COMMENTARY

A Good-News Story in the Substance Abuse Field

Disclosures

January 20, 2017

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Hello and welcome. I am Dr George Lundberg and this is At Large at Medscape.

In the minds of many, 2016 was a bummer. Eternally optimistic, I tried to find a good-news story with which to begin 2017. I succeeded —with teens and drugs, no less.

Since 1975, the National Institute on Drug Abuse (NIDA) has funded a large annual survey[1] to assess the prevalence of attitudes and substance use by US students in grades 8, 10, and 12. The work of the Monitoring the Future survey has been performed by Dr Lloyd Johnston and colleagues at the University of Michigan. It is notoriously difficult to get reliable information of this sort. I cannot swear to the accuracy of these data but they probably come as close to a gold standard as you can find. I do believe in its precision, meaning reproducibility year by year, and that is what makes its trend lines so credible.

Overall, more than 45,000 students from nearly 400 public and private US schools participated in the 2016 survey; it found steady, sometimes dramatic declines in alcohol, nicotine, and illicit drug use. The 2016 rates for cocaine, amphetamines, heroin, and inhalants are the lowest that this team has ever recorded.

As you know, for all drugs that can lead to addiction, the likelihood of addiction declines for every year of additional age in children and teenagers before exposure and use occurs, as their brains are continuing to develop. That fact makes these use trends extremely gratifying. Even cannabis use was down for 8th and 10th graders and was stable for 12th graders.

During the press conference announcing the survey results, NIDA's director, Nora Volkow, MD, noted that data show that nicotine primes the brain for the reinforcing effects of other drugs. Low smoking rates remove those priming effects, and therefore teens are less likely to become users of other drugs.

The measured prevalence of e-cigarette use, although declining, is a concern because, although far less hazardous than combustible tobacco cigarettes over the long term, nicotine delivered this way surely can lead to addiction nonetheless.[2] There is a place for aggressive regulatory and educational efforts to limit teen use of e-cigarettes now.

Heroin use remains very low, just 0.3% over the past year for high school seniors.

One survey question asks about the use of any prescription drug, including amphetamines, sedatives (barbiturates), narcotics other than heroin, or tranquilizers "...without a doctor telling you to use them." Results of this question were reported for 12th graders only. I am not sure why. But these numbers are big ones: 18% lifetime use, 14% past year, 6% past month. This validates the huge concern that many of us have about prescription drug abuse and the necessity for caution by prescribing physicians.

In summary, the hazards of psychoactive drug use by anyone include overdose, mixed drug effects, psychological dependence, addiction, and behavioral consequences such as accidents and interpersonal violence. In addition, the route of administration conveys its own hazards, especially when intravascular.

My all-time favorite doctor in this field is Joseph Zuska, a career Navy physician, who founded the Alcohol Rehabilitation Program at Long Beach Naval Hospital, called "Drydock Number One," the first US military facility dedicated to treating and rehabilitating drunken active duty military, mostly sailors and marines.[3] I worked with Joe for many years, using brutal confrontational education on the pathology and toxicology of alcohol and drug abuse as one part of the program. We believed that defendable truth was our strongest weapon in countering harmful drug use. My personal bias is that the decline in teen drug use can be credited, at least in part, to the vast improvement in truth-telling about drugs–especially tobacco and cannabis—that our society has finally adopted as a norm. We must not backslide on that.

Joe Zuska's successor at Long Beach was the famed Joseph Pursch. Upon military retirement, Joe Pursch once directed the extraordinary Betty Ford Center in Rancho Mirage, California. Joe Pursch published the single best description of addiction that I have ever seen, in an article entitled, "Is There a Common Basis for All Addictions?"[4]

He wrote:

Addicts are people who have learned how to give themselves a quick chemical fix or achieve an emotional high when they either want to or have to change how they feel, and when they want to ignore real-life problems. Most people do that, but the next morning they feel sick or foolish. They don't do it again because it didn't work for them.

What makes addicts different is that they are willing—or feel compelled—to do it again and again even though they 'know' that doing so will get them into trouble.

Hear Joe Pursch. Apply that wisdom to yourself, your family and friends, and to your patients.

Happy New Year.

That is my opinion. I am Dr George Lundberg, at large at Medscape.

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