Discuss Discrepancy Adolescent Drinking: The ProblemAlcohol is the most commonly used and abused drug among youth in the United States, more than tobacco and illicit drugs

Underage drinkers consume about 11 percent of all the alcohol purchased in the United States, and the vast majority of this alcohol is consumed in a risky fashion

Drinking if responsible for more than 4,300 annual deaths among underage youth

Adolescent Drinking: The ConsequencesAdolescents who start drinking before the age of 15 years are 5x more likely to develop alcohol problems later in life than those who wait until they are 21

They are:4x more likely to develop alcohol dependence6x more likely to be in a physical fight after drinkingAlmost 5x more likely to suffer from other unintentional injuries after drinkingMore than 6x more likely to be in a motor vehicle crash because of drinking (In 2012, there were 31 Under 21 Alcohol Impaired Driving Fatalities in GA)

Whats going on with Marijuana?

Just to remind us why we care about this based on the MJ/Cig crossover paper published by Nora, Wilson, and Marsha in 2009: Changes in Cigarette and Illicit Drug Use Among US Teenagers, Arch Pediatr Adolesc Med.2009;163(9):869-870.

What were looking at here is past month mj and cig use among 10th graders (for illustration)lighter colors cig/darker colors mj. Crossover appears in all three surveys now- so unlike in prior generations of mj users we are faced with the situation where youth may be using marijuana before or without smoking cigarettes.

Arpana Agrawal had a paper last year in Psychological Medicine examining differences in order of initiation in a twin sample of women and found that among AA women but not the EA women mj first (before alcohol) lead to a more rapid progression and more cannabis-related problems.Sartor, C E; Agrawal, A; Lynskey, M T; Duncan, A E; Grant, J D; Nelson, E C; Madden, P A F; Heath, A C; Bucholz, K K. Cannabis or alcohol first? Differences by ethnicity and in risk for rapid progression to cannabis-related problems in women. Psychol Med. 2013 Apr;43(4):813-23.

36Marijuana: What is the percent of high school seniors in Georgia who used marijuana in the past 30 days?

10%15%20%25%30%

16% of High School Seniors used marijuana in the past 30 days.

Georgia Student Health Survey, 2012-2013What is the percentage of adolescents in Georgia, aged 12-17, who perceive that there is no great risk from smoking marijuana once a month?

50%55%60%65%70%75%

Percentage of U.S. 12th Grade Students Reporting Past Month Use of Cigarettes and MarijuanaSOURCE: University of Michigan, 2013 Monitoring the Future Study.CigarettesMarijuana

41 12th Graders Past Year Marijuana Use vs. Perceived Risk of Occasional Marijuana UseSOURCE: University of Michigan, 2013 Monitoring the Future Study422013: non-sig dec in perceived risk

Change in perceived risk precedes change in use by a year in some casesInc in PY use and dec in perceived risk are NS here, but about 12% increase over 5 years.

More on MJ prevalence in other grades later in presentation.Percent Perceiving Great Risk of Smoking Marijuana RegularlyDenotes significant difference between 2012 and 2013SOURCE: University of Michigan, 2013 Monitoring the Future Study432013: Decreases in smoking regularly in all 3 grades, and a decrease in occ among 8th

2012: 10th sig dec in regularly, occasionally, and 8th and 10th sig dec in 1-2x2011: didnt see any sig declines in perceived harm but clearly continuing to trend downward2010: Sig dec 10 and 12 grade, also sig dec grade 10 for occasional smoking.2009:Sig dec in 8th and 10th, Also risk of smoking occasionally declined among 8th.2008 sig dec in 8th, all indicators of mj riskSource of Marijuana* among 12th Graders in 2012 and 2013, by State Policy

*Categories not mutually exclusive ** Statistically significant differenceSOURCE: University of Michigan, 2013 Monitoring the Future StudyB021. Where did you get the marijuana you used during the last year? (Mark all that apply)Overall 3.1% said they got their mj from own mmj prescription- split to 5.5 in mmj state vs 1.6 in non-mmj state (?).B021a. Did you get any of the marijuana you used during the last year from someone else's medical marijuana prescription?Overall 18.4% said they got the mj they used from someone elses prescription over 1/3 of those in mmj states said yes to this question compared to less than 9% in non-mmj states 44Marijuana: Whats the harm?

Addiction

Motor Vehicle Accidents

Motivation, Mood, Paranoia, Psychosis

451 in 6 teens become addictedThe adolescent brain is especially susceptible to marijuana use. When kids use, they have a greater chance of addiction since their brains are being primed.

Wagner, F.A. & Anthony, J.C. , 2002; Giedd. J. N., 2004

1 in 11 adults and 1 in 6 adolescents who try marijuana will become addicted to it.

46Marijuana addiction is linked to a withdrawal syndrome that can make it hard to quit. Symptoms include:

irritability,sleeping difficulties,craving,anxiety, andincreased aggression.Marijuana withdrawal is now recognized in DSM-5Marijuana and Addiction47Addiction:About 9% of cannabis users (1 in 6 who start in adolescence and 25-50% of daily users)* Nonmedical UseSource: Anthony JC et al., 1994Estimated Prevalence of Dependence Among Users **48Addictive Nature of Drugs When Different Drug Use Starts in AdolescenceTobacco24%15%8% 9%AlcoholMarijuanaCocaineStimulantAnalgesicsPsychedelics

Source: Anthony JC, Warner LA, Kessler RC (1994): Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology 2: 244 - 268Heroin 25% 20%17%14%49

Todays marijuana is not the marijuana of the 1960s.

In the past 15 years, marijuana potency has tripled and since 1960 it grown 5 times stronger.

Increased Potency50THC:Psychoactive IngredientAlso can you get rid of the gray shaded box behind these data?52Marijuana & The Brain (IQ)Meier et al. (2012). Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of Sciences.

It can affect parts of the brain responsible for:memory, learning attention, and reaction time.

These affects can last up to 28 days after abstinence from the drug

...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Cannabinoid Receptors Are Located Throughout the Brain and Regulate: Brain Development Memory and Cognition Motivational Systems & Reward Appetite Immunological Function Reproduction Movement Coordination Pain Regulation & Analgesia

54Slide 2: Brain regions and neuronal pathwaysCertain parts of the brain govern specific functions. Point to sensory, motor, association and visual cortex to highlight specific functions. Point to the cerebellum for coordination and to the hippocampus for memory. Indicate that nerve cells or neurons travel from one area to another via pathways to send and integrate information. Show, for example, the reward pathway. Start at the ventral tegmental area (VTA) (in magenta), follow the neuron to the nucleus accumbens, and then on to prefrontal cortex. Explain that this pathway gets activated when a person receives positive reinforcement for certain behaviors ("reward"). Indicate that you will explain how this happens when a person takes an addictive drug.

L (yellow) and R (blue) amygdala L(red) and R(green) hippocampusHippocampal and amygdalar volumes were smaller in cannabis users than in controls.

HippocampusAmygdala Brain abnormalities associated with long-term heavy cannabis useYucel et al., Arch Gen Psychiatry. 2008 Jun;65(6):694-701.Morphology and function of hippocampus has been linked to reduced memory performance in heavy cannabis users55

Early ( 26% (2013)Decrease of 5%

Tobacco Use 22% (2007) -> 17% (2013)Decrease of 5%

Marijuana Use14% (2007) -> 16% (3013)Increase of 2%

Trends: Perception of Harm Georgia Student Health Survey12th Grade (2007-2013)Alcohol 78% (2007) -> 75% (2013)Decrease of 3%

Tobacco 95% (2007) -> 88% (2013)Decrease of 7%

Marijuana76% (2007) -> 64% (2013)Decrease of 12%Discussion Activity:

Why is understanding our perceptions of behavior and harm so important?Use Examples and Choose Solution Field

Prevention Treatment Recovery Smart International Enforcement EffortsCurrent Dichotomy of Solutions Public Health Approach - disease - treatmentPublic Safety Approach - illegal behavior - punishHigh Attrition High Recidivism 80

Successful Programs Use an Integrated Public Health-Public Safety StrategyBlends functions of Prevention, Criminal Justice, and Treatment

(Optimize Outcomes)Community-based PreventionOpportunity to avoid incarceration or criminal recordConsequences for noncompliance: certain and immediate81Addictions are common, developmental brain diseases expressed as compulsive behavior through continued use of a drug despite negative consequences: Onset depends on many intrinsic and extrinsic factors.AddictionDRUG/ALCOHOLBrain MechanismsBiologyGenes/DevelopmentEnvironmentGene-Environment-Development82

83ENTRY/PRETRIAL(Arrest)ADJUDICATION(Trial)PROSECUTION(Court, Pre-Trial Release, Jail)SENTENCING(Fines, Community Supervision,Incarceration)CORRECTIONS(Probation, Jail, Prison)COMMUNITY REENTRY(Probation, Parole, Release)Crime victimPoliceFBI

Crime victimPoliceFBIJudge

Key PlayersScreening/Referral

Intervention Opportunities ProsecutorDefense AttorneyDefendantJuryJudge

JudgeJuryProbation OfficersCorrectional Personnel

Probation/ Parole OfficersFamilyCommunity-based providersDiversion ProgramsCommunity CourtsDrug CourtsCommunity TreatmentTASC

Community CourtsDrug CourtsTerms of IncarcerationRelease Conditions

Drug Treatment

Drug treatmentAftercareHousingEmploymentMental HealthHalf-way HouseTASC

N/AAddressing Drug Abuse in the Criminal Justice System84ConclusionsAdolescence is a critical period of brain developmentDevelopment is modified by the environment

Adolescents are prone to risk takingDelayed development of prefrontal cortex

Alcohol and Marijuana have profound effects on the brain

Thanks!

bradley.nelson@dbhdd.ga.govChart167491465689247542548218828161937443521443220066616243591939

20042008

Sheet120042008Alcohol674914656892Cocaine475425482188Marijuana281619374435Heroin214432200666Stimulants16243591939To resize chart data range, drag lower right corner of range.