Epidemiology of Youth Drug Abuse

Research Findings from September, 1999 Director's Report

This section lists selected summaries from NIDA funded research projects that investigate the epidemiology, etiology, and prevention research. The summaries provided were selected from recent issues of the Director's Report to the National Advisory Council on Drug Abuse. For a more comprehensive listing of NIDA funded projects see the Director's Report.

In the Past 6 Months

Despite the leveling epidemic, consequences of cocaine use have increased among aging users in some cities; increases among younger age groups in some indicators in several areas have been reported recently. New heroin use among young populations continues to be reported in several cities; in general, prices continue to decline as purity increases.

Marijuana indicators continue to escalate across the country.

Use of "Club drugs," especially GHB and MDMA, continue to be reported across the country.

Despite its appearance in midwestern and southern rural areas, abuse of methamphetamine remains a predominantly western problem; however, indicators suggest declines in some areas.

The 46th meeting of the Community Epidemiology Work Group (CEWG) was held in Vancouver, British Columbia, Canada on June 8-11, 1999.

The CEWG, established by NIDA in 1976 is a network of researchers from 21 U.S. metropolitan areas and selected foreign countries which meets semiannually to report surveillance data and discuss the current epidemiology of drug abuse. The following are highlights of the 46th meeting:

Cocaine - Cocaine remains the Nation's dominant drug problem, driven mainly by aging users who continue to experience adverse consequences. Recent indicators show a mixed picture. Mortality figures increased in six cities (Chicago, Detroit, Honolulu, Phoenix, San Francisco, and Seattle) and declined or remained stable in four (Miami, Minneapolis/St. Paul, Philadelphia, and San Diego). Emergency department (ED) mentions increased significantly in four cities (Atlanta, Dallas, Philadelphia, and Washington, DC) and declined significantly in one (San Francisco). The largest shift was a 46-percent increase in Dallas. Nonsignificant increases were reported in the majority of the other cities. Among treatment admissions, cocaine (including crack) is now the foremost primary drug of abuse (excluding alcohol-only but including alcohol-in-combination) in only 8 of the 21 CEWG areas. Among adult arrestees, cocaine-positive urinalysis percentages declined in the majority of cities, especially among males in Chicago, New York City, and St. Louis, and among females in St. Louis; percentages increased, however, for males in Philadelphia and Detroit and for females in Houston. Increases generally corresponded to increases in self-reported powder cocaine use and declines in self-reported crack use. Among younger age groups, recent slight increases in some indicators have been reported: ED mentions in Dallas, Denver, and Phoenix; treatment admissions in Los Angeles; school survey data of Texas border youth; and arrestee urinalysis data in Atlanta, Los Angeles, New Orleans, Phoenix, and San Antonio. Changing sales strategies in some cities, such as New York, are masking cocaine activity that would normally appear on law enforcement indicators.

Heroin - Heroin indicators show mixed trends. Mortality figures1 increased in seven cities (Chicago, Detroit, Miami, Minneapolis/St. Paul, Phoenix, San Francisco, and Seattle) and declined in three (Honolulu, Philadelphia, and San Diego). Heroin ED rates2 per 100,000 population increased significantly in six cities (Atlanta, Denver, Miami, Newark, New Orleans, and Washington, DC) and nonsignificantly in another six cities; conversely, rates declined significantly in San Francisco and nonsignificantly in seven other cities. During that same time period, heroin as a percentage of total ED mentions remained generally stable, except for increases in Newark and Chicago. Heroin is now the predominant primary drug problem (excluding alcohol-only, but including alcohol-in-combination) in 8 of the 21 CEWG areas: Baltimore, Boston, Detroit, Los Angeles, Newark, New York, Phoenix, and San Francisco. Opiate-positive screens among arrestees remained relatively low and generally stable; they often involved polydrug use. Heroin purity increased4 in nearly every city, while prices generally declined. Purity increases were particularly large in Detroit, New Orleans, and Philadelphia. Younger populations are increasingly initiating heroin use in several cities, including New York, where street informants indicate a steady increase in young buyers. In Boston and other Massachusetts areas, new and younger users are reportedly progressing from snorting to injecting. A Chicago study identified a high percentage of suburban youth, particularly young women, who are injectors. Suburban heroin activity is also reported around the Baltimore area, both among youth and young professionals.

Marijuana - Marijuana now accounts for more than 10 percent of total ED mentions in 12 cities (Atlanta, Boston, Chicago, Dallas, Detroit, Los Angeles, Miami, New Orleans, Philadelphia St. Louis, San Diego, and Washington, DC), up from just 6 cities a year earlier--the result of increases2 in 7 cities; no significant declines were noted. Marijuana is the predominant primary drug treatment problem in three cities (Denver, Seattle, and Minneapolis/St. Paul). Treatment percentages decreased in New Orleans, Newark, Chicago, and Seattle and increased in San Diego. Among adult male arrestees, marijuana-positive findings were equal to or exceeded cocaine-positives in 10 cities; percentages declined substantially in 2 cities and increased in 13. In many cities, marijuana use appears to be increasing among youth, as is reflected in the percentages of juvenile arrestees testing positive for the drug: in six of the seven CEWG sites where ADAM tests juveniles, the percentage testing positive for marijuana was substantially greater than in the adult population. In Boston, cannabis is reportedly as available as alcohol, and use among adolescents is common, approaching that of cigarettes among older students. Blunt usage continues to grow or retain popularity in Chicago, Minneapolis/St. Paul, New York City, Philadelphia, and Seattle. Marijuana is combined with crack in Chicago ("primos" or "diablitos"), Philadelphia ("turbo"), and Houston (where it is a declining fad among young people); with PCP in Chicago ("wicky sticks" or "donk"), Minneapolis/St. Paul ("happy stick"), New York, Philadelphia ("loveboat" or "wet"), and St. Louis; with formaldehyde in Minneapolis/St. Paul and Seattle; with PCP plus formaldehyde in Houston ("fry," "amp," "water-water"); and with psilocybin mushrooms in Minneapolis/St. Paul. Marijuana combinations are not frequently reported in Denver, but the drug reported to be used to come down from or temper excited highs.

Stimulants - Despite its appearance in midwestern and southern rural areas, methamphetamine remains concentrated in the West. However, indicators suggest some declines in that region. Available mortality figures show methamphetamine-related deaths declined in four cities (Honolulu, Philadelphia, San Diego, and Seattle) and increased in three (Minneapolis/St. Paul, Phoenix, and San Francisco). Following increases in 1997, methamphetamine ED mentions declined significantly in six cities (Denver, Los Angeles, Minneapolis/St. Paul, Phoenix, San Francisco, and Seattle) and increased only in Dallas. Methamphetamine remains the number-one primary drug treatment problem in San Diego and Honolulu. Methamphetamine-positive percentages among arrestees remained stable across most sites, except for San Diego, where levels declined notably. Methamphetamine users are heterogeneous, consisting of many small subgroups, as suggested by ethnographic data in Atlanta. Furthermore, use patterns and contexts vary widely, depending on population, location, and history of use, as suggested by ethnographic research in Seattle. Injecting remains the predominant route of administration in several areas, including San Francisco and Denver; however, it has been declining somewhat while snorting or smoking have been increasing. Mexico remains the source of methamphetamine for many areas; however, local clandestine methamphetamine labs also proliferate in several areas, including parts of Arizona, Minnesota, Texas, and Washington State.

Methylenedioxymethamphetamine (MDMA) - ("ecstasy," "blue lips," "blue kisses," "white dove,""E,"and "XTC") availability is reported, primarily as a club drug at "raves" and dance parties, in Atlanta, Austin, Boston, Chicago, Dallas, Detroit, Houston, Miami, St. Louis, Seattle, and Washington, DC. Young cohorts of users have been identified in several of those cities. Reports of increases in indicators of use of the drug continue in Boston and throughout Massachusetts. Though it is not readily available in Newark, it is becoming trendy on college campuses across New Jersey. In New Orleans, the drug is less available than crystal methamphetamine. In Austin, where it is often crushed and re- pressed with methamphetamine, psilocybin mushrooms, or LSD, three types of MDMA are available: "liquid ecstasy"; "chocolate sprinkles,"a heroin-based white pill with brown spots popular in the topless bar scene and in gay bars; and a nickel-sized wafer form. MDMA is used with methamphetamine, LSD, and marijuana in Washington, DC, where law enforcement officers recently noted increased trafficking. Methylenedioxy-amphet-amine (MDA) is reportedly available in St. Louis. Methylphenidate (Ritalin) is readily obtainable in Boston, Chicago, Detroit, and Minneapolis/St. Paul. It is crushed and snorted in Detroit and Minneapolis/St. Paul, and it is mixed with heroin instead of cocaine and injected as a "speedball" in Chicago. Phenmetrazine (Preludin) is also reportedly injected in Chicago. Despite concern about sibutramine (Meridia), a new weight loss drug, there were no reports of diversion or abuse.

Depressants - Gamma-hydroxy butyrate (GHB), a central nervous system depressant, continues to be reported across the country, with recipes for its manufacture easily accessible on the Internet. GHB has been increasingly involved in poisonings, overdoses, date rapes, and fatalities in Boston, Denver, Los Angeles, South Florida, San Diego, Seattle, and parts of Arizona and Texas. It is available at gyms, nightclubs, raves, gay male party venues, or on college campuses in Atlanta, Baltimore, Boston, Chicago, Denver, Detroit, Los Angeles, Miami, Minneapolis/St. Paul, Newark, New Orleans, San Diego, San Francisco, Seattle, and parts of Arizona and Texas. GHB is available in several forms: clear liquid, white powder, tablets, and capsules. It is used in combination with ketamine or MDMA in Detroit; alcohol in South Florida and New Orleans; and alcohol and ketamine in a "G and B" in Minneapolis. Gamma butyrolactone (GBL) is contained in commercial products (Blue Nitro, Renew-Trient, and ReVivarin); it metabolizes into GHB and produces clinical symptoms identical to GHB. The drug was responsible for overdoses, poisonings, and hospitalizations in Detroit, South Florida, Minneapolis, Newark, and in Texas, where it was also responsible for a death.

Another club drug, ketamine ("Special K" or "vitamin K") is reported in cities such as Baltimore, Boston, Detroit, Miami, Minneapolis/St. Paul, Newark, New Orleans, New York City, and San Diego. It is injected intramuscularly by young, white, middle-class needle exchange clients in Boston; converted into a white powder and snorted in Minnesota; injected, smoked, or mixed in beverages in New Orleans; and boiled down to crystal form and snorted as an alternative to cocaine in New York City. Ketamine has been responsible for deaths in New Orleans and San Diego.

Clonazepam (Klonopin or Rivotril) was recently mentioned in hospital emergencies in New York City; in Texas, it is used by juveniles in combination with beer, just as flunitrazepam (Rohypnol) has been used. Alprazolam (Xanax, or "sticks"), along with clonazepam, has replaced flunitrazepam among adolescents in Miami, where "xanax candy bars" have caused several medical emergencies. In New York City, it is the most sought-after diverted prescription pharmaceutical and has almost replaced diazepam on the street. Diazepam is the most readily available and frequently used pharmaceutical depressant on the street in Chicago; it is the leading psychoactive prescription drug in New York City ED mentions; and is injected with heroin in Seattle. Flunitrazepam is common in Atlanta, popular among hard-core heroin and cocaine users in Los Angeles, continues to be abused in New Orleans, and is beginning to emerge in treatment indicators among youth along the Texas-Mexico border. In New Jersey, flunitrazepam no longer appears to be a problem. Trazedone (Desyrel) has been involved in numerous poisonings and one death in Detroit.

Depressants are used in Chicago in combination with a variety of drugs including heroin, cocaine, methamphetamine, or alcohol. In Miami, the use of diverted Schedule III and IV medications associated with concomitant upper and downer abuse appears on the rise, with "rolling and trolling" the rage among the "young and unknowing." Benzodiazepines are used in Phoenix to reduce "the edge" from cocaine or methamphetamine.

Hallucinogens - Ethnographic, ED, law enforcement, and survey data suggest continued low-level abuse of lysergic acid diethylamide (LSD) and phencyclidine (PCP). Hallucinogen use appears to be increasing in Massachusetts, where lifetime use among students has been rising since 1994. In Chicago, primary hallucinogen admissions are increasing; LSD use in New Orleans is reportedly on the rise; the drug has sporadically reappeared in St. Louis-area high schools and rural areas. A new form of LSD appearing as a hard plastic translucent bubble pack with colors of light blue or red was reported in Detroit. In Texas, blotter acid is available on sugar cubes and triangular window panes, in a gel tab form called "jelly bean" that is popular in clubs, and in liquid form that is becoming more common around university and club scenes.

PCP use appears to be increasing in Chicago, where it is sprayed on a tobaccolike substance ("mint leaf" or "love leaf"), used as a dip on cigarettes ("sherm sticks"), or mixed with marijuana ("wicky stick" or "donk"). It appeared in 1997 ED mentions for the first time this decade in Minneapolis; a resurgence of manufacturing, mostly by African-American street gangs, is noted in Los Angeles. PCP-related ED mentions are declining in New York City, where it is available as a powder sprinkled on green mint leaves or on marijuana and as a liquid in small shaker bottles. It continues to be used as a dip on marijuana joints in St. Louis. Psilocybin mushrooms ("shrooms") were reported by Minneapolis law enforcement agencies.

Other Drugs - Dextromethorphan (DXM) abuse is reported by teens in Boston, apparently encouraged by mentions on the Internet. In addition to the readily available store-bought liquid, DXM is available in Minneapolis as a white powder packaged in clear, unmarked capsules. Use of ephedrine, nitrous oxide, and other inhalants (including propane) is reported in Detroit. One accidental death in Minnesota was attributed to inhalation of an industrial solvent, and inhalant abuse has declined among students in grades 6, 9, and 12 since 1995. Toluene "huffing" is reportedly common among white males in their preteens or early teens in Philadelphia; in Texas, use of inhalants such as liquid or spray paint and correction fluid is increasing among school students. Khat seizures continue in Detroit; khat first appeared in Minnesota in 1997, and interceptions have increased in recent years.

Cigarette Smoking Among U.S. High School Seniors

This study identified high school seniors at low, moderate, and high risk for cigarette use to examine changes in the prevalence of daily smoking within risk groups from 1976 to 1995. Data were taken from the Monitoring the Future Project's national surveys of high school seniors. Risk classification was based on grade-point average, truancy, nights out per week, and religious commitment. Logistic regression models were used to estimate trends for all seniors and separately for White (n = 244,221), African American (n =41,005), and Hispanic (n=18,457) male and female subgroups. Risk group distribution (low = 45%, moderate = 30%, high = 25%) changed little over time. Between 1976 and 1990, greater absolute declines in smoking occurred among high-risk students (17 percentage points) than among low-risk students (6 percentage points). Particularly large declines occurred among high-risk African Americans and Hispanics. Smoking increased in all risk groups in the 1990s. Among high school seniors, a large part of the overall change in smoking occurred among high-risk youth. Policies and programs to reduce smoking among youth must have broad appeal, especially to those at the higher end of the risk spectrum. An, L.C., O'Malley, P.M., Schulenberg, J.E., Bachman, J.G., and Johnston, L.D. American Journal of Public Health, 89(5), pp. 699-705, 1999.

Initial Drug Opportunities and Transitions to First Use

Researchers at Johns Hopkins University examined initial opportunities to try selected drugs and transitions from first opportunity to first use of those drugs. Target drugs were marijuana, cocaine, heroin, and hallucinogens. Investigators examined sex and race-ethnicity differences in estimates of having a drug opportunity, and in the probability of progressing from having an opportunity to try a drug to actually using the drug. Self- report interview data collected for the National Household Surveys on Drug Abuse (NHSDA) from 1979 to 1994 were analyzed. Results showed that an estimated 51% of US residents have had an opportunity to try marijuana; comparative estimates for cocaine, hallucinogens, and heroin are 23, 14, and 5%, respectively. Among those who eventually used each drug, the vast majority made the transition from first opportunity to first use within 1 year. Males were more likely than females to have opportunities to try these drugs, but were not more likely than females to progress to actual use once an opportunity occurred. Time trends indicate recent increases from 1990 to 1994 in the estimated probability of using an illicit drug once an opportunity occurs, particularly for hallucinogens. This study sheds light on the epidemiology of the earliest stages of drug involvement in the USA. Van Etten, M.L., and Anthony, J.C. Comparative Epidemiology of Initial Drug Opportunities and Transitions to First Use: Marijuana, Cocaine, Hallucinogens and Heroin. Drug and Alcohol Dependence, 54(2), pp. 117-125, 1999.

Inhalant Use and Delinquent Behavior Among Adolescents

To evaluate the association between inhalant use and delinquent or criminal behavior, an analysis of a large statewide sample survey of high school students was conducted. Five groups were identified based on reported drug use: inhalant experimenters, other drug experimenters, inhalant users, other drug users and non-users. Inhalant users were compared with other drug users and inhalant experimenters with other drug experimenters on measures of problem behavior. Over 13,000 students in grades 7-12 participated in the 1993 survey on drug use. Three measures of problem behavior were included: drinking and drug-taking, "trouble behavior", and minor criminal activity. Among upper (9-12) grade level students only, both inhalant users and inhalant experimenters reported more minor criminal activity than other drug users and other drug experimenters, respectively. A similar trend was noted for trouble behavior. The same was not found for drinking and drug-taking behavior. The findings suggest that inhalant use is categorically different from other drug use, and that it has more in common with general delinquency than with general drug use. Prevention and treatment strategies should take this into consideration. Mackesy-Amiti, M.E. and Fendrich, M. Addiction, 94(4), pp. 555-564, 1999.

High Rate of Coexisting Psychiatric Disorders among Adolescents with Substance Use Disorders in the Community

To investigate the extent to which adolescents in the community with current substance use disorders (SUD) experience co-occurring psychiatric disorders, diagnostic data were obtained from probability samples of 401 children and adolescents, aged 14 to 17 years, and their mothers/caretakers, who participated in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Results indicate the rates of mood and disruptive behavior disorders are much higher among adolescents with current SUD than among adolescents without SUD. Comparison with adult samples suggests that the rates of current comorbidity of SUD with psychiatric disorders are the same among adolescents as adults, and lower for lifetime disruptive disorders/antisocial personality disorder among adolescents than adults. The high rate of coexisting psychiatric disorders among adolescents with SUD in the community needs to be taken into account in prevention and treatment programs.. Kandel, D.B., Johnson, J.G., Bird, H.R., Weissman, M.M., Goodman, S.H., Lahey, B.B., Regier, D.A., and Schwab-Stone, M.E. Psychiatric Comorbidity among Adolescents with Substance Use Disorders: Findings from the MECA Study. Journal of the American Academy of Child and Adolescent Psychiatry, 38(6), pp. 693-699, 1999.

Flunitrazepam Becoming Health Concern to Sexually Active Young Women in Southwestern U.S.

Flunitrazepam [Rohypnol"] is a short-acting benzodiazepine with general properties similar to those of diazepam. In a cross-sectional survey to determine prevalence, patterns, correlates and physical effects of voluntary flunitrazepam use in a sample of sexually active adolescent and young women 14 to 26 years of age (N=904) using university-based ambulatory reproductive health clinics, lifetime use was reported by 5.9% (n = 53) of subjects, with frequency of use ranging from 1 to 40 times. Flunitrazepam was taken most often with alcohol (74%), and 49% took this substance with other illicit drugs. Logistic regression analyses controlling for age and race/ethnicity found that users were significantly more likely than were nonusers to report lifetime use of marijuana (odds ratio [OR] = 3.6) or LSD (OR = 5.2), having a peer or partner who used flunitrazepam (OR = 21.7), pressure to use flunitrazepam when out with friends (OR = 2.7), and a mother who had at least a high school education (OR = 2.6). Finally, 10% of voluntary users reported experiencing subsequent physical or sexual victimization. Voluntary use of flunitrazepam is becoming a health concern to sexually active young women who reside in the southwestern United States. Young women who have used LSD or marijuana in the past or who have a peer or partner who used this drug appear to be at the greatest risk. Rickert, V.I., Wiemann, C.M., Berenson, A.B. Prevalence, Patterns, and Correlates of Voluntary Flunitrazepam Use. Pediatrics 103(1), pp. E61-E65, 1999.

Drinking and Driving Among U.S. High School Seniors

This article reports the prevalence of, and trends in, driving after drinking and riding in a car with a driver who has been drinking among American high school seniors, based on data from more than a decade (1984-1997) of annual national surveys. Logistic regression was used to assess the effects of demographic factors (gender, region of country, population density, parental education and race/ethnicity) and selected "lifestyle" factors (religious commitment, high school grades, truancy, illicit drug use, evenings out per week, and miles driven per week). Rates of adolescent driving after drinking and riding with a driver who had been drinking declined significantly from the mid-1980s to the early or mid-1990s, but the declines have not continued in recent years. Rates of driving or riding after drinking were higher among high school seniors who are male, White, living in the western and northeastern regions of the United States, and living in rural areas. Truancy, number of evenings out, and illicit drug use all related significantly positively with the dependent variables, whereas grade point average and religious commitment had a negative relationship. Miles driven per week related positively to driving after drinking. O'Malley, P.M., and Johnston L.D. American Journal of Public Health, 89(5), pp. 678-684, 1999.

Different Characteristics Associated with Reported Versus Unreported Cases of Childhood Rape; Few Cases of Childhood Rape Actually Reported to Authorities

This study was to examine whether there would be differences in reported versus unreported cases of childhood rape on incident characteristics including life threat, physical injury, identity of the perpetrator, frequency of assault(s), and rates of posttraumatic stress disorder or major depression. Using a telephone interview, a national probability sample of 4,008 (weighted) adult women was screened for a history of completed rape in childhood. Respondents were also assessed for DSM-III-R diagnoses of major depressive episode and/or posttraumatic stress disorder (PTSD), and substance use. Three hundred forty-one (8.5%) of these women were victims of at least one rape prior to the age of 18, for a total of 437 completed rapes. Of these 437 rape incidents, 52 (11.9%) were reported to the police or other authorities. Significant differences were obtained between reported versus nonreported cases on incident characteristics, including life threat, physical injury, identity of the perpetrator. Reported cases were more likely to involve life threat and/or physical injury, and were more likely to have been committed by a stranger than nonreported cases. No significant differences between reported and nonreported cases were found concerning whether the rape involved a single incident versus series of events, or rates of PTSD or major depression. Findings suggest that different characteristics are associated with reported versus unreported cases of childhood rape. Hanson, R.F., Resnick, H.S., Saunders, B.E., Kilpatrick, D.G., and Best, C. Factors Related to the Reporting of Childhood Rape. Child Abuse and Neglect 23(6) pp. 559-569, 1999.