Substance Abuse Among Adolescent Populations: Challenges, Implications, and Opportunities

Abstract

Substance abuse among adolescents is a growing public health problem that affects the social, political, and economic facets of the global community. Irrespective of age, substance abuse represents a significant public safety and public health concern, but the prevalence of substance abuse among the adolescent population is particularly startling. The Youth Risk Behavior Survey (YRBS, 2011), conducted by the Centers for Disease Control (CDC) and the World Health Organization (WHO, 2012) demonstrated that adolescence is the typical age of onset for experimentation with drugs and alcohol. Considering that the adolescent brain has not fully matured, this age-group is especially vulnerable to the lure of tobacco, alcohol, and drugs. The effects of these substances, in conjunction with a developing brain, tend to lower inhibitions, impair judgment and to increase the risk for addiction. All these factors pose a threat to adolescent health and safety that can be mollified through an educational approach that addresses the effects, prevalence and dangers of substance abuse.

By addressing the dangers of adolescent substance abuse via the social collectivist model, this approach will serve as a teaching tool to educational and healthcare institutions aimed at educating adolescent audiences. In applying evidence-based practice (EBP), this paper addresses substance abuse education using four educational models: 1) opiates: morphine, codeine, heroin, Oxycontin and Vicodin, 2) prescription stimulants: Adderall, Ritalin, and Concerta, 3) depressants: alcohol, Xanax, Valium and marijuana, and 4) other compounds: GHB, Ketamine, K2/spice, bath salts and dexamethasone (DMX), the active ingredient in cough medication. In using these four models, the relevant substances are categorized in such a way that they can easily be utilized in conjunction with New Jersey’s Comprehensive Health and Physical Education (NJ CCCS) standards. Beginning in eighth grade, these standards address the harmful consequences of substance abuse and their effects upon health and quality of life to educate and dissuade adolescents from abusing substances.

As such, these findings will be distributed as an evidence-based product to educational facilities and other relevant institutions (e.g., community centers, hospitals, and youth-advocacy organizations). The information serves to provide an overview of the issue’s urgency, with the pervasiveness of adolescent substance abuse proven through YRBS (2011) and WHO (2012) data. This data provides the framework for analysis before the four educational models of opiates, stimulants, depressants, and other compounds are explored in greater depth. Furthermore, the four-model framework can be easily translated into a four-stage presentation for the benefit of an adolescent audience.

Introduction

Adolescent substance abuse is a growing public health concern that affects the social, political, and economic segments of the global community. Specifically, substance abuse negatively impacts families, schools, and local communities, causing significant and enduring damage to the abuser’s social network over time. According to the Centers for Disease Control (CDC, 2013), substance abuse is generally rising among adolescent populations in the United States, warranting meaningful interventions that successfully target the most at-risk populations. As such, the following inquiry provides a comprehensive overview of adolescent substance abuse, affording particular attention to types of drugs which most urgently need to be targeted through multidimensional interventions, before delving into the use of evidence-based practice (EBP) for educating adolescent populations regarding dominant types of substance abuse. This work theorizes that substance abuse among adolescent populations can be effectively addressed through culturally competent interventions that seek to empower and inspire adolescents to cultivate a high-quality life for themselves, with this work being a teaching tool usable by relevant institutions and organizations.

While substance abuse represents a substantial health problem across all ages, the dangers of youth substance abuse are particularly grave. With drug use, the growing adolescent brain not only becomes more vulnerable to increased addiction rates, but those addictions are less treatable through interventions than the addictions of older substance users (Koehn and Cuttliffe, 2012). Additionally, adolescents are far more susceptible to substance abuse due to peer-pressure, socially influenced judgment, lower levels of impulse control, and higher instances of risk-taking. Significant empirical evidence suggests that adolescents engaging in substance abuse are far more likely to become adults addicted to substances, with over 90% of adults affected by substance abuse disorders having used the substance to which they are addicted before the age of eighteen (Koehn and Cuttliffe, 2012). Early intervention in substance abuse problems among adolescent populations is then critical to halting addiction later in life.

Methodology Overview and Rationale for Evidence-Based Product

This study serves as an evidence-based educational product, with evidence drawn from national and global health organizations. The specific issues to which early substance abuse are connected include poor academic performance, unprotected sex with higher incidences of HPV, suicides, mental health problems, violence, and self-injury (Mohommadpoorasl et al., 2012). Over three-quarters of adolescents in the United States have engaged in substance abuse, with the most common types of substance abuse in the nation being alcohol, tobacco, marijuana, and cocaine. The most recent Youth Risk Behavior Surveillance System (YRBS) survey was conducted in 2011 and was implemented in order to prioritize risk behaviors that contribute to death and social problems among adolescents in the United States. The survey focused on substance abuse as well as high-risk sexual behavior, obesity, and violence. This current study sources data from the YRBS (2011) in order to identify plausible interventions for participating populations and to identify the attendant risk behaviors.

The YRBS (2011) focuses on participants aged fifteen through eighteen attending both public and private schools in the United States. Substance abuse alone is acknowledged as a risk behavior, with the role of substance abuse additionally explored in alternative categories. For instance, the “Behaviors that Contribute to Unintentional Injuries” included riding in a vehicle driven by someone who had been consuming alcohol, with nearly one-quarter of participants surveyed having engaged in this behavior during the thirty days prior to survey participation. The YRBS surveys students in all fifty states using a three-stage sample design in order to yield a diverse and representative sample of students attending public and private schools. The response rate for the 2011 YRBS was 71%, with the identified goal of the YRBS being to identify behaviors that are largely preventable and assess the most at-risk populations.

The YRBS (2011) assessed the national adolescent population in the United States concerning reported usage of tobacco, alcohol and other substances. With respect to tobacco use, the YRBS (2011) reported that 44.7% of participants had engaged in cigarette smoking, with nearly 20% of participants having smoked at least one cigarette during the thirty days prior to survey participation. In addition to tobacco use, alcohol and other substance abuse represent a common behavior among adolescent populations. The YRBS (2011) cites that nearly 71% of participants had engaged in drinking alcohol, with 38.7% of all students drinking at least one drink during the thirty days prior to survey participation. More alarmingly, 21.9% of all students had engaged in binge drinking during the thirty days prior to survey participation, drinking five or more drinks in a row within only several hours. Marijuana use was relatively frequent among participants, with nearly 40% of all participants having used marijuana at some point during their lives. Cocaine (6.8%), inhalants (11.4%), heroin (2.9%), methamphetamines (3.8%), steroids (3.6%) were prominent among participants, with all of these trumped significantly by the frequency with which participants used prescription drugs in the absence of a doctor’s prescription (20.7%). The most common prescriptions abused included Oxycontin, Percocet, Vicodin, codeine, Adderall, Ritalin, and Xanax, all of which are available through prescription in the United States (YRBS, 2011).

In addition to the quantitative data yielded by the YRBS (2011), recent empirical literature sourced from peer-reviewed scholarly journals during the past five years will be used in order to address common intervention strategies, cultural factors surrounding the most at-risk populations, and meaningful contextual evidence regarding the sociological, physiological, and psychological implications of substance abuse among adolescent populations. Empirical evidence suggests that the global community is affected by adolescent substance abuse on a rising scale, with additional data sourced from scholarly evidence highlighting the implications of adolescent substance abuse for the global community (Tang et al., 2012). The World Health Organization (WHO, 2012) cites that alcohol alone results in 2.5 million deaths within the global community, with 320,000 people aged fifteen through twenty-nine dying from alcohol-related problems. WHO (2012) posits further that 15.3 million people worldwide are addicted to substances, with 148 nations reporting injectable drugs as a major health problem particularly as it relates to HIV/AIDS. Data available within the global community sourced from WHO (2012) will be used to quantitatively complement the national data sourced from the YRBS (2011) and scholarly literature.

Outline of Educational Tool

This educational product is grounded in available evidence from YRBS (2011) and WHO (2012), using a social constructivist approach to educate adolescent populations regarding the prevalence of national and global substance abuse among their own age group. Foundational to this study is the belief that young populations can be empowered to derive meaningful solutions and workable interventions for substance abuse prior to adulthood, with awareness representing a key step in yielding these solutions. The importance of using evidence from national and global health organizations is significant in that it validates the use of this product for its target facilitators and learners.

Review of Literature

Understanding the causes, effects, and outcome of substance abuse within adolescent populations is a crucial step toward addressing, preventing and/or delaying its onset. As this paper will show, the consequences of substance abuse for younger populations are inherently detrimental for a few reasons. Not only can substance abuse adversely affect school performance, physical health and social development, but it carries risk factors that can lead to drug dependence in adulthood. Consequently, adolescent substance abuse detrimentally affects brain development and generally lowers the life quality of the individual, thereby leading to comorbidity between substance abuse and other mental and physical disorders (Parker, 2010). The YRBS (2011) rationalizes their large-scale study by asserting substance abuse and other risky behaviors as the leading causes of death among younger populations. This inquiry further asserts that the reduction in life quality is significant with respect to substance abuse, as it creates conditions for other high-risk delinquent behaviors and, by extension, death. WHO (2011) argues that commonly abused substances within the global community, and among younger populations in particular, must be identified through constantly updated and revised research due to the dynamic nature of synthetically produced substances. To wit, “Any substance can be harmful to a human body if taken in large enough doses, too frequently or in an impure form. The health effects of substances can occur immediately or in the long-term. The effects are influenced by the dose, the method of administration as well as whether the substance is used with another drug” (p. 5). Younger populations are more vulnerable to both the immediate and sustained impact of substance abuse. The following review of the literature highlights the dominant themes of the research questions through sourcing data from recent and relevant scholarly literature, in addition to that garnered from WHO and the YRBS (2011). To begin this review, it is important to briefly address the potential risk factors that may lead adolescents to experiment with drugs. These drugs, their use, their popularity and their effects upon the adolescent population will establish the pressing need for comprehensive programs that help to deter and delay adolescent substance abuse.

Risk Factors

Studies indicate that the onset of alcohol use in early childhood can be correlated with peer pressure, poor parent-child relationships and high substance availability (Nargiso, Friend, Florin, 2013). While the findings of Nargiso et al., are important in addressing specific social factors, it is also crucial to evaluate other studies that suggest that, contrary to adult studies, there remains little to no correlation between gender, ethnicity/race and adolescent substance abuse (Swendsen, Burstein, Case, Conway, Dierker, He, & Merikangas, 2012). In fact, Swendsen et al., conclude that more research needs to be done in order to track the trajectory of drug use and the stages of drug use in adolescents. Part of the Swendsen, et al. research posits that there are four identifiable stages to adolescent substance abuse that may merit differing forms of intervention that are stage dependent. Currently, this method of tracking adolescent substance abuse has not yet been undertaken. To conclude their analysis, Swendsen, et al. strongly suggest that a four-stage substance abuse tracking is imperative to isolate the various stages of adolescent substance abuse in order to yield useful results and to reveal possible intervention strategies.

Opiate Usage in Adolescent Populations

Luckily, trials have already been conducted using three different models for intervention in adolescents with opiate substance abuse. Trials analyzing prescription and opiate abuse (Spoth et al., 2013) examined long-term prescription drug misuse and opiate abuse and their receptivity to brief structured intervention. These studies categorized the interventional success rates from seventh to twelfth grade using three different trials: family intervention, family with school intervention, and evidence-based family and school intervention. Of the three trials, the most effective route was family intervention combined with school intervention for both low-risk and high-risk groups.

While this is good news for the efficacy of evidence-based intervention, the Spoth, et al. study has its limitations. Essentially, this study confines itself to rural populations of adolescents in Iowa with communities that already have intervention programs. In addition to these findings that promote a family/school success route for intervention, the trials noted a general downward trend for opiate abuse.

In 2011, Monitoring the Future (MTF), a comprehensive drug-use study from the University of Michigan, published their study concerning teen drug abuse trends among middle school and high school students. The MTF authors (Johnston, O’Malley, Bachman & Schulenberg, 2011) demonstrated a downward trend for opiate usage with a significant number of these adolescents reporting a general fear of and distrust toward heroin and a low reportage of use. These groups also report high disapproval for heroin and associate its use with high-risk behavior. The use of Vicodin, Oxycontin and Percocet has either remained steady or begun to decline since its zenith in 2004.

Stimulant Use

The MTF study (Johnston et al., 2013) noted a decline in amphetamine usage among middle schoolers, but an increase in use by twelfth graders. The disapproval surrounding amphetamine use and its perceived unavailability contributes to the slight decline in usage. Perhaps the media attention surrounding the negative effects of methamphetamine is a contributing factor to its low usage and very negative assessment among high school seniors.

These low rates of amphetamine usage are encouraging, but the abuse of Adderall, although decreasing among other adolescent groups, has been steadily increasing among twelfth graders. As the MTF study noted (Johnston et al., 2013), further inquiry revealed that high school Adderall users tended to use Adderall for its perceived performance-enhancing benefits in contact sports. Moreover, other studies (Spoth et al., 2013) have also noted that the abuse of prescription stimulants is climbing at an alarming rate.

Depressant Use

In contrast to the upward climb of adolescent prescription drug use, marijuana usage among adolescents has consistently been the most common form of reported illicit drug use (Johnston et al., 2013). Over time, this usage has tended to remain steady, but the 2013 MTF study noted a sharp increase in the number of adolescents who report smoking marijuana daily. This increased frequency of use is directly related to marijuana’s perceived low risk and its ubiquity. It cannot be underestimated how marijuana use has achieved a degree of social acceptance. Furthermore, the MTF study revealed that in proportion to the perceived low risk, the stigma surrounding marijuana use within adolescent groups has fallen.

The MTF study also demonstrates that the trends for marijuana tend to mirror trends for alcohol. Both substances are perceived as widely available, low-risk and carry low disapproval. However, the MTF study makes clear that alcohol usage and availability is declining among younger adolescents. While binge-drinking has high negatives within younger adolescent groups, the older adolescent groups attach only a moderate stigma to that behavior. Regardless, studies have also indicated that younger adolescents are particularly vulnerable to peer-pressure in alcohol usage (Kelly, Chan, Toumbourou, O’Flaherty, Homel, Patton, & Williams, 2012).

While peer-pressure may contribute to the drinking habits of younger adolescents, according to the MTF study, the use and abuse of Xanax across all adolescent populations is relatively low. The use of Ritalin among adolescents has only been charted by MTF since 2001, but its overall usage has continued to decline. Accordingly, the MTF study did not analyze the disapproval levels for tranquilizers, but it did note that there is a perception that Xanax and other tranquilizing substances are difficult to obtain.

Use of Other Compounds

Along with the perceived low-availability/low-desirability of tranquilizers, the adolescent use of so-called “club drugs” (e.g., MDMA/ecstasy/”Molly,” special K, GHB, etc.) has been steadily declining since its zenith in 2001 (Johnston et al., 2013). A major concern with evaluating the effects of “club drugs” on adolescent populations is that much of the research involves subjects who are post-adolescent. In fact, the most recent study that traces the trajectory of MDMA use is an Australian study that tracked young adult subjects (ages 19-23) for thirty months (Smirnov, Najman, Hyatbakhsh, Plotnikova, Wells, Legosz, & Kemp, 2013) and concluded that the majority of users were infrequent “binge” users of ecstasy that were using the drug in recreational settings because of positive experiences with the drug. The authors also noticed no correlation between ecstasy use and availability or price. Even though the use of MDMA is in decline and its usage is transient, it remains to be seen if a resurgence will happen with MDMA’s “rebranding” as “molly.” As the 2013 MTF study indicates, the use of GHB, special K, and Rohypnol among adolescents is so low that no further analysis was done to determine its availability and perception.

By contrast, the over-the-counter availability of Spice/K-2 and its rumored properties as a substitute for marijuana have made it increasingly popular with adolescent populations. As the MTF study reveals, usage of Spice/K-2 among the adolescent populations is the third most popular illicit drug, lagging slightly behind marijuana and inhalants. Essentially, the MTF study points out that there are two main reasons for the popularity of Spice/K-2: wide availability and low perceived risk. Spice/K-2 is available from many liquor stores and makers of Spice/K-2 change chemical formulations in order to skirt DEA illegalities. The amorphous character of Spice/K-2 keeps it in wide circulation and its ease of procurement suggests to potential users that the substance is non-harmful (Johnston et al., 2013).

Another easily obtained and amorphous substance is “bath salts.” Until recently, bath salts, like Spice/K-2, could be purchased from liquor stores and through the internet. While the toxicity of bath salts has now been established, and some current research has suggested that the bath salt “epidemic” is largely a media creation (Stogner & Miller, 2013). Whether or not bath salt usage has been overestimated by the media, the fact remains that there is very little extant research about the effects of bath salts, let alone the effects of bath salts on the adolescent population.

Contributing factors

Although not specific toward adolescent substance abusers, the findings from the Swedish National Adoption Study (Kendler, K. Sundquist, Ohlsson, Palmér, Maes, Winkleby, & J. Sundquist, 2012) revealed prevalence for substance abuse among the offspring of substance abusing parents. Even with this genetic component, the Swedish researchers point that the etiology of substance abuse is multi-faceted and subject to many factors: mental illness, divorce, environment, etc. Within the environment, the most important factors tend to be the availability of the substance and usage among peers. When substances are difficult to obtain and have a negative perception among peers, their use tends to plummet. While the onset of adolescent substance abuse doesn’t have a clear gender, ethnicity or socio-economic basis, there appears to be a correlation between the risk of adolescent substance abuse and combative home relationships (Spoth, 2013).

Substance Abuse and the Brain: A Neurological Perspective

The research concerning the hazardous effects of substance abuse upon the developing adolescent brain is clear. Neurological research into alcohol and drug use during adolescence has also signified that it can result in cogitative impairment in early adulthood (Hanson, Medina, Padula, Tapert, & Brown, 2011). According to Hanson et al., these cognitive impairments involved general memory function and verbal acuity.

Abusing various substances leads to relatively rapid and profound changes in the brain which, among other detrimental outcomes, leads to greater vulnerability for addiction. Parker (2010) posits that certain substances permanently change the brain structure, with younger populations particularly susceptible to these changes due to higher levels of brain plasticity. Drug abuse, according to the same author, has a recidivism rate of over 90%, with this alarming statistic inextricably bound to the ways in which the neurological structures in the human body respond to substances and, if applicable, rehabilitative treatments.

The drug, undoubtedly, impacts the ways in which its abuse will affect the brain. Parker (2011) describes the experience of the abuser, generally, as follows:

Before looking at brain changes accompanying the development of drug abuse, it's important to consider the changes that occur in the experience of the drug abuser as the problem develops. Depending on the drug of choice, individuals vulnerable to becoming drug abusers typically experience an intense feeling of euphoria on taking the initial few doses of their drug of choice. Stimulant drugs like amphetamine or cocaine often require an initial few doses to sensitize the user, at which point the peak pleasure experience occurs. This initial part of the process can be seen as the reward stage, in which the habit of seeking this intense pleasure state is established (p. 2).

The drug’s peak impact on the brain is associated with extreme pleasure, with this feeling-state sourced from just a single experience with the substance. When this pleasurable feeling-state subsides, a less-pleasurable plateau state then follows, persisting for a certain period until a negative, coming-down feeling takes its place as the drug exits the bodily system (Parker, 2010).

The briefest state experienced by the abuser of most substances is then the most intense, with the user seeking the intense pleasure state when s/he chooses to take the same drug again. Parker (2010) argues, however, that the original high experienced by the first-time user can never again be reached, with the neurological motivation to replicate the original feeling then essentially insatiable, because the same pleasure-intensity will never be reached. Addiction emerges when the individual continually seeks out the same intensity as the initial experience, often taking higher and higher doses of the same drug in order to affect the brain in a similar way; this is impossible, however, as the pleasure centers of the brain have been altered by the first experience of the drug. A tolerance begins to build as the addicted person uses the substance either more frequently and takes greater quantities each time, marking the beginning of physical dependence on the drug. If the user is unable, for various reasons, to use the drug on which s/he has become dependent, withdrawal symptoms begin to occur. These symptoms irrefutably vary in intensity depending on which substance is the addictive drug. Parker (2010) describes withdrawal as follows:

It's important to note that the withdrawal symptoms are opposite to the original effect of the drug. Heroin and alcohol as classified as depressant drugs because they reduce the activation of the brain and body. However, withdrawal from these drugs produces an activated body state. Symptoms include restlessness, pain, irritability, and muscle cramps and uncontrollable tremors. In contrast, withdrawal symptoms from stimulants like cocaine and amphetamine include apathy, a loss of sex drive, insomnia, a general lack of energy, and, significantly, mental depression. To the extent that the habit reduces the drug abuser's quality of life and induces him or her to take desperate measures to obtain the next dose, the abuser is likely to reach the point where treatment is attempted. Assuming that the abuser has received treatment, and is no longer actively taking the drug, he or she is now in the final stage of the process, known as end-stage drug abuse (p. 5). The younger substance abuser’s brain is more vulnerable to these effects, with addiction occurring more rapidly than in adults (Parker, 2010).

The ways in which the young brain is permanently altered represents a significant issue with respect to substance abuse and public health. Anhedonia, or the permanent damaging of pleasure centers in the brain, is prevalent among those who began abusing drugs at a young age. Parker (2010) posits that those with anhedonia can no longer derive the feeling-state of pleasure from once-pleasurable stimuli, even if these stimuli are not associated at all with the drug itself. Because healthy stimuli which were once-pleasurable no longer yield a positive feeling in the abuser, s/he craves the substance to which s/he is addicted even more strongly. Parker (2010) associates anhedonia closely with end-stage drug use or the most insidious stage of addiction after which either recovery or death tend to follow; quality of life has been so detrimentally impacted during the end-stage that the user is faced with a choice to recover or succumb detrimentally to the substance’s power. Among younger populations, the cravings associated with end-stage drug use are more pronounced and enduring (Parker, 2010).

Theoretical Framework: One-Time Drug Use, Substance Abuse, and Life Quality

The developing brain, in short, is structured to become addicted to substances after only a single experience with the drug (Parker, 2010). Moreover, the young brain can become permanently wired to need the drug in order to derive pleasure, significantly reducing life quality (Briggs et al., 2011; Laudet, 2011). Laudet (2011) cites that substance abuse, in its various forms, is always characterized by maladaptive patterns of substance use which then yield severe impairments to psychological and physical functioning. Personal safety, social networks, obligations, work, and other areas of life are detrimentally impacted by substance abuse, regardless of the age of the user, with the continued use of the drug reinforced by a continual reduction in life quality. In essence, the user is experiencing negative life changes as a result of drug use, then using the drug more often to escape these changes; this is reinforced by the aforementioned neurological changes which occur during substance abuse, thereby creating potentially permanent damage to the user.

Laudet (2011) contends that quality of life is an under-examined issue with respect to drug abuse and, by extension, treatment. No universal definition of quality of life exists within the literature, but the author posits that it is a subjective concept inherent to the individual’s perspective of clinical, personal, and functional issues. Health-related life quality represents the individual’s perspective on his/her health status and, more saliently, the relationship of that status to psychological, social, and physical well-being. Alternatively, WHO (2011) defines quality of life as the individual’s perspective of their own positioning within the context of their lives, culture, and value systems (ctd. In Laudet, 2011); Laudet (2011) supplements WHO’s (2011) definition by citing that life quality additionally relates to the individual’s perspective of their lives with relation to their unique goals, standards, and expectations.

Substance abuse relates intimately to life quality, with consistent abuse of substances negatively impact all areas of life quality functioning; these include social, familial, vocational, physical and psychological health, service access, and residential status (Laudet, 2011). Laudet (2011) cites that a critical aspect of life quality is the relationship between perspectives of life quality variables and the individual’s satisfaction with those variables; if the individual defines social life quality, for instance, in terms of a significant number of friendships, then s/he is less likely to be satisfied with his/her life if expectations are unmet in this area. Similarly, Laudet (2011) cites that life quality significantly impacts the individual’s likelihood to remain in treatment programs; if individual’s perspectives on their own life quality do not improve during the treatment, they are more likely to drop out of the program and, by extension, continue to abuse substances in order to escape lower life quality conditions. Laudet (2011) posits that life quality research is a core component of addressing substance abuse problems for all generations, with a general dearth of research examining how life quality relates to substance abuse:

The addiction field lags far behind other mental health and biomedical disciplines in embracing QOL as an essential outcome, especially in the United States…. Systematic use of QOL indicators to monitor outcomes has been scarce, despite the wide-ranging effects of SUD on patients, families, and society…. QOL is poorer among substance-dependent individuals and SUD treatment seekers than among cohorts without SUD…. This finding is consistent across comparisons with clinical and nonclinical cohorts, primary care patients, groups with chronic physical or mental health conditions, and healthy nonabusers…. For example, on the SF-36 indices of physical and mental functioning, clients in SUD treatment score significantly lower than the general population, as low as or lower than patients with lung disease and diabetes, and significantly lower than patients awaiting cardiac surgery… (p. 49). Laudet (2011) cites further that research is increasingly and consistently highlighting that all quality of life domains are negatively affected by substance abuse.

YRBS (2011) Data and Substance Abuse Among American Youth

The YRBS (2011) rationalizes their comprehensive study by citing that risk behaviors are at once preventable and a significant source of death among younger populations. The YRBS (2011) cites that in the United States, nearly three-quarters of all deaths are related to automobile accidents, unintentional injuries, homicide, and suicide, with significant linkages between these outcomes and high-risk behaviors among youth. The YRBS (2011) cites that the leading causes of morbidity and mortality among youth all fall into six, prioritized categories of health-risk behaviors; these are those contributing to injury and violence, tobacco use, substance abuse, sexual behaviors leading to sexually transmitted infections (STI) and unintended teen pregnancy, physical inactivity, and unhealthy diet. YRBS (2011) highlights that “these behaviors frequently are interrelated and are established during childhood and adolescence and extend into adulthood. To monitor priority health-risk behaviors in each of these six categories and obesity and asthma among youth and young adults, CDC developed the Youth Risk Behavior Surveillance System (YRBSS)” (p. 9). Data is sourced from school-based surveys among samples of students in grades nine through twelve, with the YRBS having been conducted every two years since 1991.

The YRBS (2011) is the largest public health surveillance system in the United States which focuses on younger populations. Data from the YRBS (2011) is then utilized in a wide spectrum of instances, including but not limited to comparisons between health-risk behaviors among students according to various demographic variables, assessing trends in risk behaviors over time, monitoring progressive trends and changes in health-risk behaviors in meeting identified health objectives, comparing data between states, grounding policy development, and other intervention program creation. For the purposes of this study, the YRBS (2011) data will be used to identify substance-abuse related behaviors, particularly those falling into the alcohol and other drug abuse category, among young populations in the United States according to the research questions.

Significant variation in risk behaviors was found by the YRBS (2011) with respect to subpopulations of students according to two key traits; these were gender and race/ethnicity. Notably, male students throughout the nation are significantly more likely than high school students to participate in most risk behaviors, including all forms of substance abuse. Male students were more likely to currently smoke cigarettes and cigars as well as use smokeless tobacco. Male students were additionally more likely than their female counterparts to binge drink, use marijuana, cocaine, ecstasy, heroin, methamphetamines, and hallucinogenic drugs (YRBS, 2011). With respect to race and ethnicity, white students were more likely than their minority counterparts to smoke cigarettes on a daily basis and use smokeless tobacco products, while African American and Hispanic students were more likely to have had their first drink before age thirteen, ever use cocaine and inhalants, and have used ecstasy. The YRBS (2011) acknowledges that, despite these clear demographic divisions, the research was unable to identify clear behavioral differences with respect to socioeconomic status (SES) and culture.

When identifying high-risk populations, however, SES should not be discounted despite a lack of clear outcomes in the research. The YRBS (2011) suggests that as poverty-income ratios decrease, it is likely that substance abuse, including tobacco use, increases among American youth. YRBS (2011) cites that “additional research is needed to assess the effect of specific educational, socioeconomic, cultural, and racial/ethnic factors on the prevalence of health-risk behaviors among high school students” (p. 39). The scholarly literature will, by extension, be explored for issues related to SES and substance abuse among younger populations.

Trends identified in the YRBS (2011) overtime are additionally, particularly relevant, with alcohol abuse increasing steadily since 1991 among younger students. While tobacco use has stayed relatively consistent, the percentage of students who attempted to quit smoking decreased steadily between 2001 and 2011. A notable decrease in marijuana use was detected between 2009 and 2011, with other types of drug use varying considerably from state to state; it was difficult to pinpoint nation-wide trends specific to each substance because state variability was so extreme. YRBS (2011) cites that clear division between urban and non-urban locales were evident with respect to substance abuse, rendering urban populations of young students particularly vulnerable to many high-risk behaviors. Specifically, the average percentage of students from non-urban locales who have ever smoked cigarettes was 23.1%, with urban students being 59.5%. The percentage of non-urban students who ever drank alcohol was 35.1%, with urban averages totaling over 75% on average. Similar disparities are evident with respect to marijuana use (19.6% versus 46%), cocaine (1.5% versus 9.3%), ecstasy (2.7% versus 16.4%), heroin (.8% versus 5.3%) and methamphetamines (1.3% versus 6.9%).

The YRBS (2011) data suggest that tobacco, alcohol, marijuana, and cocaine are among the most prevalent substances abused by American youth, with interventions ideally considering additional disparities between urban and non-urban areas and with respect to gender and race/ethnicity. Particularly notable is the higher percentage of substance abuse among urban populations in general, with white males being particularly susceptible to tobacco usage. The YRBS (2011) suggests trends toward greater alcohol consumption in general but particularly among Hispanic and African American populations; this suggests the need for culturally competent interventions for these, particularly minorities. The YRBS (2011) concludes by citing that it seeks to fulfill the following goals:

[YRBS] provides ongoing, systematic monitoring of youth risk behaviors at the national, state, and local levels. During the preceding 20 years, analysis and interpretation of YRBSS data have been instrumental in planning, implementation, and evaluation of public health and school-based policies and practices. Additional support for YRBSS will ensure data on priority risk behaviors are available to enhance and inform future efforts to protect and promote the health of youth (p. 164).

This study sources YRBS (2011) data to acknowledge the dominant risk-behavior trends among American youth in order to identify primary themes and inform meaningful interventions. The following section explores the relationship between the YRBS (2011) data and quality of life literature, particularly with respect to culturally competent interventions for the most at-risk populations. WHO (2011) data, additionally, will be reviewed in order to compare trends in the United States to those within the global community.

WHO Data and Substance Abuse in the Global Community

WHO (2011) posits that between 155 and 250 million individuals within the global population abused various substances inclusive of cannabis, cocaine, opiates, non-prescribed medications, and amphetamines; this constitutes between 3.5% and 5.7% of the worldwide community. Most used among the global community is cannabis, abused by between 129 and 190 million, with amphetamines ranking second among the global community. WHO (2011) asserts that cocaine and opiates are additionally commonplace:

The use of psychoactive substances causes significant health and social problems for the people who use them, and also for others in their families and communities. WHO estimated that 0.7% of the global burden of disease in 2004 was due to cocaine and opioid use, with the social cost of illicit substance use being in the region of 2% of GDP in those countries which have measured it. We know what can and needs to be done to help reduce the burden of psychoactive substance use. Therefore, WHO is committed to assisting countries in the development, organization, monitoring and evaluation of treatment and other services.

Additional statistics from WHO (2011) highlight that alcohol leads to 2.5 million deaths annually, with 320,000 individuals aged fifteen through twenty-nine dying from alcohol-related causes; this means that 9% of all deaths among this age group in the world are due to alcohol. Injectable substances are problematic in 148 nations worldwide, contributing significantly to high levels of HIV/AIDS.

WHO (2011) identifies street children as one of the most vulnerable populations around the world with respect to substance abuse, with statistics reflecting that between 25% and 90% of all children living in unstable or on-the-street home environments abusing substances. WHO (2011) defines substance as “any psychoactive material which when consumed affects the way people feel, think, see, taste, smell, hear or behave;” the organization posits further that substances can be legal, including alcohol and cigarettes, or illegal including heroin and cannabis. Moreover, the legality of substances varies considerably from nation to nation.

Unlike the YRBS (2011) data which is purely quantitative in nature, the data sourced from WHO (2011) aims to identify the relationship between vulnerability factors among youth in the global community and substance abuse, both in its onset and sustained abuse. WHO (2011) identifies stress, normalization of certain behaviors relative to substance abuse, the impact of behaviors and situations, certain attachment conditions, skills, and resources as vulnerability and protective factors that affect the likelihood that a child will engage in substance abuse.

WHO (2011) classifies the same substances as YRBS (2011), affording attention to alcohol and tobacco in addition to psychoactive substances. The organization qualifies their definition of psychoactive substances as follows: “The types of psychoactive substances street children use can be many and varied and it may be difficult to determine what substances they are using. Substances that are sold on the market can be identified by their generic name. This is the standard name used throughout the world” (p. 2). The following descriptions offered by WHO (2011) regarding the types of psychoactive substances are more in-depth than those offered by YRBS (2011), with the latter organization operating solely in the United States and therefore having more narrow definitions for substances than those which must apply to the global community at large.

Opiates are classified as any substances which can be framed as analgesics, alleviating physical pain or depressants; these can be opiates derived synthetically or from poppies. Codeine, heroin, morphine, opium, methadone, and synthetic opiates are described by WHO (2011) as the most prevalent examples of opiates in the global community. As a substantial and growing problem among American youth, opiates are of concern for this present study.

Hallucinogens are described by WHO (2011) as a substance that alters not only an individual’s mood but also his/her perceptions. In changing the way the user perceives his/her surroundings, body, and other internal and external forces, hallucinogens are particularly dangerous. Like opiates, hallucinogens are both naturally occurring and chemically produced, with Lysergic Acid Diethylamide (LSD) being the most common. Mescaline, psilocybin mushrooms, phencyclidine (PCP) are the most used hallucinogens in the global community after LSD, many of which are legal in certain nations and used for religious purposes.

As the most used substance worldwide, cannabis grows naturally in many nations around the world. WHO (2011) describes cannabis as follows: “Preparations containing different concentrations of cannabis are consumed. Marijuana: the leaves and flowers of the marijuana or hemp plant. Hashish (oil and resin): these forms of cannabis are made from the resin of the flowering heads of the plant; Tablets containing THC (Tetrahydrocannabinol, the main active ingredient in cannabis)” (p. 5). Critical is it to note that cannabis is legal in many nations throughout the global community and surrounded by significant controversy with respect to its addictive nature.

Hypnosedatives diverge from opiates for several reasons, having their own classification according to WHO (2011). Most notably, they are synthetically made and do not occur naturally. With many varying substances falling under this categorical umbrella, the common thread between them is their ability to subdue the physical nervous system. Many hypnosedatives are legal in nature, abused in the form of non-prescribed pills. Xanax, Valium, Rohypnol, Serepax, Normison, and Pentobarbital represent the most common hypnosedatives abused in the global community.

Stimulants, in contrast to hypnosedatives, enhance nervous system activity, with multiple legal stimulants consumed worldwide; these include caffeine found in tea, chocolate, certain sodas, and coffee. Cocaine, produced from leaves from the coca plant, and amphetamines represent common examples of illegal substances, with amphetamines varying significantly around the world. Diet pills, ecstasy, and khat represent common stimulants, all of which are affected by a wide spectrum of street names and additives; this renders it difficult for WHO (2011) and other organizations to pinpoint precisely which substances are most harmful and common in the global community. Additionally, the dynamic nature of synthetic substance production renders it critical that WHO (2011), the CDC, and other world health organizations continually research substance abuse in the global community.

Finally, WHO (2011) identifies inhalants and a miscellaneous category for substance abuse, with the former including widely available products such as gases and aerosols; these conclude butane, petrol, and paint thinners. The miscellaneous category is described by WHO (2011) as follows:

Some substances do not neatly belong in any of the categories above. Kava: a drink made from the roots of a shrub, which is used in the South Pacific for social and ceremonial purposes. Betel nut: this substance is the seed of an Asian palm tree. It has been noted through the WHO project on substance use among street children that street children claim that inhaling through a wet carbon paper, inhaling vapour produced by a mixture of fibre matting and boiling toothpaste, inhaling fumes from burning insects, and inhalation of raw sewerage can produce desired effects. Efforts should be made to learn about the types of substances that are being used by the street children locally. This information could be obtained from specialists in your community, such as pharmacists and medical personnel. The specialists may provide samples of the products so that you are familiar with them (p. 4).

Additionally, rendering empirical assessments of substance abuse among youth within the global community is the wide spectrum of usage methods; these include chewing, swallowing, placed on mucous membranes, rubbed onto the skin, injected, smoked, and inhaled.

WHO (2011) describes the negative impact of alcohol abuse as particularly detrimental for younger populations because of lower body weights, smaller livers, and greater levels of body fat which contribute to alcohol absorption. Both the immediate and long-term effects of alcohol abuse are exacerbated by a younger age. Immediate effects include reduced inhibitions, drowsiness, reduced physical coordination, blurred vision, memory impairment, slurred speech, and poor decision-making. Binge drinking’s impact on the body includes nausea, vomiting, headache, and, most negatively, coma and death (WHO, 2011). Alcohol represents one of the most detrimental substances to human health in the global community, with sustained abuse contributing to skin problems, depression, loss of appetite and consequent vitamin deficiencies, reduced sex drive, heart disease, liver damage, and long-term memory loss.

Unlike YRBS (2011) which describes a classification for tobacco, WHO (2011) labels its similar category as nicotine, highlighting the drug as the active substance found in tobacco. WHO (2011) cites that once a younger individual begins using tobacco, s/he is likely to continue its use for a sustained period of their life. Immediate effects of tobacco use include alertness, blood pressure surges, dizziness, reduced appetite, and nausea. The long-term impact of tobacco use is far more alarming, with WHO (2011) listing these effects as follows: “Heart and lung disease, blockage of arteries (peripheral vascular disease), high blood pressure, breathing difficulty, cancer of the lung (with cigarette smoking) and cancers of the mouth (with pipe smoking and tobacco chewing) may occur” (p. 8). Tobacco is legal in most nations and represents one of the most dangerous substances in the global community, with younger populations who engage in tobacco use very likely to continue and experience the long-term effects of the substance.

Opiates’ short-term and long-term effects are markedly damaging to younger populations as well, with the immediate impacts of opiates, both naturally derived and artificial, including dreamy and detached feelings, fatigue, nausea, vomiting, depression, constipation, loss of consciousness, and death (WHO, 2011). Dependence on opiates is highly likely after only a few usages, with addiction developing very quickly for young populations. WHO (2011) cites that addiction is the most dangerous effect of most opiates, as the body is unable to sustain use for a long period of time.

Less problematic on a global scale are hallucinogens, with immediate effects including shifts in perception with respect to the senses; these effects can be unpleasant and induce panic and confusion. The drug itself affects the ways in which sensory information is received and processed in the brain, with the precise experience impacted by the context in which the hallucinogen is taken. WHO (2011) describes the long-term effects of hallucinogens as unique “flashbacks” through which the user experiences the same initial effects of the drug long after it was taken, with sustained use of hallucinogens resultant in memory loss, depression, and a wide spectrum of alternative health issues.

The short- and long-term impacts on users by cannabis are particularly contested within the literature, with WHO (2011) citing that immediate effects include euphoria, relaxation, and a general sense of calm; this depends on the user and the dosage. Inhibition loss, increased heart rate, increased appetite, and loss of motor coordination are also immediate effects, with long-term effects including memory impairment and loss of concentration. WHO (2011) cites there “there is no evidence that using cannabis occasionally in small quantities causes any significant long-lasting health problems” (p. 5). However, significant evidence suggests that cannabis use is likely to parallel the use of other drugs (YRBS, 2011).

Hypnosedatives, conversely, have significant effects after sustained use, but these effects vary considerably according to the type of drug. Generally, slowed movements, inability to concentrate, slowed thinking, sleepiness, and lack of coordination characterize the use of hypnosedatives, with all these effects bolstered if alcohol is used in parallel. Sustained use of hypnosedatives leads to dependence, memory problems, inability to learn, and delirium (WHO, 2011).

In contrast to hypnosedatives and opiates, stimulants make the user feel energetic and confident; they decrease appetite and are often used to battle fatigue. Overdoses of stimulants are very common, making the individual feel irritable and anxious. Long-term effects of amphetamines and cocaine lead to sustained inability to sleep, hallucinations, and, on the most severe end of the spectrum, significant mental health problems (WHO, 2011).

Inhalants are associated with markedly short-duration feelings of euphoria, with the most detrimental short-term effect being sudden sniffing death in the event of an overdose. Sustained usage is associated with nose bleeds, rashes around the mouth and nose, appetite loss, liver toxicity, and break down in the heart and brain functioning (WHO, 2011). Inhalants are not a significant problem in the global community but are cited by YRBS (2011) as increasingly popular in certain states in the United States.

A critical point asserted by WHO (2011) with respect to youth in the global community is that younger populations tend to be impacted not by a single substance but by a wide spectrum of substance abuse, classified as polysubstance use; common combinations vary according to nation, with WHO (2011) describing this phenomenon as follows: “In developed countries, this often includes using alcohol, nicotine, opiates, stimulants, hypnosedatives, hallucinogens and inhalants. The combined use of substances makes the assessment of substances that the child is using more difficult. In addition, it complicates the process of detoxification or withdrawal. A combination of substances increases the risk of overdose and thus the chances of accidents, death, violence and suicide” (p. 11). WHO (2011) cites that polysubstance abuse is common among younger populations in the global community, particularly capable of exacerbating specific risk factors including malnutrition.

Socioeconomically challenged children in the global community are already impacted by malnutrition which is associated with a wide spectrum of health issues. Alcohol abuse, however, impedes the absorption of certain vitamins and minerals, thereby affecting the amount of nutrition garnered from already limited food intake (WHO, 2011). In addition to malnutrition, young people with mental health issues, more common among socioeconomically challenged populations, are detrimentally impacted by polysubstance abuse. Schizophrenia is significantly exacerbated by hallucinogens and the sustained use of other types of drugs.

WHO (2011) highlights that younger populations experiencing conditions of social immobility, and residentially challenged youth, are vulnerable to substance abuse due to its ability to extricate them from their problems temporarily. WHO (2011) cites that the very problems from which the younger user attempts to escape are usually rendered fair use by the substance abuse, particularly if it is sustained over a period of time. Notably, there are divergent reasons for substance abuse among young populations in developed and developing nations. WHO (2011) describes children in developing nations “who use substances often do not fit the stereotype of an adolescent substance user in the developed world who tends to be unhappy, insensitive and disrespectful. Young substance users on the street are often cheerful, affectionate, and respectful of authority. They do not use substances because they reject mainstream society, but rather because they have lost their place in it” (p. 18). The role of stress in the lives of substance-abusing children is often a prominent one, both in developing and developed nations, with sources of stress varying significantly from individual to individual.

Major life events, for instance, constitute a major stress source, including the death of parents, abandonment, war and civil conflict, disasters, and sexual assault, with substance abuse aiming to lessen the pain associated with these experiences. More often, it is enduring strains of events in the lives of young substance users that serve as the primary stressors. WHO (2011) defines these issues as long-term problems such as poverty, illness, rejection by family members, psychological issues, and physical pain. Life’s transitions and conditions specific to the adolescent and teen years tend to significantly high levels of stress that demand adequate coping mechanisms; in the absence of these, substances are used as an escape mechanism.

Recovery Methods

Current psychological research into the treatment of adolescent substance abuse strongly encourages adolescent-specific intervention as opposed to putting an adolescent into adult substance abuse treatment. Under older methodologies, adolescent substance abusers were thrust into adult treatment centers and/or subjected to intense “breaking down” as part of some intervention strategies. Additionally, adolescents tend to be motivated by specific strategies that appeal to their deference toward peers (Winters, Botzet, & Fahnhorst, 2011). The findings of Winters et al. echo the previously cited research by Sporth et al. in its suggestion that family therapy combined with school/social intervention. Regardless, available interventions can be combined for effectiveness and tailored to the specific needs of the adolescent and their substance abuse problem (Winters, 2011). These interventions begin with education and include both inpatient and outpatient care.

Nevertheless, an intensive inpatient facility might be too expensive or simply unavailable for low-income or fixed-income families. In such cases, various twelve-step programs are available in most cities for no charge. The main issue with the twelve-step model is that it is not adolescent-specific and, in fact, may delay cessation of substance abuse in some subjects. Since adolescent treatment appears to be more successful with family involvement, twelve-step programs might be a bit too insular to be effective.

Prevention

The foundation for all treatment (therapy, inpatient, outpatient, etc.) begins with education for both the abuser and their family. This educational aspect is one reason why a comprehensive evidence-based program is so very crucial for both schools and interested adolescent-focused organizations.

More controversially, medical marijuana has even been suggested as a form of diversion therapy for adolescent substance abuse (Thurstone, Lieberman, & Schmiege, 2011). This medical marijuana intervention is extremely problematic in that it would just be ‘masking’ one form of substance dependence with another. It also neglects to consider the serious legal ramifications involving the federal designation of marijuana as a schedule 1 substance.

Conclusion

Despite voluminous research and varying degrees of social pressure, adolescent substance abuse has remained a public and private hazard for decades. The review of the current literature relating to adolescent substance abuse has assumed major studies (e.g., WHO, YRBS and MTF) as the foundation for exploring various substances, interventions, and outcomes.

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