Long-Term Effects of Adolescent Substance Use Disorder (SUD)

Do Teens Grow Out of Adolescent Substance Use Disorder?

On June 9^th, 2020, the United States Preventive Services Task Force (USPSTS) released a Recommendation Statement in the Journal of the American Medical Association (JAMA) directed toward primary care providers about screening patients for unhealthy drug use. For those who haven’t heard of the USPSTS, don’t worry. Not many people have. Here’s who they are, along with their mission statement:

“The U.S. Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. The Task Force works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services.”

And here’s what they recommended in their June 2020 statement:

1. The USPSTF recommends screening by asking questions about unhealthy drug use in adults 18 years or older.
2. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents.

This recommendation puzzled many people who work in the substance use disorder treatment community, including us. We weren’t alone. A group of researchers looked into the statement “current data is insufficient…” to verify its accuracy. They concluded that, unfortunately, “relatively little is known about the long-term sequelae of SUD symptoms from adolescence through adulthood.”

Given the current opioid crisis, the increasing number of drug overdose deaths over the past two decades, and the potential impact of pandemic-related mental health stress on adolescent drug use and substance use disorder, the researchers knew what to do to rectify this gap in knowledge. They could analyze the results of a long-term study based on data from the Monitoring the Future Survey (MTF) that tracked participants from 1976-2008. The study focused on individuals with SUD symptoms at age 18, and tracked their SUD symptoms status for 32 years with follow-up surveys administered at age 35, 40, 45, and 50.

Their primary research question was this:

“What are the long-term sequelae [consequences] of substance use disorder (SUD) symptoms from adolescence through adulthood?”

This article will discuss that study and present the results of the research. Then, anyone reading this article can reconsider the USPSTF recommendation, in light of the evidence. Spoiler alert: we think screening for unhealthy drug use is a good idea. Disclaimer: screening means “asking questions about unhealthy drug use,” as opposed to administering drug tests.

With that said, let’s take a look at the current data on drug use among adolescents, then dive into the results of that long-term study.

Drug Use and Teens: Current Statistics

We’ll take the time here to present the most recent statistics on drug use among teens. We haven’t included this level of statistical detail on adolescent drug use since the beginning of the coronavirus pandemic in 2020. Our attention – and everyone else’s attention – has been on the risks to teen mental health created by the pandemic.

It’s time for an update – and all these numbers are relevant to the question at the core of this article: should primary care providers screen adolescents for unhealthy drug use?

For those who don’t want to read all the details, please feel free to scroll by. For the rest, get comfortable: there’s a lot of data coming your way. We’ll offer the latest figures on:

1. Lifetime Drug Use. Question: Have you ever used [any drug, specific drug]?
2. Past-Year Drug Use. Question: In the past 12 months, have you used [any drug, specific drug]?
3. Past-Month Drug Use. Question: In the past 30 days, have you used [any drug, specific drug]?

Let’s take a look at the data.

Lifetime Drug Use: 2021 Monitoring the Future Survey

• Any illicit drug:
  • 15.9% of 8^th graders
  • 25.0% of 10^th graders
  • 41.3% of 12^th graders
• Illicit drug other than marijuana:
  • 8.8% of 8^th graders
  • 9.1% of 10^th graders
  • 12.8% of 12^th graders
• Marijuana:
  • 10.2% of 8^th graders
  • 22.0% of 10^th graders
  • 43.3% of 12^th graders
• Vaping Marijuana:
  • 6.5% of 8^th graders
  • 16.5% of 10^th graders
  • 25.7% of 12^th graders
• Hallucinogens:
  • 1.8% of 8^th graders
  • 3.5% of 10^th graders
  • 1% of 12^th graders
• Cocaine:
  • 0.6% of 8^th graders
  • 1.2% of 10^th graders
  • 2.5% of 12^th graders
• Heroin:
  • 0.5% of 8^th graders
  • 3% of 10^th graders
  • 4% of 12^th graders
• Amphetamines:
  • 5.8% of 8^th graders
  • 5.2% of 10^th graders
  • 4.9% of 12^th graders

There’s good news in these numbers: compared to the 2020 MTF survey lifetime drug use among adolescents decreased during 2021.

Annual (Past Year) Drug Use: 2021 Monitoring the Future Survey

• Any illicit drug:
  • 10.2% of 8^th graders
  • 18.7% of 10^th graders
  • 30.0% of 12^th graders
• Illicit drug other than marijuana:
  • 4.6% of 8^th graders
  • 5.1% of 10^th graders
  • 2% of 12^th graders
• Marijuana:
  • 7.1% of 8^th graders
  • 3% of 10^th graders
  • 5% of 12^th graders
• Vaping Marijuana:
  • 4.7% of 8^th graders
  • 4% of 10^th graders
  • 3% of 12^th graders
• Hallucinogens:
  • 0.8% of 8^th graders
  • 1.5% of 10^th graders
  • 2.5% of 12^th graders
• Cocaine:
  • 0.2% of 8^th graders
  • 0.5% of 10^th graders
  • 1.2% of 12^th graders
• Heroin:
  • 0.2% of 8^th graders
  • 0.1% of 10^th graders and 12th graders
• Amphetamines:
  • 3.0% of 8^th graders
  • 2.7% of 10^th graders
  • 2.3% of 12^th graders

There’s also good news in these numbers: across the board, compared to the 2020 MTF survey, past-year drug use among adolescents decreased during 2021.

Thirty Day (Past Month) Drug Use: 2021 Monitoring the Future Survey

• Any illicit drug:
  • 5.9% of 8^th graders
  • 10.9% of 10^th graders
  • 20.6% of 12^th graders
• Illicit drug other than marijuana:
  • 3.4% of 8^th graders
  • 4.3% of 10^th graders
  • 3% of 12^th graders
• Marijuana:
  • 4.1% of 8^th graders
  • 10.1% of 10^th graders
  • 21.0% of 12^th graders
• Vaping Marijuana:
  • 2.9% of 8^th graders
  • 8.4% of 10^th graders
  • 12.4% of 12^th graders
• Hallucinogens:
  • 0.4% of 8^th graders
  • 0.8% of 10^th graders
  • 1.0% of 12^th graders
• Cocaine:
  • 0.1% of 8^th graders
  • 0.2% of 10^th graders
  • 0.3% of 12^th graders
• Heroin:
  • 0.1% of 8^th, 10th, and 12th graders
• Amphetamines:
  • 1.7% of 8^th graders
  • 1.4% of 10^th graders
  • 1.0% of 12^th graders

This data set also contains good news. In all categories, compared to the 2020 MTF survey, past-month drug use among adolescents decreased during 2021. We’re starting to understand how it’s possible the USPSTS might recommend against screening for unhealth drug use among adolescents. By all measures – with the exception of an increase in vaping marijuana between 2014 and 2019 – drug use among adolescents has decreased over the past two decades.

Before we move on to the data from the study we mention in the introduction of this article, we’ll offer one last fact:

In 2020, 1.6 million adolescents had SUD, but only 6.5% received treatment for SUD. That means 93.5% –  almost 1.5 million – adolescents diagnosed with SUD do not receive the treatment they needed.

Now let’s take a look at that new study.

Does Adolescent Aubstance Use Disorder Predict SUD in Adulthood?

Published in April, 2022, the study “Longitudinal Analysis of Substance Use Disorder Symptom Severity at Age 18 Years and Substance Use Disorder in Adulthood” followed 11 separate groups of people, called cohorts, from age 18 (1976-1986) to age 50 (2008-2018). Baseline surveys were administered in classrooms when participants were seniors in high school, and the follow up surveys – at five-year intervals from age 35-50 – were administered by mail. The goal was to determine whether symptoms of SUD at age 18 predicted SUD or problem drug use during adulthood.

The study group contained:

• 5,317 people
• 52% female/48% male
• 78% white/22% non-white

To establish a baseline, researchers assessed adolescent substance use disorder symptoms at age 18, based on criteria identified in the  Diagnostic and Statistical Manual of Mental Disorders, Volumes IV and V (DSM-IV, DSM-V)used to diagnose:

• Alcohol use disorder (AUD)
• Cannabis use disorder (CUD)
• Other drug use disorder (ODUD)

Researchers posed participants a total of 15 questions about drug/addiction and related behavior, such as:

• Has alcohol and/or substance use resulted in a failure to fulfill major family, work, or school obligations?
• Have you continued to use alcohol and/or substances despite persistent or recurrent interpersonal or social problems?
• Have you continued to use alcohol and/or substances when you know they’re physically or psychologically hazardous?

Researchers then calculated the results and created three categories, based on the number of symptoms each participant reported they experienced. Here are the categories, and the percentage of participants in each category at baseline (age 18):

• Mild: 2 to 3 SUD symptoms: 20%
• Moderate: 4 to 5 SUD symptoms: 12.1%
• Severe: 6 or more SUD symptoms: 11.5%

Here’s the collated data from responses to follow-up surveys administered at ages 35, 40, 45, and 50 years old.

SUD Symptoms at Age 18 and Drug Use During Adulthood: Results

• Participants with 2 or more SUD symptoms at age 18 were 1.5 times more likely to report past-year medical prescription drug use in adulthood. Here’s what they were prescribed:
  • Opioids: 50%
  • Sedatives: 54%
  • Tranquilizers: 55%
  • At least one of the three above medications: 52%
• Participants with 2 or more SUD symptoms at age 18 were twice as likely to report prescription drug misuse in adulthood.
• Among participants with 6 or more SUD symptoms at baseline:
  • 62% had 2 or more SUD symptoms during adulthood
  • By disorder:
    • AUD symptoms: 63.9%
    • CUD symptoms: 64.2%
    • ODUD symptoms: 64.1%
  • Among participants with 1 or more SUD symptoms at age 18:
    • Prescription drug use increased between ages 35 and 50
    • Prescriptions drug misuse increased between ages 35 and 50
    • Overall SUD symptoms decreased between ages 35 and 50

 These numbers tell a story that’s hard to miss: adolescent substance use disorder symptoms predict SUD symptoms during adulthood. The more severe the SUD participants reported at baseline, the greater the number of SUD symptoms they reported as adults. Therefore, the answer to the question posed in the heading above is:

In some cases, yes.

We’ll elaborate – and then discuss a wrinkle in the data addressed by Dr. Nora Volkow, Director of the National Institute on Drug Abuse (NIDA).

What These Results Mean

At risk of repeating what may be obvious to many, the primary takeaway from this data is that the more symptoms of SUD an individual has at age 18, the more likely they are to:

• Have SUD symptoms during adulthood
• Receive prescriptions for opioids, sedatives, or tranquilizers during adulthood
• Misuse prescription medication during adulthood

In other words, there is a direct connection between adolescent drug misuse and adult drug misuse. That misuse applies to illicit drugs and prescription drugs alike, and hold true for alcohol, cannabis, and other drugs of misuse/abuse. And to answer the question in the subheading at the top of this article: no, teens with severe SUD rarely “grow out of it.” They may, however, learn to manage their symptoms in a healthy and productive manner, which means they may not experience the negative consequences of adolescent SUD during adulthood.

Here’s how Dr. Volkov sees this research:

“By identifying the severity of SUD in adolescence as a variable suggestive of future problems, this study highlights the potential value of pediatric screening that captures the intensity of substance use as well as the need for interventions aimed to reduce the severity of SUD in this age group.”

That’s not the only thing Dr. Volkov points out. She observes that for some, the relationship of SUD during adolescence and prescription medications taken for anxiety, insomnia, or pain during adulthood may reveal an underlying mental health disorder that developed during adolescence and resulted in self-medication. This self-medication, in turn, during adulthood, may lead to the need to seek medication from a physician. In addition, severe drug use during adolescence may also cause neurological impairments or disorders that cause symptoms that physicians need to treat during adulthood.

In either case, Dr. Volkov clearly hopes this research persuades her colleagues at USPSTS to revisit their recommendation about screening for unhealthy adolescent substance use. We hope they change their recommendation, too. We work with teenagers every day, and know that screening and assessment cause no harm, and can yield a lifetime of benefit. The facts on treatment for adolescents are well-established: the earlier a mental health disorder is diagnosed, including adolescent substance use disorder, and the earlier a teen with a mental health disorder receives treatment for that disorder, including SUD, the better the outcome, the better the long-term prognosis, and the less likely that teen will experience the symptoms of that disorder during adulthood.