Alcohol and Other Substance Use Before and During the COVID-19 Pandemic Among High School Students - Youth Risk Behavior Survey, United States, 2021

Changes in Illicit Drug Use Among High School Students in Southeastern U.S. States-2009 to 2019

To determine if decreasing lifetime use of methamphetamines, cocaine, ecstasy, and inhalants among high school students occurring from 2009 to 2019 in the U.S. also occurred in five southeastern states, Youth Risk Behavior Survey data representative of high school students in grades 9-12 in 2009 and 2019 were analyzed. In a classroom setting, lifetime use of methamphetamines, cocaine, ecstasy, and inhalants were self-reported. Students nationwide (n = 30,087) were compared to students in Alabama, Georgia, Louisiana, Mississippi, and South Carolina (n = 18,237). Lifetime methamphetamine use significantly increased from 4.8% in 2009 to 6.2% in 2019 in the southeast but decreased from 4.1 to 2.2% nationwide. Use of cocaine, ecstasy, and inhalants remained stable in the southeast while decreasing significantly nationwide from 2009 to 2019. During a period when use of methamphetamines, cocaine, ecstasy, and inhalants among high school students in the U.S. decreased, use in southeastern states did not change. Culturally specific programs and interventions may be needed to prevent illicit drug use in communities of southeastern states where youth remain at risk.

Addiction Medicine Treatment Utilization by Race/Ethnicity Among Adolescents With Substance Use Problems Before Versus During the COVID-19 Pandemic

PURPOSE

To examine changes in addiction medicine treatment utilization during the COVID-19 pandemic among adolescents (aged 13-17 years) and differences by race/ethnicity.

METHODS

We compared treatment initiation (overall and telehealth), engagement, and 12-week retention between insured adolescents with substance use problems during pre-COVID-19 (March to December 2019, n = 1,770) and COVID-19 (March to December 2020, n = 1,177) using electronic health record data from Kaiser Permanente Northern California.

RESULTS

Compared to pre-COVID-19, odds of treatment initiation, overall (adjusted odds ratio [95% confidence interval] = 1.42 [1.21-1.67]), and telehealth (5.98 [4.59-7.80]) were higher during COVID-19, but odds of engagement and retention did not significantly change. Depending on the outcome, Asian/Pacific Islander, Black, and Latino/Hispanic (vs. White) adolescents had lower treatment utilization across both periods. Changes in utilization over time did not differ by race/ethnicity.

DISCUSSION

Addiction medicine treatment initiation increased among insured adolescents during the pandemic, especially via telehealth. Although racial/ethnic disparities in treatment utilization persisted, they did not worsen.

Health literacy and adolescents' substance use behaviors and correlates: a scoping review

From 2011 to 2023, substance use increased by 23% worldwide. Given that substance use initiation is highest during adolescence, it is crucial to identify amenable correlates of substance use prevention [e.g. health literacy (HL)], which, if embedded in interventions, may improve uptake and outcomes. Hence, this study conducted a scoping review to answer the question: What is known from the existing literature about the relationship between HL and substance use correlates and behaviors in adolescents? Five electronic databases and the bibliography of review articles were searched and a total of 1770 records were identified. After removing duplicates and engaging in three levels of screening to identify studies that included adolescents ≤ 25 years old and assessed the relationship between general HL (vs. behavior/disease-specific health knowledge) and substance use behaviors and correlates, 16 studies were retained. Studies assessed alcohol-related (n = 11), tobacco-related (n = 12), electronic vapor product use-related (n = 4), cannabis-related (n = 1), and amphetamines/methamphetamines-related (n = 1) outcomes. Studies spanned Africa, Asia, Europe, and North and Central America. Most studies included substance use as an outcome and found an inverse relationship between HL and use. Few studies examined substance use correlates (e.g. risk perception). There were no longitudinal or intervention studies. This review highlighted that the topic of adolescent HL and its relationship with substance use remains inadequately researched. Notable gaps for future studies include intervention and longitudinal designs, expansion of outcomes (e.g. more studies on marijuana, prescription drug misuse, vaping, substance use-related correlates), and examining HL as a mediator or moderator of substance use and its correlates.

Disordered Sleep in Adolescents Recovering From Surgery

BACKGROUND AND OBJECTIVES

Sleep is essential for postoperative recovery. Prescription opioid can be associated with disordered sleep. There is little research on sleep patterns among adolescents using opioids for postoperative pain. Our objective was to identify factors associated with disordered sleep among adolescents undergoing surgery.

METHODS

Prospective single-center survey-based cohort study of adolescents (13-20y) undergoing eight surgeries commonly associated with an opioid prescription. Participants completed a preoperative survey measuring clinical, mental health, and sociodemographic factors, and postoperative surveys at 30- and 90-days. All surveys administered the Sleep Problems Questionnaire. Repeated measures logistic regression evaluated the impact of surgery on worsening postoperative sleep scores. Linear change model evaluated sleep score trajectories; Poisson regression identified the impact of preoperative disordered sleep on opioid use.

RESULTS

Overall, 167 adolescents (median 15y, 64% female) were included. Twenty-seven (16.2%) reported disordered sleep preoperatively and 41 (24.6%) postoperatively. Prescription opioid use was not associated with development of disordered sleep postoperatively (OR:1.33; 95% CI:0.38-4.68). Adolescents were 2.20 (95% CI:1.42-3.40) times more likely to report disordered sleep postoperatively. Preoperative disordered sleep, time after surgery, and mental health comorbidities were associated with worsening postoperative sleep score trajectories (p < 0.01). Adolescents with preoperative disordered sleep were not more likely to use opioids (OR:2.56, 95% CI:0.76-8.63, p = 0.13) nor did they use more pills (IRR:0.84, 95% CI:0.62-1.15, p = 0.27).

CONCLUSIONS

Adolescents were more likely to report disordered sleep postoperatively. Preoperative disordered sleep and mental health comorbidities, but not prescription opioid use, were associated with worsening sleep after surgery. Future efforts to improve adolescent postoperative sleep should address baseline disordered sleep and mental health comorbidities.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Prospective cohort study.

Neuromodulation for Cannabis Use: A Scoping Review

This scoping review explores the use of neuromodulation techniques in individuals with cannabis use. Our goal was to determine whether cannabis use alters cortical excitation and inhibition in the context of neuromodulation and to determine whether neuromodulation affects craving and cannabis use patterns. A systematic search was conducted using PubMed, OVID Medline, and PsycINFO from inception to 20 December 2022. Our review identified ten relevant studies, eight of which used Transcranial Magnetic Stimulation (TMS), while two employed Transcranial Direct Current Stimulation (tDCS). Findings from TMS studies suggest that cannabis users exhibit altered cortical inhibition, with decreased short interval intracortical inhibition (SICI) compared to non-users. Single sessions of rTMS did not have any impact on cannabis craving. By contrast, two studies found that multiple sessions of rTMS reduced cannabis use, but these changes did not meet the threshold for statistical significance and both studies were limited by small sample sizes. The two included tDCS studies found contradictory results, with one showing reduced cannabis craving with active treatment and another showing no effect of active treatment on craving compared to sham. Future studies should further explore the effects of multiple treatment sessions and different neuromodulation modalities.

Computer-Facilitated Screening and Brief Intervention for Alcohol Use Risk in Adolescent Patients of Pediatric Primary Care Offices: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Alcohol and other substance use disorders usually begin with substance use in adolescence. Pediatric primary care offices, where most adolescents receive health care, are a promising venue for early identification of substance use and for brief intervention to prevent associated problems and the development of substance use disorder.

OBJECTIVE

This study tests the effects of a computer-facilitated screening and brief intervention (cSBI) system (the CRAFFT [Car, Relax, Alone, Forget, Family/Friends, Trouble] Interactive System [CRAFFT-IS]) on heavy episodic drinking, riding with a driver who is substance impaired, or driving while substance impaired among adolescents aged 14 to 17 years presenting for a well visit at pediatric primary care practices.

METHODS

We are conducting a cluster randomized controlled trial of the CRAFFT-IS versus usual care and recruiting up to 40 primary care clinicians at up to 20 pediatric primary care practices within the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings network. Clinicians are randomized 1:1 within each practice to implement the CRAFFT-IS or usual care with a target sample size of 1300 adolescent patients aged 14 to 17 years. At study start, intervention clinicians complete web-based modules, trainer-led live sessions, and mock sessions to establish baseline competency with intervention counseling. Adolescents receive mailed recruitment materials that invite adolescents to complete an eligibility survey. Eligible and interested adolescents provide informed assent (parental permission requirement has been waived). Before their visit, enrolled adolescents seeing intervention clinicians complete a self-administered web-based CRAFFT screening questionnaire and view brief psychoeducational content illustrating substance use-associated health risks. During the visit, intervention clinicians access a computerized summary of the patient's screening results and a tailored counseling script to deliver a motivational interviewing-based brief intervention. All participants complete previsit, postvisit, and 12-month follow-up study assessments. Primary outcomes include past 90-day heavy episodic drinking and riding with a driver who is substance impaired at 3-, 6-, 9-, and 12-month follow-ups. Multiple logistic regression modeling with generalized estimating equations and mixed effects modeling will be used in outcomes analyses. Exploratory aims include examining other substance use outcomes (eg, cannabis and nicotine vaping), potential mediators of intervention effect (eg, self-efficacy not to drink), and effect moderation by baseline risk level and sociodemographic characteristics.

RESULTS

The AAP Institutional Review Board approved this study. The first practice and clinicians were enrolled in August 2022; as of July 2023, a total of 6 practices (23 clinicians) had enrolled. Recruitment is expected to continue until late 2024 or early 2025. Data collection will be completed in 2025 or 2026.

CONCLUSIONS

Findings from this study will inform the promotion of high-quality screening and brief intervention efforts in pediatric primary care with the aim of reducing alcohol-related morbidity and mortality during adolescence and beyond.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04450966; https://www.clinicaltrials.gov/study/NCT04450966.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55039.

Cannabis Use Among Students in Grades 8, 10, and 12, by Sex - King County, Washington, 2008-2021

Cannabis use during adolescence is associated with poor outcomes, including cognitive impairment, cannabis use disorder, and impaired driving. To guide prevention and use reduction strategies, Public Health - Seattle & King County described recent trends in cannabis use by sex among King County, Washington students in grades 8, 10, and 12 and examined trends in sex-based differences. Data collected during seven 2008-2021 survey periods by the Healthy Youth Survey (administered by the Washington State Department of Health) and restricted to King County students in grades 8, 10, and 12 (range = 33,439-39,391 students per cycle) were analyzed. Prevalence estimates were generated and sex-based prevalence differences (PDs) in current use (≥1 day during the previous 30 days) and frequent use (≥6 days during the previous 30 days) were assessed. PD models used weighted generalized linear regression with an interaction between sex and survey year. During 2008-2021, cannabis use declined among both male and female students. During 2008-2014, cannabis use was higher among male students than among female students (e.g., PD in 2008 = 4.8%) and not significantly different during 2014-2016; however, in 2021, current-use prevalence was lower among male students than among female students for the first time (PD = -1.3%). Frequent-use prevalence was similar among males and females. By grade levels, the highest prevalence of both current and frequent cannabis use was observed among 12th grade students, followed by 10th and 8th graders. Sex-specific differences by grade mirrored overall patterns. Developing tailored interventions that consider potential differences in risk and protective factors by sex or gender identity could promote equity in youth (grades 8, 10, and 12) cannabis use reduction measures.

Synthetic Marijuana: Assessment of Usage, Motivation and Associated Risks in Adolescent Substance Users

Objectives

Use of Synthetic and designer products, including synthetic marijuana (SM), among adolescents poses a major risk to public health. Little is known about the motivating factors of synthetic substance use in adolescents. This study examined the motivations, predictors, perceived risks and benefits, and differences with SM versus natural marijuana among adolescents.

Methods

Between April 2016 and May 2018, a convenience sample of adolescents receiving substance use treatment from a local counseling center completed an anonymous survey to assess the use of natural and synthetic marijuana use, the Strengths and Difficulties Questionnaire to assess levels of current psychiatric symptoms and the Community Assessment of Psychic Experiences-Positive Scale to assess symptoms of psychosis.

Results

A total of 80 adolescents (age range of 14-18 years; 71% male; 53% Caucasian) completed the study. Of these, 39 (49%) reported natural marijuana use (natural marijuana users) and 41 (51%) reported both synthetic and natural marijuana use (dual users). The most commonly reported reasons for using SM were its low cost and reduced risk of detection. Participants who were familiar with SM and reported a desire to avoid detection on drug tests were likelier to use SM (all P < .05). Dual users reported more benefits and risks associated with SM use when compared to natural marijuana users (P ⩽ .05). The use of SM also heightened the perceived medical risks of natural marijuana, including seizures and respiratory issues (P < .05), compared with natural marijuana users. While dual users self-reported more conduct (P = .009) and externalizing problems (P = .024) when compared to natural marijuana users, there were no group differences in psychotic symptoms, nor correlations with the frequency of synthetic or natural marijuana use and psychotic symptoms except that persecutory ideation correlated with the frequency of natural marijuana use during the past 12 months (rp = 0.28, P = .04).

Conclusions

These results suggest that reports of cost savings, and lack of detection on urine drug screens are common reasons for SM use in adolescents despite being aware of the risks of using SM. Perceived benefits of using synthetics and other novel substances appear diverse, and merit further exploration as a better understanding of what motivates adolescents to use specific novel substances may guide prevention and treatment efforts.

An update on the clinical pharmacology of kratom: uses, abuse potential, and future considerations

INTRODUCTION

Kratom (Mitragyna speciosa) has generated substantial clinical and scientific interest as a complex natural product. Its predominant alkaloid mitragynine and several stereoisomers have been studied for activity in opioid, adrenergic, and serotonin receptors. While awaiting clinical trial results, the pre-clinical evidence suggests a range of potential therapeutic applications for kratom with careful consideration of potential adverse effects.

AREAS COVERED

The focus of this review is on the pharmacology, pharmacokinetics, and potential drug-drug interactions of kratom and its individual alkaloids. A discussion on the clinical pharmacology and toxicology of kratom is followed by a summary of user surveys and the evolving concepts of tolerance, dependence, and withdrawal associated with kratom use disorder.

EXPERT OPINION

With the increasing use of kratom in clinical practice, clinicians should be aware of the potential benefits and adverse effects associated with kratom. While many patients may benefit from kratom use with few or no reported adverse effects, escalating dose and increased use frequency raise the risk for toxic events in the setting of polysubstance use or development of a use disorder.

Associations Between Parental Drinking and Alcohol Use Among Their Adolescent Children: Findings From a National Survey of United States Parent-Child Dyads

PURPOSE

Underage drinking is common and costly. This study examined associations between parent and child drinking using recent United States national survey data.

METHODS

We analyzed responses of 740 parent-child dyads from 2020 SummerStyles and YouthStyles surveys. Parents and their adolescent children answered questions about past 30-day alcohol use. We estimated prevalence of adolescent drinking and explored differences by sociodemographics. A multivariable logistic regression model assessed whether parents' drinking behaviors were associated with drinking among their children.

RESULTS

Overall, 6.6% of adolescents drank alcohol, with no significant differences by sociodemographics. Adolescents whose parents drank frequently (≥5 days/month), or binge drank, had significantly higher odds of drinking than adolescents whose parents did not drink or did not binge drink, respectively.

DISCUSSION

Parents could drink less to reduce the likelihood of drinking among their children. Implementation of effective population-level strategies (e.g., increasing alcohol taxes, regulating alcohol sales) can reduce excessive drinking among both adults and adolescents.

Impact of Physical Activity on the Association Between Unhealthy Adolescent Behaviors and Anxiety Among Korean Adolescents: A Cross-sectional Study

OBJECTIVES

Adolescents who engage in unhealthy behaviors are particularly vulnerable to anxiety. We hypothesized that participation in physical activity could influence the relationship between anxiety and unhealthy behaviors in adolescents. These behaviors include smoking, alcohol consumption, and unsafe sexual activity.

METHODS

This study included 50 301 students from the first year of middle school to the third year of high school, all from Korea. The unhealthy adolescent behaviors examined included current alcohol consumption, current smoking, and unsafe sexual behavior. Anxiety levels were assessed using the Generalized Anxiety Disorder-7 questionnaire (GAD-7).

RESULTS

The participants had a mean age of 15.19 years and an average GAD-7 score of 4.23. No significant differences were observed in GAD-7 score among exercising participants when categorized by smoking status (p=0.835) or unsafe sexual behavior (p=0.489). In contrast, participants in the non-exercise group who engaged in these behaviors demonstrated significantly higher GAD-7 scores (p<0.001 and 0.016, respectively). The only significant interaction was found between unsafe sexual behavior and exercise (p=0.009). Based on logistic regression analysis, within the non-exercise group, significant positive associations were observed between current smoking and anxiety (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.18 to 1.57), as well as between unsafe sexual behavior and anxiety (OR, 1.33; 95% CI, 1.02 to 1.73). However, within the exercise group, no significant association was found between anxiety and either smoking or unsafe sexual behavior. Furthermore, no significant interaction was observed between unhealthy behaviors and exercise.

CONCLUSIONS

These findings are insufficient to conclude that physical activity influences the relationship between unhealthy behaviors and anxiety.