DRUG DEPENDENCE DISORDER AND DRUG USE TRENDS (SUMMARY OF DOCUMENTS)

PART I DRUG DEPENDENCE DISORDER

I. BASIC CONCEPTS Drug use occasional use strongly influenced by environmental factors. Drug use implies intake for non-medical purposes, it may be or not may be accompanied by clinically significant impairment or distress on a given occasion. Drug use is not considered a medical disorder either by DSM - IV 4th edition or ICD-10. Drug abuse According to DSM-IV, drug abuse is characterized as including regular, sporadic, or intensive use of higher doses of drugs leading to social, legal or interpersonal problems. ICD-10 identifies a nondependent but problematic syndrome of drug use and calls it harmful use instead of abuse. That syndrome is defined as use resulting in actual physical or psychological harm. Drug dependence (or addiction) is characterized in both DSM-IV and ICD-10 as drug seeking behavior involving compulsive use of high doses of one or more drugs, either licit or illicit, for no clear medical indication, resulting in substantial impairment of health and social functioning. Dependence is usually accompanied by tolerance and withdrawal. Like drug abuse is generally associated with a wide range of social, legal, psychiatric and medical problems. Unlike patients with chronic pain or persistent anxiety, who take medication over long periods of time to obtain relief from a specific medical or psychiatric disorder (often with resulting tolerance and withdrawal), persons with dependence seek out the drug and take it compulsively for non medical effects. As a consequence of its compulsive nature involving the loss of control over drug use, dependence (or addiction) is typically a chronically relapsing disorder. Although individuals with drug dependence can often complete detoxification and achieve temporary abstinence, they find it very difficult to sustain that condition and avoid relapse over time. Tolerance refers to the situation in which repeated administration of a drug at the same dose elicits a diminishing effect or involves the need for an increasing dose to produce the same effect. Tolerance occurs when certain medications are taken repeatedly. With opiates for example, it can be detected after only few days of use for medical purposes such as the treatment of pain. If the patient suddenly stops taking the drug, a withdrawal syndrome may occur. Physicians often confuse this phenomenon, referred to as physical dependence with true addiction. Withdrawal Is a syndrome characterized by physical or motivational disturbances when the drug is withdrawn. It is important to emphasize that the phenomena of tolerance, dependence and withdrawal are not associated uniquely with drugs of abuse since many medications used clinically that are not addicting (clonidine, propanodol, tricyclic antidepressants) can produce these types of effects. Addiction and dependence For some scientists the proper terms for compulsive drug seeking is addiction, rather than dependence. In their view, addiction more clearly signifies the essential behavioral differences between compulsive use of drugs for their non-medical effects and the syndrome of physical dependence that can develop in connection with repeated medical use. In response, many scientists argue that dependence has been defined in both ICD-10 and DSM-V to encompass the behavioral features of the disorder and has become the generally accepted term in the diagnostic nomenclature. Moreover, some scientists object the term addiction because it is associated with stigmatizing social images and argue that a less pejorative term would help to promote public understanding of the medical nature of the condition.

II. DIAGNOSTIC CRITERIA Diagnostic Criteris According to DSM-IV 4th revision Substance abuse Considers the following criteria: A. A maladaptive pattern of substance abuse leading to clinically significant impairment or distress, as manifested by one (or more) of the following , occurring within a 12-month period: 1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home (e.g. repeated absences or poor work performance related to substance abuse; subtance-related absences, suspensions, or expulsions from school, neglect of children or household). 2) Recurrent substance use in situations in which it is physically hazardous (e.g. driving an automobile or operating a machine when impaired by substance abuse). 3) Recurrent substance-related legal problems (e.g. arrests for substance-related disorderly conduct). 4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g. arguments with spouse about consequences of intoxication, physical fights). B. The symptoms have never met the criteria for Substance Dependence for this class of substance. Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following occuring at anytime in the same twelve-month period: 1) Tolerance, as definedby either of the following: a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the same amount of the substance 2) Withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance b. the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms 3) The substance is often taken in larger amounts or over a longer period than was intended 4) There was a persistent desire or unsuccessful efforts to cut down or control substance use. 5) A great deal of time is spent in activities necessary to obtain the substance (e.g visiting multiple doctors or driving long distances), use the substance (e.g. chain smoking) or recover from its effects. 6) Important social, occupational, or recreational activities are given up or reduced because of substance use. 7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by the substance (e.g. current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an uler was made worse by alcohol consumpotion). Specifiy if: With physiological dependence: evidence of tolerance or withdrawal (e.g. either item 1 or 2 is present) Without physiological dependence: No evidence of tolerance or withdrawal withdrawal (e.g. neither item 1 nor 2 is present)

Diagnostic Criteria for Harmful Use and Dependence (ICD-10) Harmful Use: A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (as in cases of hepatitis from the self- administration of injected drugs) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol). Diagnostic guidelines The diagnosis requires that actual damage should have been caused to the mental or physical health of the user. Harmful patterns of use are often criticized by others and frequently associated with adverse social consequences of various kinds. The fact that a pattern of use or particular substance is disapproved of by another person or by the culture, or may have led to socially negative consequences such as arrest or marital arguments is not in itself evidence of harmful use. Acute intoxication or hangoveris not in itself sufficient evidence of the damage to health required for coding harmful use. Harmful use should not be diagnosed if dependence syndrome, a psychotic disorder , or another specific form of drug-or alcohol-related disorder is present. Dependence Syndrome Diagnostic guidelines A definite diagnosis of dependence should usually only be made if three or more of the following have been experienced or exhibited at same time during the previous year: 1) A strong desire or sense of compulsion to take the substance. 2) Difficulties in controlling substance-taking behavior in terms of its onset, termination or levels of use. 3) A physiological withdrawal state when substance use has ceased or been reduced as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms. 4) Evidence of tolerance such that increased doses of the substance are required in order to achieve effects originally produced by lower doses. (Clear examples of this are found in alcohol-and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill no tolerant users.) 5) Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amounts of time necessary to obtain or take the substance or recover from its effects. 6) Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts shouldbe made to determine that the user was actually, or could be expected to be, aware of the nature and extent to harm. Narrowing of the personal repertoire of patterns of psychoactive substance use has also been described as a characteristic feature (e.g. tendency to drink alcoholic drinks in the same way on weekends, regardless of social constraints that determine appropriate drinking behavior.

III. THE RUBRICS RUBRIC: QUANTITY The Drug Abuse Treatment Outcome Study (DATOS) supported by the National Institute of Drug Abuse (NIDA) tracked 10,010 drug abusers in nearly 100 treatment programs in 11 cities of United States who entered treatment between 1991 and 1993. DATOS researchers looked at co-occurring psychological disorders and dependencies in 7,402 patients in the DATOS programs who were diagnosed as substance dependent. They found that 32.1 percent of those patients were dependent on cocaine alone. Of that 32.1 percent, 59.1 percent were male. Another 26.3 percent of the patients were dependent on both cocaine and alcohol, and, of those, 69.8 percent were male. In addition, 10.6 percent of the patients were dependent on heroin alone,and 64.2 percent of those were male. The prevalence of co-occurring psychological disorders among the group was high, especially for antisocial personality disorder (APD) and major depression. APD was characterized as a pattern of disregard for the rights of others, irresponsibility, and lack of remorse. Major depression was characterized as either a depressed mood or a loss of interest or pleasure for 2 weeks or more. The prevalence of those two disorders differed widely among men and women. Approximately 40 percent of the group was diagnosed with APD, and males were twice was likely as females to be diagnosed with the disorder. While 12 percent of the group had experienced a major depression, female patients were twice as likely as male patients to have done so.

RUBRICS: QUANTITY (INCIDENCE) AND LOCATION

Estimates of substance use incidence, or initiation (i.e., number of new users during a given year), provide an important measure of the Nation's substance use problem. They can suggest emerging patterns of use, particularly among young people. In the past, increases and decreases in incidence have usually been followed by corresponding changes in the prevalence of use, particularly among youths. The incidence estimates are based on the NHSDA questions on age at first use, year and month of first use for recent initiates, the respondent's date of birth, and the interview date. More precisely, the rates are actually the number of new users per 1,000 person-years of exposure. The incidence estimates are based on retrospective reports of age at first use, the most recent year available for these estimates is 1999, based on the 2000 NHSDA. Estimates for the year 1999 are based only on data from the 2000 survey, while estimates for earlier years are based on the combined 1999 and 2000 data. For two of the measures, first alcohol use and first cigarette use, initiation before age 12 is common. A twoyear lag in reporting of estimates is applied for these measures, because the NHSDA sample does not cover youths under age 12. The two-year lag insures that initiation at age 10 and 11 is captured in the estimation.

1. Marijuana
1.1 Incidence: 2.0 million new users in 1999
1.2 Location

Location by time: The estimated annual number of new marijuana users has declined from 2.6 million in 1996 to about 2.0 million in 1999. This was preceded by a period of significant increase from 1990 (1.4 million new users) to 1996. In 1965, there were an estimated 0.5 million new users of marijuana. The annual number of marijuana initiates increased until reaching a peak in 1976-77 (two years before the past month prevalence rate among youth peaked in 1979) at around 3.2 million new users per year. After that, the number of initiates declined to 1.4 million in 1990 (two years before the youth past month prevalence rate reached a low point in 1992) and then increased again to 2.6 million in 1996, a recent high point. Location by age Youths aged 12 to17 have constituted about two-thirds of the new users of marijuana in recent years, with young adults aged 18 to 25 constituting most of the remaining third. Recent rates of new use among youth in 1996-1998 (averaging 86.4 initiates per 1000 potential new users) were higher than they have ever been. Rates of new use for both youth and young adults decreased between 1998 and 1999 (from 85.2 to 73.0, and from 44.1 to 31.7, respectively) (Figure 5.1). The average age of initiation of marijuana use in 1999 was 17.0 years. Since 1992, the average age has ranged from 16.5 to 17.4. The average age of marijuana initiates has generally declined since 1965; during 1965-1969 it ranged from 19.0 to 20.4 years of age, and during 1970-1991 it ranged from 17.4 to 19.2 years of age.

2. Cocaine

2.1 Incidence The total number of new initiates of cocaine has been 882,000 in 1998. 2.2 Location: Location by time The highest number of initiates of cocaine (including crack) occurred in the late 1970s and early 1980s, when there were approximately 1.0 to 1.5 million new users each year. After falling to recent lows in the early 1990s (e.g., 531,000 in 1991), the total number of new initiates of cocaine rose to 882,000 in 1998. Location by age The total increased between 1991 and 1998 both for youths aged 12 to 17 and young adults ages 18 to 25; however, the number increased more for youths than for young adults. In 1991, among youths there were only 92,000 new initiates of cocaine. By 1998, the number of new cocaine initiates among youth had risen to 339,000. This represents a higher rate of increase and a higher absolute increase than for young adults, which rose from an estimated 284,000 new initiates to 444,000 during the same period. Since 1965, the highest annual rate of first use among youth occurred in 1998 (14.5 per 1,000 potential new users), while the rate for young adults in 1998 (17.9 per 1000 potential new users) was only about three-fifths of its highest level (29.0 per 1000 potential new users) attained in 1983. The estimates of the number of cocaine initiates and age-specific rates for 1999 appear to be generally lower than the corresponding estimates for 1998; however, the differences are not statistically significant. The average age of cocaine initiates in 1999 was 19.5 years. This is younger than the average age of cocaine initiates for any year since 1973. From 1980 to 1993, the average age of cocaine initiates generally remained above 22 years. 3. Heroin 3.1 Incidence: There were an estimated 104,000 new users of heroin in 1999. 3.2 Location: Location by time This number of new initiates is similar to the number in 1998 (140,000). Comparisons for youth and young adults show no statistically significant difference between the 1998 and 1999 numbers of new initiates. Location by age The number of new initiates among those aged 18 to 25 (53,000) was larger than the number among those aged 12 to 17 (34,000), as has been the historic pattern.

4. Hallucinogens 4.1 Incidence: In 1998, the estimated number of new users of hallucinogens (including LSD and PCP) was 1.2 million, 4.2 Location Location by time The estimated number of 1,2 millions new users (1998) has been the highest estimate since 1965. The number of new users in 1999 (1.4 million) appears to be even higher than in 1998, but this increase is not statistically significant. Location by age The estimated number of new users among youths aged 12 to 17 (669,000) and young adults aged 18 to 25 (604,000) in 1999 are similar to the all-time high numbers of initiates in 1998. 5. Inhalants 5.1 Incidence: In 1999, the estimated number of new users of inhalants was 1.0 million,. 5.2 Location: Location by time The number of 1.0 million new users found in 1998 is not significantly different than the estimates for 1998 (918,000) or 1997 (975,000). However, these estimates are the highest annual number of inhalant initiates since 1965. 6. Psychotherapeutics This category includes nonmedical use of any prescription-type pain reliever, tranquilizer, stimulant, or sedative. It does not include over-the-counter substances. 6.1 Incidence: Among the psychotherapeutics, pain relievers had the highest number of new users in 1999, a total of approximately 1,469,000 persons. 6.2 Location Location by time: This number has been increasing since the mid-1980s, when there were fewer than 400,000 initiates annually (Figure 5.2). Location by age: Youths aged 12 to17 constitute the majority of this increase, from 78,000 in 1985 to 722,000 in 1999. The number of young adult initiates aged 18 to 25 increased from 166,000 to 492,000 during the same period. Stimulants Incidence: The number of new users of stimulants was about 646,000 in 1999. Location by time:This number is similar to the estimates for 1997 and 1998 (about 700,000 new users in each of those years). Location by age: Since 1994, there have been more new users among youths aged 12 to 17 (322,000 in 1999) than among young adults aged 18 to 25 (213,000 in 1999).
a.

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Tranquilizers Incidence:There were approximately 642,000 new users of tranquilizers in 1999. Location by time: While the number of new users of all ages in 1999 appears to be slightly lower than the number in 1998 (814,000). Location by age: both the numbers of users for youth and young adults were similar to corresponding numbers in 1998. For youth, these estimated numbers of new users are the highest since 1965.
b.

Sedatives: Incidence: The estimated number of new initiates of sedatives was the smallest among the psychotherapeutics, at 143,00 new users in 1999. Location by time: The number of new users of sedatives was significantly higher in the early 1970s (about 300,000 to 500,000). The number of initiates has been relatively lower since the early to mid 1980s with a reported low of about 42,000 in 1991.
c.

7. Alcohol 7.1 Incidence: In 1998, approximately 5.1 million persons initiated the use of alcohol. 7.2 Location: Location by time: With reported data back to 1965, this puts the number of new users (5.1 millions in 1998) as high or higher than any estimate since the early 1970s. The largest contributors to this rise are youths aged 12 to 17, who now constitute about 67 percent of total new initiates. The late 1980s and early 1990s were a recent low for the number of new initiates. Location by age: Estimates of new users of alcohol among youth at that time were about 1.7 to 1.8 million per year, and initiates among young adults aged 18 to 25 were 0.9 to 1.1 million. In 1998, the number of new users among youth grew dramatically to 3.4 million, while the initiates among young adults increased slightly to 1.2 million. The 3.4 million new users aged 12 to 17 represents about 15 percent of all youth in the nation. 8. Cigarettes 8.1 Incidence: The incidence rate for cigarette use among youth aged 12 to 17 decreased between 1998 and 1999, from 141.4 to 120.0 persons per 1,000 potential new users. 8.2 Location: Location by time: New use of cigarettes on a daily basis has decreased since its recent peak in 1997 at 1.9 million new users. In 1998, the number of initiates dropped to about 1.7 million and it dropped again in 1999 to about 1.4 million. Contributing to this decrease was the smaller number of new daily smokers among youths aged 12 to 17, falling from about 1,163,000 in 1997 to 783,000 in 1999. Translated to a per-day basis, the number decreased from 3,186 per day in 1997 to 2,145 per day in 1999. The average age at first daily smoking was 17.7 years in 1999. While there have been some small variations in this average age, it has changed little since 1965, ranging from 17.6 to 19.3.

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Location by age: The numbers and rates among young adults aged 18 to 25 remained stable between 1998 and 1999. The overall annual number of persons who first tried a cigarette had increased between 1991 and 1996 from about 2.4 million to 3.4 million, then decreased to 2.9 million in 1998 (Figure 5.3). The average age at first use of cigarettes was 15.4 years in 1998. While there have been some fluctuations, the average age has generally changed very little since 1965, ranging only from 14.9 to 16.2. a. Smokeless Tobacco Incidence: about a million of new users per year Location by time: The estimated annual number of new users of smokeless tobacco was stable during 1997 to 1999 at about a million per year (996,000 in 1997, 972,000 in 1998, and 982,000 in 1999) (Figure 5.3). Location by age: More than half of smokeless tobacco initiates in 1999 were aged 12 to 17. b. Cigars Incidence: 3.6 millions new users in 1998 Location by time: The estimated number of new users of cigars fell dramatically between 1998 and 1999, from 4.6 million to 3.6 million. In 1998, the number of new cigar users had been at its highest level since 1965. The number had been only 1.4 million in 1991. Location by age: The incidence rates for those aged 12 to 17 and 18 to 25 also declined significantly between 1998 and 1999, from 94.2 to 74.0 and from 83.5 to 60.7, respectively. During 1999, 415,000 fewer youth and 407,000 fewer young adults initiated cigar use than initiated use in 1998 (Figure 5.3).

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Rubric: Causes
No single variable or set of variables totally explains the use of drugs by an individual and, the same factor would not necessarily affect all individuals in the same way. Also, there is not reason to believe that the factor that influence the initiation of drug use are of equal importance in the continuation or escalation of use. Biological Factors Genetic vulnerability Family studies have investigated generational differences in the transmission of drug abuse. Those studies have revealed that drug use or abuse is elevated among siblings of drug abusers and that there is a direct relationship between parental drug use or abuse and offspring use or abuse (Merikangas et al, 1992). Some studies have focused on the familial aggregation of alcoholism and illicit drug abuse (Merikangas, 1990; Glantz and Pickens, 1992; Gordon, 1994). Sons and daughters from alcoholics show a three to fourfold risk of developing alcoholism (Cotton, 1979, Schuckit, 1986). Differences in the risk of alcohol and illicit drug use among individuals with a parental history of alcoholism may emerge at the time of transition from late adolescence to early adulthood, which may be a critical period for the expression of drug use vulnerability (Pandina and Johnson, 1989). The high recurrence of alcoholism among offspring of parents with alcoholism demonstrates that family history is one of the most potent predictors of vulnerability to alcohol abuse, which results to some extent from genetic factors (Marikangas, 1990; Pickens et al, 1991). However, the mechanism through which the family confers an increased risk is unknown. In addition to the contributions of genetic and biological factors to individual vulnerability for drug abuse, both transmitted and nontransmitted family factors as well as unique environmental factors, appear to be involved in the vulnerability for drug abuse (Pickens et al, 1991). Family studies by themselves, however, cannot definitively determine the effect of genetic versus the environment on the development of alcoholism or drug abuse. Many twins studies have also provided evidences regarding the possible role that the genetic factors may play in the familial aggregation of drug abuse (Cloninger et al, 1981; Gurling et al, 1981; Hrubec and Omenn, 1981; Pedersen, 1981; Murray et al, 1983; Pickens et al, 1991) Cloninger and colleagues (1981) and others have found that monozygotic twins are about twice as likely as dizygotic twins (of the same sex) to be concordant for alcoholism. The highest twin correlations were found for nicotine and caffeine, based o a study of the Swedish twin registry (Pederson et al, 1981). The role of genetic factors for monozygotic twins reared apart has been studied (Grove et al, 1990). Researchers examined the concordance for alcoholism, illicit drug use and antisocial personality disorder among monozygotic twin pairs separated at birth and found that the heritability of illicit drug abuse exceeded that of alcoholism. Pickens and colleagues (1991) found that the drug abuse concordance rate was significantly greater for the monozygotic twins than for dizygotic twins in males but not in females. Illicit drug use has been found to be associated with conduct disorder in childhood and with antisocial personality in adulthood. The aggregate of these findings suggest that genetic factors explain some of the variance in the development of drug abuse and that a large proportion of the heritability of drug use in adulthood may be attributed to genetic factors that underlie the development of behavior problems in childhood (Cadoret et al, 1980; Grove et al, 1990).

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Also, cross-adoption studies of children of alcoholics who were raised by nonalcoholic adoptive parents have shown a three to four fourfold increased risk for alcohol abuse and dependence compared to adoptees whose parents were not alcoholics (Schucki et al, 1972; Goodwin et al, 1973; Cadoret et al, 1980; Bohman et al 1981, Cloninger et al, 1981). Psychosocial Factors Since many studies that explore for risk factors are cross sectional it is difficult to disentangle the risk factors for use from those for abuse and dependence. Many of these studies fail to control for parental alcoholism, psychiatric disorders or other risk factors, and many of them do not distinguish between use and abuse. Personality traits Relatively few studies have examined the role the specific role of personality traits in the development of drug abuse and dependence. The majority of studies have focused on the characteristics of alcoholics (Mc Cord and Mc Cord, 1960; Robins, 1966; Vaillant and Milofsky, 1982; Tarter, 1990). For example, the landmark studies of Mc Cord and Mc Cord (1960) and Robins (1966) revealed that alcoholism in adulthood was associated with antisocial behavior and aggressivity in childhood. Aggressive behavior has been found to predict heavy alcohol use in late adolescence (Kellam, et al, 1983). The onset of drinking is signaled by several antecedent personality attributes reflecting lower levels of conventionality, for example, lower values on academic achievement (Jessor and Jessor, 1975; Brook et al , 1986a), lower expectations of academic achievement (Jessor et al, 1972; Jessor and Jessor, 1975), more tolerant attitudes toward deviant behavior (Jessor and Jessor, 1975; Brook et al, 1986a), lower levels of religiosity (Jessor and Jessor, 1975; Webb et al, 1991) less of an orientation to hard work (Brook et al, 1986a), greater rebelliousness (Brook et al 1986a), rejection of parental authority (Webb et al, 1991); rejection of parental authority (Webb et al, 1991), fewer reasons for not drinking or less negative beliefs about the harmfulness of drinking (Jessor et al , 1972; Jessor and Jessor, 1975; Margulies et al, 1977), and greater positive expectancies about the social benefits of drinking (Christiansen et al, 1989; Smith and Goldman, 1994). Studies of the association between adolescent personality characteristics and illicit drug use found that many of the characteristics that signaled the onset of drinking also predict drug use. The most powerful predictors of more frequent drug use are the unconventionality variables, including rebelliousness, tolerance of deviance, and low school achievement (Brook et al, 1986a). Similar antecedent personality attributes reflecting lower levels of conventionality and more positive attitudes toward drug use predict the initiation of smoking, drinking and drug use (Chassin et al, 1984; Krohn et al, 1985; Skinner et al, 1985; Mittelmark et al 1987). In general, adolescents who start to use marijuana are less conventional in their attitudes and values and have weaker binds to the conventional institutions of school and religion. This is shown in more tolerant attitudes toward deviance (Jessor et al, 1973; Brook et al, 1980), lower religiosity (Jessor et al, 1973), greater rebelliousness and lower obedience (Smith and Fogg, 1979), lower educational expectations (Brook et al, 1980), greater opposition to authority (Pederson, 1990) and more favorable beliefs about marijuana use (Jessor et al, 1973; Kandel and Andrews, 1987). Psychopathology Adult deviant behavior and antisocial behavioral patterns are often preceded by problem behavior (i.e. rejection of societal rules, goals and values) in late childhood and early adolescence (Jessor and Jessor, 1977; Robins, 1978). These behaviors coupled with increasing life stresses appear to be risk factors for drug abuse. Conduct disorder has been shown to precede the onset of drug abuse in several studies (Robins, 1966;

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Mc Cord, 1981; August et al, 1983; Gittelman et al, 1985; Boyle et al, 1992) and to occur conjointly with drug abuse in others (Loeber, 1982; Lilienfeld and Waldman, 1990; Loeber et al, 1995). A prospective longitudinal study by Boyle and colleagues (1992) revealed that an earlier diagnosis of conduct disorder indicated grater risk for the initiation of marijuana and other illicit drug use four years later. It should be noted, however, that the majority of children with problem behaviors or conduct disorders do not become antisocial or drug-abusing adults. Although studies have observed that early antisocial behaviors and deviance are risk factors for drug abuse (Robins, 1966; Elliott et al, 1985; Kaplan et al, 1986; Robins and McEvoy, 1990), the two most common psychopathologies that have been identified repeatedly are depression and antisocial personality (Cadoret et al 1980, Alterman et al 1985; Grove, 1990). Studies of clinical and epidemiological samples also have suggested that drug abuse and psychopathology are often linked (Merikangas et al; 1994; Kessler et al, 1996). Inpatient and outpatient surveys reveal that approximately one-third of patients in treatment for psychiatric disorders are drug abusers (Crowley et al, 1974; Fisher et al, 1975; Davis, 1984, Eisen et al, 1987). In these samples, disorders that have been associated with increased risk of alcoholism and drug abuse include conduct and oppositional disorders, especially those manifesting antisocial behavior, attention deficit disorder; and the anxiety disorders, particularly phobic disorders and depression (Weiss et al, 1988; Fergursson et al 1994; Kessler, 1996). The commonality of these findings across these studies and samples further supports the results, in particular the studies of treated samples, delinquents, general population samples and samples of different ages, such as adolescents (Riggs et al 1995) or adults (Kessler et al, 1996). Also a high incidence of drug abuse has been found among psychiatric patients (Miller et al, 1989). A number of family factors may be associated with the development of drug use and abuse. As reviewed in Glantz and Pickens (1992) these may include poor quality of the child-parent relationship, family disruptions (e.g. divorce, acute or chronic stress), poor parenting, parent or sibling drug use, parental attitudes sympathetic to drug use and social deprivation.

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Rubric : Mechanisms:
All drugs of abuse interact initially with receptor or reuptake proteins. Opiates activate opiod receptors and cocaine inhibits reuptake proteins for the monoamine neurotransmitters (which include dopamine, norepinephrine and serotonin). These initial effects lead to alterations in the levels of specific neurotransmitters receptors in the brain. Opiate activation of opiod receptors, for example, leads to recruitment of inhibitory and related G protein. This, in turn, leads to activation of K+ channels and inhibition of CA2+ channels. Both are inhibitory actions, because more K+ flows out of the cell and less Ca2+ flows into the cell. Thus, the electrical properties of the target neurons are affected relatively rapidly by opiates. Recruitment og the inhibitory G protein also inhibits adenylyl cyclase, and reductions in cellular Ca2+ levels decrease CA2+ dependent protein phosphorylation cascades, altering the activity of still additional ion channels. These effects, along with changes in many other neural processes within target neurons, contribute further to the acute effects of opiates. The sum of such changes presumably triggers the long-term effects of the drugs that eventually lead to abuse, dependence, tolerance and withdrawal. Table No. Acute effects of abused drugs on neurotransmitters___________________________________ Drug Opiates Cocaine Amphetamine Alcohol Nicotine Cannabinoids Action_____________________________________________________ Agonist at opoid receptors Inhibits monoamine reuptake transporters Stimulates monoamine release Facilitates GABA A receptor function and inhibits N-methyl-D-aspartate (NMDA) glutamate receptor function a Agonist at nicotinic acetylcholine receptors Agonist at cannabinoid receptors b

Hallucinogens Partial agonist at 5-HT 2 c serotonin receptors Phencyclidine (PCP) Antagonist at NMDA glutamate receptors _______________________________________________________________________________________ a The mechanisms by which alcohol produces these effects has not been established but would not appear to involve direct alcohol binding to receptors as is the case for the other drugs listed in the table b Although a specific receptor for cannabinoids has been identified in the brain, the endogenous ligand for this receptor has not been identified with certainty. c 5-Hydroxytryptamine-2.

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Neural Substrates of Drug Abuse Neural Substrate of Reinforcement A multineurotransmiter system called the medial forebrain bundle which courses from the ventral midbrain to the basal forebrain, has long been associated with reinforcement and reward (Olds and Milner, 1954; Olds, 1962; Stein, 1968; Wise, 1989). Electrical stimulation through electrodes implanted along this bundle is considered to be pleasurable or rewarding because animals will perform certain tasks repeatedly (e.g. pressing a bar) to trigger the stimulation (self-stimulation). Thresholds for that intracraneal self-stimulation are lowered by drugs of abuse, suggesting that they sensitize the brain reward system. Recent advances exploring the neurobiological effects of drugs of abuse have focused on specific neurochemical systems that make up the medial forebrain bundle reward system. Psychomotor stimulants, such as cocaine and amphetamine, appear to depend on an increase in the synaptic release of dopamine in the mesolimbic system (Koob, 1992b). This system has its cell bodies of origin in the ventral tegmental area and projects to the nucleus accumbens, olfactory tubercle, frontal cortex and amygdala. Cocaine is thought to act mainly to block reuptake of dopamine by binding to a specific protein, the dopamine transporter receptor protein, involved in reuptake; amphetamines both enhance dopamine release and block its reuptake. Three of the five cloned dopamine receptor subtypes have been implicated in the reinforcing actions of cocaine (Woolverton, 1986; Koob, 1992b; Caine and Koob, 1993). Opiate drugs bind to opioid receptors to produce their reinforcing effects. The mu receptors appears to be most important for the reinforcing effects of heroin and morphine, and the most important brain sites for the acute reinforcing actions of those drugs appear to be in gthe ventral tegmental area and the nucleus accumbens. Opiates stimulate the release of dopamine in the terminal areas of the mesolimbic dopamine system, and there also appears to be a dopamine-independent action in the region of the nucleus accumbens on neuronal systems that receive a dopaminergic input (Koob, 1992a). Ethanol and other sedative hypnotics clearly have multiple sites of action for their acute reinforcing effects, which depend on facilitation of GABAergic neurotransmission, stimulation of dopamine release at low doses, activation of endogenous opioid peptide systems, and antagonism of serotonergic and glutamanergic neurotransmission. The exact sites for these actions are under study but appear again to involve the mesolimbic dopamine system and its connections in the basal forebrain, particularly in limbic areas such as amygdala. The neurobiological substrates for the acute reinforcing actions of psychedelic drugs are less well understood. Indeed, rodents and nonhuman primates will not self administer psychedelic drugs. Lysergic acid diethylamide (LSD) clearly involves a serotonergic action, possibly as a postsynaptic agonist. However, the brain sites and specific subtypes involved are still under study. Little is known about the neurobiology of the acute reinforcing actions of marijuana, but the cloning of the tetrahydrocannabinol (THC) receptor and the discovery of endogenous THC compounds in the brain offer possible new approaches to this question (Matsuda et al; Devane et al, 1992). Neural Substrate for Drug Tolerance The neural subtrates for drug tolerance overlap significantly with those associated with dependence since tolerance and dependence may be components of the same neuroadaptive process. Tolerance also involves associative processes (processes of learning where previously neutral stimuli come to adquire significance through pairing with biologically significant events), however, and the role of associative processes has been most explored in the context of opiate drugs and sedative-hypnotics such as alcohol (Young and Goudie, 1995). Both operant (behavioral tolerance) and classical (context-dependence tolerance) conditioning have been shown to play a role in drug tolerance, and mechanisms for these associative processes may involve several neurotransmitters independent of their role in dependence.

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Norepinephrine and serotonin are well known as involved in the development of tolerance to ethanol and barbiturates (Tabakoff and Hoffman, 1992). More recently, administration of glutamate antagonists has been shown to block the development of tolerance, again consistent with an associative component of tolerance (Trujillo and Akil, 1991). Neural Substrate of Withdrawal Withdrawal from chronic use of drugs of abuse is characterized by a dependence syndrome that is made up of two elements:physical and psychological.. Physical signs of alcohol are tremor and autonomic hyperactivity; abdominal discomfort and pain are associated with opiate withdrawal. The self reported psychological signsof drug withdrawal , which may be considered more motivational, are usually different components of a negative emotional state including disphorya, depression, anxiety and malaise (Koob et al, 1993) and are difficult to measure directly in animals. Behavioral history is a primary determinant of whether withdrawal and the negative affective state associated with it produce drug-seeking behavior. For individuals with a history of self-medication of opiates and alcohol, physical dependence is an important factor in motivating individuals to seek out and self-administer opiates and alcohol. The phenomenon of of physical dependence, however, does not produce drug-seeking behavior in the majority of individuals made physically dependent in the course of a treatment with an opiate for medication.

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RUBRIC: INTERVENTION AND PREVENTION PREVENTION: Principles of Drug use Prevention (NIDA, 2001): Prevention programs should be designed to enhance "protective factors" and move toward reversing or reducing known "risk factors." They should target all forms of drug abuse, including the use of tobacco, alcohol, marijuana, and inhalants. Prevention programs should include skills to resist drugs when offered, strengthen personal commitments against drug use, and increase social competency (e.g., in communications, peer relationships, self-efficacy, and assertiveness), in conjunction with reinforcement of attitudes against drug use. Prevention programs for adolescents should include interactive methods, such as peer discussion groups, rather than didactic teaching techniques alone. Prevention programs should include a parents' or caregivers' component that reinforces what the children are learning-such as facts about drugs and their harmful effects-and that opens opportunities for family discussions about use of legal andillegal substances and family policies about their use. Prevention programs should be long-term, over the school career with repeat interventions to reinforce the original prevention goals. For example, school-based efforts directed at elementary and middle school students should include booster sessions to help with critical transitions from middle to high school. Schools offer opportunities to reach all populations and also serve as important settings for specific subpopulations at risk for drug abuse, such as children with behavior problems or learning disabilities and those who are potential dropouts. Family-focused prevention efforts have a greater impact than strategies that focus on parents only or children only. Community programs that include media campaigns and policy changes, such as new regulations that restrict access to alcohol, tobacco, or other drugs, are more effective when they are accompanied by school and family interventions. Community programs need to strengthen norms against drug use in all drug abuse prevention settings, including the family, the school, and the community. Prevention programming should be adapted to address the specific nature of the drug abuse problem in the local community. Prevention programs should be age-specific, developmentally appropriate, and culturally sensitive. The higher the level of risk of the target population, the more intensive the prevention effort must be and the earlier it must begin. Effective prevention programs are cost-effective. For every dollar spent on drug use prevention, communities can save 4 to 5 dollars in costs for drug abuse treatment and counseling.

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Prevention in the Community: To assess the level of risk, it is important to: Assess the extent of drug use and community awareness of the problem; gain an understanding of the community's culture and how that culture is affected by drug use; consult with community leaders working in drug abuse and related areas; and learn about efforts already under way to address the problem. Then, a more formal process of identifying problems and assessing community needs can begin. Many tools have been tested in research and can be used to assess the community's drug problem. For example, drug abuse epidemiologists have used: household and school surveys; methods to collect available information from health departments, hospitals, drug abuse treatment facilities, law enforcement agencies, and school systems; ethnographic studies, which use a systematic, observational process to describe behaviors in natural settings, such as urban heroin use, and also document the perspectives of the individuals under observation; and more informal methods, such as convening focus groups with representatives of drug-using subpopulations to determine what is going on in the community.

Each of these methods has advantages and disadvantages, so NIDA recommends, if resources allow, the use of multiple strategies to assess community risk to provide the best information possible. The information obtained in this early assessment can help communityleaders make sound decisions about programs and policies and will contribute to later evaluation efforts.

Evaluation of Prevention Programs (judging the effectiveness of current prevention efforts) With the growing problem of adolescent drug use, shrinking resources, and limited expertise in evaluation, the task of assessing current program effectiveness and planning for future needs may appear daunting. any communities can undertake formal evaluations by working with their local universities to obtain help in developing and implementing well-designed evaluation strategies. These strategies try to track drug use among the young people who have been reached by the program and compare those results with drug use among a control group (young people of similar characteristics who have not been involved with the program). Another approach is for communities to conduct a structured review of current prevention programs to determine, first, whether the programs in place were tested according to rigorous scientific standards during their development; and second, whether these incorporate the basic principles of prevention that have been identified in research. A checklist can assist in determining whether specific programs include researchbased prevention principles (see Appendix I).

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INTERVENTION Types of Drug Abuse Treatment: Outpatient methadone programs administer the medication methadone to reduce cravings for heroin and block its effects. Counseling, vocational skills development, and case management to help patients access support services are used to gradually stabilize the patients functioning. Some patients stay on methadone for long periods, while others move from methadone to abstinence. Long-term residential programs offer around-the-clock, drug-free treatment in a residential community of counselors and fellow recovering addicts. Patients generally stay in these programs several months or up to a year or more. Some of these programs are referred to as therapeutic communities. Outpatient drug-free programs use a wide range of approaches including problem-solving groups, specialized therapiessuch as insight-oriented psychotherapy, cognitive-behavioral therapy, and 12-step programs. As with long-term residential treatment programs, patients may stay in these programs for months or longer. Short-term inpatient programs keep patients up to 30 days. Most of these programs focus on medical stabilization, abstinence, and lifestyle changes. Staff members are primarily medical professionals and trained counselors. Once primarily for alcohol abuse treatment, these programs expanded into drug abuse treatment in the 1980s. In addition, THE national Institute of Drug Abuse NIDA (1997) has funded the development of several new behavioral treatments for cocaine abuse that have shown good success in clinical trials. Family therapies for adolescents, contingency management approaches, and cognitive-behavioral therapies are available for use in treatment programs. In addition, clinics around the Nation are using medications such as methadone and the NIDA-developed LAAM (leva-alpha-acetyl-methadol) in combination with behavioral treatments to treat heroin addicts successfully. A NIDAs supported Drug Abuse Treatment Outcome Study (DATOS) - a major research effort that tracked more than 10,000 patients in almost 100 programs in 11 cities around United States over 3years, have obtained the following results (NIDA, 1997): The study identified an alarming drop over time in the provision of services such as medical, legal, employment, and financial help. This decline is of special concern, since drug abusers often need help in one or more of these areas to get into and stay in treatment. Since NIDA's last national study of treatment outcomes, conducted from 1979 to 1981, the provision of these services has declined strikingly while the need for them has increased. From 1991 to 1993, during the time DATOS researchers were collecting data, the typical length of stay in short-term inpatient treatment dropped from 28 days to 14 or fewer days as insurers reduced coverage for addiction treatment. These changes did not go unnoticed by patients. More than half of DATOS participants in the four kinds of treatment programs surveyed did not report receiving support services that they said they needed. And, nearly 75 percent of patients in shortterm inpatient programs reported not getting the psychological help they needed. (See "DATOS Documents Dramatic Decline in Drug Abuse Treatment Services".)

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Patients in programs surveyed for DATOS showed a marked reduction in drug use after treatment regardless of the type of treatment program in which they participated. DATOS analyses focused on marijuana use instead of heroin use among patients in short-term inpatient programs and outpatient drug-free programs because the number of patients using heroin in those programs was too small to allow statistical comparisons.

* Weekly or more frequent use with 5 or more drinks at a sitting. ** Outpatient methadone patients still in treatment were interviewed approximately 24 months after admission.

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The DATOS data showed reductions after treatment in illegal acts, which included assault, robbery, burglary, larceny, forgery, and fencing; less than full-time employment; and suicidal thoughts and suicide attempts, indicators of depression.

* Outpatient methadone months after admission.

patients

still

in

treatment

were

interviewed

approximately

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Retention It has been found by DATOS (1997) a significant diversity in how well the types of treatment are doing at keeping patients in treatment DATOS (1997) states that programs with low retention rates tended to have patients with the most problems, particularly antisocial personality disorder, cocaine addiction, or alcohol dependence. In addition, heroin abusers who also abused crack cocaine but not powder cocaine had significantly lower retention rates than other heroin abusers did. It has been emphasized that the programs are dealing with some tough people. Programs with the highest concentration of these problem patients tend to have low retention. Major predictors that makes a patient stay in treatment were: high motivation; legal pressure to stay in treatment; no prior trouble with the law; getting psychological counseling while in treatment; and lack of other psychological problems, especially antisocial personality disorder.

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RESEARCH NEEDS: According to NIDA (1997) Factors that influence patients' readiness for treatment and motivation to change. There is a need of exploring alternative approaches to drug abuse treatment for patients unable or unwilling to seek help in traditional treatment programs. Drug abuse treatment for special populations such racial and ethnic minorities, the homeless, persons with disabilities, and pregnant women. Unique treatment needs, potential barriers to treatment, and culturally appropriate treatment models to set research priorities to improve treatment for these populations. Integrating medical and mental health services and drug abuse treatment. Promote cross-system health services research by increasing communication and interaction between medical health services researchers and drug abuse treatment researchers. Financing drug abuse treatmentand services. It is important to develop research recommendations to address both the immediate and long-term funding needs of providers of treatment resources. Evaluate the validity and reliability of instruments that researchers are currently using to assess whether drug abuse treatment reduces AIDS risk behaviors; and Ways to improve and expand the use of the heroin treatment medication naltrexone.

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REFERENCES
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-V) Washington DC: American Psychiatric Association. Etheridge, R.M.; Hubbard, R.L.; Anderson, J.; Craddock, S.G.; and Flynn, P.M. Treatment structure and program services in DATOS. Psychology of AddictiveBehavior, (in press). Flynn P.M.; Craddock, S.G.; Luckey, J.W.; Hubbard, R.L.; and Dunteman, G.H. (1996) Comorbidity of antisocial personality and mood disorders among psychoactive substance-dependent treatment clients. Journal of Personality Disorders 10(1):56-67. Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of one-year follow-up outcomes in DATOS. Psychology of Addictive Behavior, (in press). Institute of Medicine (1996) Pathways of Addiction. Washingtom DC: National Academy Press NIDA notes September/ocober 1997. www.nida.nih.gov/NIDA_Notes/NNVol12N5/Study. NIDA (2001) www.nida.nih.gov/Prevention/PREVPRINC.html Simpson, D.D.; Joe, G.W.; Broome, K.M.; Hiller, M.L.; Knight, K.; and Rowan-Szal, G.A. Program diversity and treatment retention rates in DATOS. Psychology of Addictive Behavior, (in press). WHO (World Health Organization) 1992. International Statistical Classification of Diseases and Related Health Problems. 10th Revision. Geneva: WHO.

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PART II TRENDS IN DRUG USE

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TRENDS IN DRUG USE: ANY ILLICIT DRUG Estimates of "any illicit drug" use reported in United States by the National Household Survey of Drug Abuse (NHSDA, 2000) reflect use of any of the nine substance categories; marijuana, cocaine, heroin, hallucinogens and inhalants and nonmedical use of prescription-type pain relievers, tranquilizers, stimulants, and sedatives. Use of alcohol and tobacco products, while illegal for youths, are not included in these estimates. Findings from the 2000 NHSDA on illicit drug use are summarized below. In 2000, an estimated 14.0 million Americans were current illicit drug users, meaning they had used an illicit drug during the month prior to interview. This estimate represents 6.3 percent of the population 12 years old and older. Marijuana is the most commonly used illicit drug. It is used by 76 percent of current illicit drug users. Approximately 59 percent of current illicit drug users consumed only marijuana, 17 percent used marijuana and another illicit drug, and the remaining 24 percent used an illicit drug but not marijuana in the past month. Therefore, about 41 percent of current illicit drug users in 2000 (an estimated 5.7 million Americans) use illicit drugs other than marijuana and hashish, with or without using marijuana as well (Figure 2.1). Of the 5.7 million users of illicit drugs other than marijuana, 3.8 million were using psychotherapeutics nonmedically. This represents 1.7 percent of the population aged 12 and older, about the same rate as in 1999 (1.8 percent). Psychotherapeutics include pain relievers (2.8 million users), tranquilizers (1.0 million users), stimulants (0.8 million users), and sedatives (0.2 million users). The percentage of the population using illicit drugs did not change from 1999 to 2000 (6.3 percent in both years). There were no statistically significant changes in the overall rates of current use of any of the major illicit drug categories tracked by the survey (Figure 2.2).

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In 2000, an estimated 1.2 million Americans were current cocaine users. This represents 0.5 percent of the population aged 12 and older. The estimated number of current crack users in 2000 is 265,000. In 2000, an estimated 1 million Americans were current users of hallucinogens. This number represents 0.4 percent of the population aged 12 and older. In 2000, an estimated 6.4 million persons had tried ecstasy at least once in their lifetime. This is more than the estimated 5.1 million lifetime users in 1999. The 2000 NHSDA was not designed to report past month or past year use of ecstasy. In 2000, an estimated 130,000 Americans were current heroin users. This represents 0.1 percent of the population aged 12 and older. Age Rates and patterns of drug use show substantial variation by age. For example, 3.0 percent of youths aged 12 and 13 reported current illicit drug use in 2000. Among youth, rates increase with age, peaking in the age group 18 to 20 years (19.6 percent). Beyond age 20, the rates generally decline with increasing age. Adults age 40 to 44 years were an exception to this pattern in both 1999 and 2000, with rates higher than the 35 to 39 year old age group. Members of this cohort in their early forties in 2000 were teenagers during the 1970s, the period when drug use incidence and prevalence rates were rising dramatically. Rates declined consistently in age groups older than age 44, but were still above 2 percent for adults in their fifties (Figure 2.3). Among youth aged 12 to 17, 9.7 percent had used an illicit drug within the 30 days prior to interview in 2000. This rate is about the same as the rate for youth in 1999 (9.8 Percent). Among youth aged 12 and 13, the rate of past month illicit drug use declined from 3.9 percent in 1999 to 3.0 percent in 2000. This was primarily due to a significant drop in inhalant use (from 1.3 percent to 0.7 percent). Marijuana use in this age group was lower in 2000 than in 1999, but this change is not statistically significant (Figure 2.4). There were no changes between 1999 and 2000 in rates of use for any of the illicit drug categories for youths aged 14 and 15 (Figure 2.5).

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Use of psychotherapeutics nonmedically increased among youths aged 16 and 17 between 1999 and 2000, from 3.4 percent to 4.3 percent. The increase was observed for pain relievers as well as stimulants (particularly methamphetamine). Overall illicit drug use among youths aged 16 and 17 was higher in 2000 than in 1999, but the change did not reach statistical significance (Figure 2.6). There were few changes in rates of drug use among adult age groups (18 to 25 years and 26 years and older) between 1999 and 2000 (Figures 2.7 and 2.8). Among young adults aged 18 to 25, past month use of crack declined from 0.3 percent to 0.1 percent, and stimulant use declined from 1.1 percent to 0.8 percent. These declines occurred among those aged 21 to 25, but not among those aged 18 to 20. There were no changes in rates for older adults aged 26 and older, although a decline in crack use and increases in hallucinogen and nonmedical pain reliever use were observed among adults age 26 to 34 years. While rates of use of most drugs in 2000 were higher among youth and young adults than among older adults, the age distribution of users varied considerably by type of drug. Overall, about half (49 percent) of current illicit drug users were under age 26. However, 83 percent of hallucinogen users and 62 percent of inhalant users were under age 26 in 2000. Conversely, only 32 percent of heroin users, 43 percent of cocaine users and 45 percent of nonmedical psychotherapeutic users were under age 26. Approximately 2.1 million youths aged 12 to 17 had used inhalants at some time in their lives as of 2000. This constituted 8.9 percent of youths. Of youth, 3.9 percent had used glue, shoe polish, or Toluene, and 3.3 percent had used gasoline or lighter fluid. Gender As in prior years, men continued to have a higher rate of current illicit drug use than women (7.7 percent vs. 5.0 percent) in 2000. However, the rates of nonmedical psychotherapeutic use were similar for males (1.8 percent) and females (1.7 percent). Between 1999 and 2000, the rate of past month marijuana use among women aged 12 and older increased from 3.1 percent to 3.5 percent. This was primarily due to an increase in use among women aged 26 and older, from 1.4 percent in 1999 to 2.0 percent in 2000. Among youths aged 12 to17 in 2000, the rate of current illicit drug use was similar for boys (9.8 percent) and girls (9.5 percent). While boys aged 12 to 17 had a slightly higher rate of marijuana use than girls (7.7 percent compared to 6.6 percent), girls were somewhat more likely to use psychotherapeutics nonmedically than boys (3.3 percent compared to 2.7 percent) (Figure 2.9). Between 1999 and 2000, there was no significant change in the rate of current illicit drug use for either males or females aged 12 to 17 years.

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Pregnant Women Among pregnant women aged 15 to 44 years, 3.3 percent reported using illicit drugs in the month prior to interview (based on the combined 1999 and 2000 NHSDA samples). This rate is significantly lower than the rate among non-pregnant women aged 15 to 44 years (7.7 percent). Among pregnant women aged 15 to 17 years, the rate of use was 12.9 percent, nearly equal to the rate for non-pregnant women of the same age (13.5 percent) (Figure 2.10). In 2000, the rate of current illicit drug use was higher among black pregnant women (7.1 percent) than among white (2.9 percent) or Hispanic (2.1 percent) pregnant women (Figure 2.11).

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Race/Ethnicity The rates of current illicit drug use for major racial/ethnic groups in 2000 were 6.4 percent for whites, 5.3 percent for Hispanics, and 6.4 percent for blacks. The rate was highest among the American Indian/Alaska Native population (12.6 percent) and among persons reporting more than one race (14.8 percent). Asians had the lowest rate (2.7 percent). Although Asians as a group had the lowest rate of current illicit drug use, there were variations among the various specific Asian subgroups. For persons aged 12 and older, the rates ranged from 1.0 percent of Chinese and 2.1 percent of Asian Indians to 6.9 percent of Koreans, 5.0 percent of Japanese, and 4.3 percent of Vietnamese. These estimates are based on combined 1999 and 2000 NHSDA data, to ensure adequate sample sizes for these population subgroups (Figure 2.12). Based on combined 1999 and 2000 data, rates of past month illicit drug use in the population aged 12 and older were 10.1 percent for Puerto Ricans, 5.5 percent for Mexicans, 4.1 percent for Central or South Americans, and 3.7 percent for Cubans (Figure 2.12). Among youths aged 12 to 17 years, the rate of current illicit drug use was highest among American Indian/Alaska Natives (22.2 percent for combined 1999 and 2000 data).

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Education Illicit drug use rates are correlated with educational status. Among adults aged 18 and older in 2000, college graduates had the lowest rate of current use (4.2 percent). The rate was 6.3 percent among adults who had not completed high school. This is despite the fact that adults who had completed four years of college were more likely to have tried illicit drugs in their lifetime when compared to adults who had not completed high school (44.6 percent vs. 28.9 percent). College Students In the college age population (aged 18 to 22 years) the rate of current illicit drug use was nearly the same among full-time undergraduate college students (18.4 percent) as for other persons aged 18 to 22 years, including part-time students, students in other grades, or non-students (18.2 percent). The rate of use was unchanged between 1999 and 2000 for both students and non-students. Employment Current employment status is also highly correlated with rates of illicit drug use. An estimated 15.4 percent of unemployed adults (aged 18 and older) were current illicit drug users in 2000, compared with 6.3 percent of full-time employed adults and 7.8 percent of part-time employed adults. Although the rate of drug use is higher among unemployed persons than other employment groups, most drug users are employed. Of the 11.8 million adult illicit drug users in 2000, 9.1 million (77 percent) were employed either full time or part time. Geographic Area The rate of current illicit drug use in 2000 was 8.0 percent in the West region, 6.6 percent in the Northeast, 5.7 percent in the Midwest region, and 5.5 percent in the South. By geographic division, rates ranged from 10.0 percent in New England and 8.3 percent in the Pacific division to 4.9 percent in the West South Central division and 4.1 percent in the West North Central division. Between 1999 and 2000, the rate in the West North Central Division declined from 5.4 percent to 4.1 percent. The rate of illicit drug use in metropolitan areas was higher than the rate in nonmetropolitan areas. Rates were 6.5 percent in large metropolitan areas, 6.7 percent in small metropolitan areas, and 5.1 percent in nonmetropolitan areas. Rural nonmetropolitan counties had lower rates of illicit drug use than other counties. Rates were 3.9 percent in completely rural counties and 4.5 percent in less urbanized nonmetropolitan counties. (Figure 2.13) Among youth in 2000, rates of any illicit drug use were similar across county types. Rates ranged from 8.0 percent in less urbanized nonmetropolitan counties to 11.5 percent in urbanized nonmetropolitan counties. The rate of use for youth in large metropolitan areas was 9.4 percent.

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Criminal Justice Populations In 2000, among the estimated 1.2 million adults on parole or other supervised release from prison during the past year, 21.6 percent had used an illicit drug in the past month. This rate is higher than the rate for adults not on parole or supervised release (5.8 percent) (Figure 2.14). Among the estimated 3.7 million adults on probation at some time in the past year, 24.2 percent reported using an illicit drug in the past month in 2000. This compares with a rate of 5.5 percent among adults not on probation (Figure 2.14).

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Frequency of Use Between 1999 and 2000, the frequency of marijuana use among past year users increased. In 1999, 31.6 percent of past year marijuana users used on 100 or more days in the past 12 months, including 10.2 percent who used on 300 or more days. In 2000, the comparable percentages were 34.7 and 11.7, respectively (Figure 2.15). This occurred among a relatively constant number of past year marijuana users (19.1 million in 1999 and 18.6 million in 2000).

There was evidence of the shift to more frequent use in each of the three primary age groups (12 to 17, 18 to 25, and 26 and older), although the change was relatively small and not statistically significant among young adults aged 18 to 25. Association with Cigarette and Alcohol Use The rate of past month illicit drug use among both adults and youths was higher among those that were currently using cigarettes or alcohol, compared with adults and youths not using cigarettes or alcohol. In 2000, 4.6 percent of nonsmokers aged 12 to 17 years used illicit drugs, while among youths who used cigarettes, the rate of past month illicit drug use was 42.7 percent. The rate of illicit drug use was also associated with the level of alcohol use. Among youths who were heavy drinkers in 2000, 65.5 percent were also current illicit drug users. Among nondrinkers, only 4.2 percent were current illicit drug users.

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Driving Under the Influence of Illicit Drugs An estimated 7.0 million persons reported driving under the influence of an illicit drug at some time in the past year. This corresponds to 3.1 percent of the population aged 12 and older, and is significantly lower than the rate in 1999 (3.4 percent). Among young adults aged 18 to 25 years, 10.7 percent drove under the influence of illicit drugs at least once in the past year. Of the 7.0 million persons who had driven under the influence of illicit drugs in the past year, most (77 percent) had also driven under the influence of alcohol.

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APPENDIX I

44

CHECKLIST TO EVALUATE THE EFFECTIVENESS OF PREVENTION PROGRAMS

Prevention Principles for Community Programs To be comprehensive, does the program have components for the individual, the family, the school,the media, community organizations, and health providers? Are the program components well integrated in theme and content so that they reinforce each other? Does the prevention program use media and community education strategies to increase public awareness, attract community support, reinforce the school-based curriculum for students and parents, and keep the public informed of the program's progress? Can program components be coordinated with other community efforts to reinforce prevention messages (for instance, can training for all program components address coordinated goals and objectives)? Are interventions carefully designed to reach different populations at risk, and are they of sufficient duration to make a difference? Does the program follow a structured organizational plan that progresses from needs assessment through planning, implementation, and review to refinement, with feedback to and from the community at all stages? Are the objectives and activities specific, time-limited, feasible (given available resources), and integrated so that they work together across program components and can be used to evaluate program progress and outcomes?

Prevention Principles for School-Based Programs Do the school-based programs reach children from kindergarten through high school? If not, do they at least reach children during the critical middle school or junior high years? Do the programs contain multiple years of intervention (all through the middle school or junior high years)? Do the programs use a well-tested, standardized intervention with detailed lesson plans and student materials? Do the programs teach drug-resistance skills throughinteractive methods (modeling, roleplaying, discussion, group feedback, reinforcement, extended practice)? Do the programs foster prosocial bonding to the school and community?

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Do the programs: teach social competence (communication, self-efficacy, assertiveness) and drug resistance skills that are culturally and developmentally appropriate; promote positive peer influence; promote antidrug social norms; emphasize skills-training teaching methods; and include an adequate "dosage" (10 to 15 sessions in year 1 and another 10 to 15 booster sessions)? To maximize benefits, do the programs retain core elements of the effective intervention design Is there periodic evaluation to determine whether the programs are effective?

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