Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs



Substance Abuse - Categories/Prevalence/Etiology (B8)

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Drug use among adolescents in many countries increased dramatically in the 1960s and 1970s and while declining during the late 1970 and 1980s increaseing again in the 1990s. Drug use and abuse patterns change from year to year, from country to country and within a country from geographic area to geographic area. It is important for a clinician to have a sense of what are the important drugs of use and abuse among youth in their area of practice.

In the United States :

  • In 2000, it was estimated that 54% of American youth tried an illicit drug before they finish high school.
  • By the 12th grade nearly one-third (29%) of adolescents have used illicit drugs other than marijuana.
  • About 2.9% of high school seniors drink alcohol daily (2000), and when surveyed, 30.0% had had five or more drinks in a row at least once in the previous 2 weeks.
  • One of the largest increases in drug use was for MDMA (ecstasy).


(Per American Medical Association Council on Scientific Affairs Task force of the Panel on Alcoholism and Drug Abuse)

  • Drug abuse: Any use of drugs that causes physical, psychological, economic, legal, or social harm to the individual user or to others affected by the drug users behavior.
  • Drug intoxication: Changes in physiological functioning, psychological functioning, mood states, cognitive processes, or all of these, as a consequence of excessive consumption of a drug; usually disruptive.
  • Drug addiction: Chronic disorder characterized by the compulsive use of a substance resulting in progressive physical, psychological, or social harm to the user and by continued use despite that harm.
  • Psychological dependence: The emotional state of craving a drug either for its positive effect or to avoid negative effects associated with its absence.
  • Physical dependence: A physiological state of adaptation to a drug, usually characterized by the development of tolerance to drug effects and the emergence of a withdrawal syndrome during prolonged abstinence.

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  • Cannabinoids: Cannabinoids include marijuana and hashish.
  • Depressants: Depressants include sedatives and minor and major tranquilizers.
  • Sedatives: Drugs that reduce anxiety and induce sleep. Sedatives can lead to physical and psychological dependence.
  • Alcohol
  • Barbiturates (amytal, nembutal, seconal, phenobarbital)
  • Methaqualone (Quaalude, no longer legally available)
  • Glutethimide (Doriden)
  • Flunitrazepam (Rohypnol)
  • Gamma-hydroxybutyrate (GHB)
  • Minor tranquilizers: Drugs that reduce anxiety including diazepam (Valium), alprazolam (Xanax), and chlordiazepoxide (Librium), triazolam (Hlcion), lorazepam (Ativan). Physical and psychological dependence commonly occurs with these drugs.
  • Major tranquilizers: This group includes the phenothiazines, such as thioridazine (Mellaril), trifluoperezine (Stelazine), and chlorpromazine (Thorazine).
  • Stimulants: Stimulants cause increased alertness and activity. They also produce tolerance and strong psychological dependence. Subgroups include:
  • Amphetamines: including clandestine methamphetamine (“speed”), pharmaceutical methamphetamine (Desoxyn) and amphetamine (Biphetamine, Adderil, Dexedrine)
  • Nicotine
  • Caffeine
  • Cocaine
  • MDMA, “ecstasy” (methyenedioxymethamphetamine) – has both stimulant and hallucinogenic properties
  • methylphenidate (Ritalin)
  • Betel Nut
  • Hallucinogens: These drugs affect sensations, emotions, and awareness, causing distortion of perceived reality. They can produce tolerance and psychological dependence but no physical dependence. This category includes: LSD (D-lysergic acid diethylamide), mescaline, DMT (dimethyltryptamine), DOM (2.5-dimethoxy-4-methylamphetamine), PCP (phencyclidine hydrochloride), psilocybin/psilocin, MDA (methylene dioxyamphetamine), and MDMA (methylene dioxymethamphetamine).
  • Opioids and morphine derivatives: Opiates are used to relieve pain. They produce tolerance and strong physical and psychological dependence. This category includes morphine, heroin, codeine, meperidine (demerol), methadone, fentanyl and opium.
  • Dissociative Anesthetics: This group includes ketamine (ketalar SV) and phencyclidine (PCP) and analogs
  • Volatile solvents: These drugs have a general depressant effect on the central nervous system and may create hallucinogenic experiences. They include solvents (paint thinners, gasoline, glues), gases (butane, propane, aerosol propellants, nitrous oxide), and nitrites (isoamyl, isobutyle, cyclohexyl). They can produce tolerance and psychological dependence but no true physical dependence.
  • Anabolic-androgenic steroids: These drugs are synthetic derivatives of testosterone, engineered by chemists to have a longer half-life (testosterone activity is measured in minutes) and less androgenic activity.

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Several excellent resources are available to follow drug use in the United States . These include:

  • Monitoring the Future : Monitoring the Future is a long-term study of American adolescent, college students and young adults. The study is conducted by the University o0f Michigan 's Institute for Social Research and includes approximately 50,000 students from 400 public and private high schools and a total of 1200 college students and 11,000 young adult post-high school graduates. Information is accessible at:
  • Youth Risk Behavior Surveillance (YRBS ): the YRBS is conducted every two years and monitors six categories of priority health-risk behaviors among youth and young adults that contribute to unintentional and intentional injuries including tobacco use, alcohol and other drug use. Summary of this information for 2001 is available at:
    General YRBS information is available at:
    The YRBS survey also interviews students in school and not students who have dropped out.
  • National Household Survey on Drug Abuse (NHSDA) : This survey is conducted by the Department of Health and Human Services. The survey is available at:

Examples from other countries include:

Health Behaviour in School-aged children: A World Health Organization Collaborative Cross-national Study (HBSC)

This study is a cross-national research study conducted in collaboration with the WHO Regional Office for Europe to gain new insight into and increase understanding of young people's health and well-being, health behaviours and their social context. This comprehensive survey of 11, 13 and 15 year olds is carried out every four years in a growing number of countries and used to investigate health issues within and across participating counties. The 36 member countries/regions include:

Austria, Belgium (French and Flemish speaking), Canada, Croatia, Czech Republic, Denmark, England, Estonia, Finland, France, Germany, Greece, Greenland, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Macedonia, Malta, Netherlands, Norway, Poland, Portugal, Russian Federation, Scotland, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Ukraine, United States, Wales.

Areas covered include demographics, health related behaviors such as tobacco use, alcohol consumption, medication use, exercise patterns, eating patterns, general perceptions of personal health, psychosocial adjustment, peer relations and support, and perceptions of the school and its influence. The study was conducted in 1994/95, 1997 and 1998 and 2001/2002. The latest survey data will be available and published in late 2003. The total sample was 123,227 adolescents in the 1997/98 survey.

More complete information is available at:

The 1997-1998 report is at:

Some information on the substance use data includes:


  • Countries with highest rates of students trying cigarettes at age 15 were Greenland, Finland, Slovakia, Latvia, and Hungary. The lowest prevalence was in USA, Belgium, Portugal, Greece and Israel.
  • Highest rates of daily smoking at 15 years of age were Greenland, Germany, Hungary, France and Austria while the lowest were USA, Estonia, Israel, Portugal and Lithuania. The highest median number of cigarettes smoked weekly was in Greece, Greenland, Northern Ireland, Scotland and Wales.
  • Factors most associated with tobacco experimentation included spending more evenings with friends, drinking and being drunk.

Drinking Alcohol

  • Countries with highest rates of students reporting weekly use of beer, wine or spirits at age 15 were Wales, Denmark, England, Greece and Scotland while the lowest were Norway, Sweden, Greenland, Lithuania and Finland.
  • Highest rates of reporting being drunk twice or more often were in Denmark, Wales, Greenland, England, Finland and Scotland while the lowest rates were in France, Portugal, Greece, Switzerland and Israel.
  • Factors most associated with tobacco experimentation included spending more evenings with friends, drinking and being drunk.


Catalonia Adolescent health survey 2001 , Joan-Carles Suris I Granell and Nuria Parera I Junyent

This survey includes nearly 7,000 youth aged 14-19 years.

Drug use : Cigarettes and alcohol: 32% of females were daily smokers and 21% of males, 30% of males drink on weekends and 26% of males. Over 10% of males have tried a synthetic drug and about 8% of females.

Health Status and risk behavior in the North of Madrid, Spain . Journal of Adolescent Health, 2000, 27:351-360. Hidalgo I. , Garrido G, Hernandez M.

Evaluated an anonymous self-administered questionnaire by 2,831 pupils aged 14-20 years from urban, suburban and rural populations in the north of Madrid .

Drug Use: Eighty-five percent had tried alcohol and regular use (frequently or every day) was as high as 24%. Males drank more than females (28% vs. 20%); 58.2% of the population drank only during weekends. Seventy percent of the sample had smoked at least once; 34.5% reported regular tobacco use. Males smoked less than females (27% vs. 42%); 3.2% smoked more than 20 cigarettes/day. The consumption of illegal drugs was very low (20% had tasted cannabis and use by males was higher). Cocaine, heroin, etc, were used by less than 5%.

Drug use among adolescent in Asturias , R. Hinojal Fonseca, Jjbobes Garcia, E hevia Rodriguez.

A survey of drug use, based on a sample of 2,537 school students in the 15 - 17 year age group selected from 11 schools in central Asturias ( Spain ). 29.1% were drug users. Cannabis was the most widely abused drug: 500 respondents, or 20.8 per cent of the total sample, became involved with this drug at some time in their lives. The percentages of the total sample show that the use of cannabis at any time ("ever" use) was followed by use of: tranquilizers (10.3%), amphetamines and amphetamine-like substances (7.9%), inhalants (2.3%), hallucinogens (2.0%), sedatives (1.7%), opiates (1.4%) and cocaine (1.2%). Males were generally more involved with drugs than females were. The average age at first drug use was 15.4 for males and 15.5 for females.

UK : The British Household Panel Survey:

British Columbia, Canada : Adolescent Health Survey:

United States Data

Cigarette Use

In spite of all the new information concerning the negative health consequences of tobacco use, the addictive properties of nicotine, and the misinformation of the Tobacco Industry, use of tobacco products by adolescents increased significantly in the early and mid-1990s, although rates have started to decline in the past few years. For example, use in the past month declined from 17.5% in 1999 among 8 th graders to 14.6% in 2000 in the Monitoring the Future Study. Similar drops were found in 10 th and 12 th graders. In addition, perceived risk of harm from smoking a pack or more of cigarettes per day increased among high school students. However, still nearly 63% of teens have tried cigarettes by the 12 th grade and almost one-third (31%) are current smokers.

Alcohol Use

Alcoholic drinks have been the most widely used substances by adolescents and adults for many years. In the MTF survey, alcohol use remained stable over the past several years through the year 2000.

Marijuana Use

Marijuana use rose sharply until about 1979, at which point the use seemed to peak. The trend toward declining use persisted until 1992, when a sharp reversal developed. This reversal continued until about 1996 in 8 th graders and 1997 in 10 th and 12 th graders. Since then there has been a modest decline through 2000. For all 25 years of the Monitoring the Future survey, marijuana was the most widely used illicit drug.

Other Drugs

According to the 2000 Monitoring the Future survey, 29% of the year 2000 high school seniors had used some illicit drug other than marijuana (23.1% of 10 graders and 15.8% of 8 th graders). Other than marijuana, the most prevalent illicit drugs used by adolescents include stimulants, inhalants, cocaine, hallucinogens, tranquilizers, and sedatives. One of the most frequently used illicit drugs other than marijuana in the year 2000 was ecstasy.


Attitudes about the potential risks to users have shown a tendency toward decreasing perceived risk. However, the great majority of high school seniors do not approve of the regular use of any illicit drug.

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Adolescent substance abuse is a complex phenomenon that includes diverse drugs, diverse usage patterns and differing etiologies. Recent research has explored both risk and protective factors and multiple etiological pathways particularly biologic. There is increasing information that addiction is a central nervous system disease with specific structural and/or functional changes within the brain that are genetically determined but triggered by particular substances.

Stages of Drug Use

MacDonald (1987) suggested five stages of adolescent substance abuse, as follows:

Stage 0: Showing curiosity.

Stage 1: Learning about the drug-induced mood swings. The teen learns more about use of drugs, but use is limited to group settings, usually on weekends. Peer pressure is frequently intense and is a prime reason for continuance.

Stage 2: Seeking the drug-induced mood swings . Having learned that these drugs can alleviate perceived pain and anxiety, the adolescent now seeks the highs of drug use. The teen may acquire a supply of drugs and paraphernalia. The drugs are now used more to relax than as part of the social scene. The teen becomes a regular weekend and occasional weekday user. There may be a decrease in school performance and abandonment of extracurricular interests.

Stage 3: Being preoccupied with the drug-induced mood swings. The teen loses control of his or her life and is concerned only with getting high. The behavioral changes are more pronounced and more obvious. New behaviors may also include stealing, school truancy, and lying. Drug dealing, to obtain the money necessary for continued drug use, may start.

Stage 4 : Burnout. At this point the teen is using drugs just to feel normal. Drugs may no longer produce euphoria. "Zombies" and "space cadets" are common terms used by adolescents to describe this group.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.