Drug Abuse

Nationwide Trends To Home Page

According to the preliminary results of the 1996 National Household Survey on Drug Abuse (NHSDA),* the number of current illicit drug users did not change significantly from 1995 (12.8 million) to 1996 (13 million). The following are highlights from the preliminary results of the 1996 NHSDA and highlights from the December 1996 meeting of NIDA's Community Epidemiology Work Group (CEWG).** CEWG is a network of researchers from 20 major U.S. metropolitan areas and selected foreign countries who meet semiannually to discuss the current epidemiology of drug abuse.

Extent of Use

Cocaine

Crack cocaine continues to dominate the Nation's illicit drug problem. The overall number of current cocaine users did not change significantly between 1995 and 1996 (1.45 million in 1995 and 1.75 million in 1996). This is down from a peak of 5.7 million in 1985. Nevertheless, there were still an estimated 652,000 Americans who used cocaine for the first time in 1995. Supplies remain abundant in nearly every city. Data indicate a leveling off in many urban areas: cocaine-related deaths were stable or up slightly in 9 of the 10 areas where such information was reported; emergency department (ED) mentions increased in only 4 of the 19 CEWG cities in the Drug Abuse Warning Network (DAWN);*** the percentage of treatment admissions for primary cocaine problems declined slightly or remained stable in 12 of the 14 areas where data were available; and prices of cocaine remained stable in most areas. Although demographic data continue to show most cocaine users as older, inner-city crack addicts, isolated field reports indicate new groups of users: teenagers smoking crack with marijuana in blunts (cigars emptied of tobacco and refilled with marijuana, often in combination with another drug) in some cities, Hispanic crack users in Texas, and in the Atlanta area, middle-class suburban users of cocaine hydrochloride and female crack users in their thirties with no prior drug history.

Heroin

There has been an increasing trend in new heroin use since 1992, with an estimated 141,000 new heroin users in 1995. The estimated number of past month heroin users increased from 68,000 in 1993 to 216,000 in 1996. A large portion of these recent new users were smoking, snorting, or sniffing heroin, and most were under age 26. Additional quantitative indicators and field reports continue to suggest an increasing incidence of new users (snorters) in the younger age groups, often among women. In some areas, such as San Francisco, the recent initiates increasingly include members of the middle class. In Boston and Newark, heroin users are also found in suburban populations. One concern is that young heroin snorters may shift to needle injecting, because of increased tolerance, nasal soreness, or declining or unreliable purity. Injection use would place them at increased risk for HIV/ AIDS. Purity has, indeed, been declining or is inconsistent in some cities, such as Atlanta, Boston, and New York. Nevertheless, purity remains high, as does intranasal use, in the East and in some Midwestern cities, notably Chicago and Detroit. Supplies remain abundant. Aggressive marketing and price cutting has intensified in some cities, such as Boston, Detroit, and New York; heroin dealers often sell other drugs too, as in Miami, Minneapolis/St. Paul, St. Louis, and some Atlanta neighborhoods. Recent mortality figures have increased or are stable at elevated levels in 5 of the 10 cities where trend data are available; rates of ED mentions have increased*** in 8 of the 19 cities in DAWN; and the percentage of those in treatment reporting heroin use has increased in 8 of 14 areas.

Marijuana

There were an estimated 2.4 million people who started using marijuana in 1995. The resurgence in marijuana use continues, especially among adolescents, with rates of ED mentions increasing*** in 10 cities, the percentage of treatment admissions increasing in 13 areas, and the National Institute of Justice's Drug Use Forecasting (DUF) percentages increasing among juvenile arrestees at numerous sites. In several cities, such as Minneapolis/ St. Paul, increasing treatment figures have been particularly notable among juveniles. Two factors may be contributing to the dramatic leap in adverse consequences: higher potency and the use of marijuana mixed with or in combination with other dangerous drugs. Marijuana cigarettes or blunts often include crack, a combination known by various street names, such as "3750s," "diablitos," "primos," "oolies," and "woolies." Joints and blunts are also frequently dipped in PCP and go by street names such as "happy sticks," "wicky sticks," "illies," "love boat," "wet," or "tical." Both types of combinations are reported in Boston, Chicago, and New York; the marijuana-crack combinations are also sold in St. Louis; and the marijuana-PCP combinations are reported in Philadelphia and parts of Texas. In several cities, such as Atlanta and Chicago, teenagers often drink malt liquor when smoking marijuana. Marijuana cigarettes are also sometimes dipped in embalming fluid, as reported in Boston (where they are known as "shermans") and areas of Texas.

Stimulants

Methamphetamine. In several western and Midwestern cities, methamphetamine indicators, which had been steadily increasing for several years, appear mixed this reporting period. All indicators suggest increases in San Francisco and Seattle, while San Diego and Los Angeles indicators show stable or slightly declining trends. However, it is too soon to predict that the indicators in those areas have peaked. Increased methamphetamine availability and use is sporadically reported in diverse areas of the country, particularly rural areas, prompting some concern about its spread outside of the areas of endemic use (the west coast). Most methamphetamine comes from large-scale Mexican operations. Recent seizures in Florida have included powder cocaine, heroin, and flunitrazepam in the same shipment with methamphetamine. Additionally, local labs remain common, with seizures increasing in areas such as Seattle, Arizona, and rural Georgia, Michigan and Missouri. All four routes of administration - injecting, snorting, smoking (including "chasing the dragon" in San Francisco), and oral ingestion - are used but vary from city to city. Reports of violence related to methamphetamine persist in Honolulu and are now also occurring in Seattle.

Other Stimulants. Methylphenidate (Ritalin) abuse continues among heroin users in Chicago and adolescents in Detroit. Methcathinone ("cat" or "goobs") has been reported in several indicators in Detroit and Michigan's Upper Peninsula, including treatment admissions and one death in Detroit. Ephedrine-based products sold at convenience stores, truck stops, and health food stores are common among adolescents in Atlanta, Detroit, Minneapolis/St. Paul, and Texas. New York State recently banned the sale of such products in an attempt to curb escalating abuse among adolescents. Methylenedioxymethamphetamine (MDMA or "ecstasy") use was reported most often among young adults and adolescents at clubs, raves, and rock concerts in Atlanta, Miami, St. Louis, Seattle, and areas of Texas.

Depressants

Use of gamma hydroxybutrate (GHB) in the club scene is becoming more widespread throughout the country, notably in Atlanta, Detroit, Honolulu, Miami, New York City (where it is also reportedly used by fashion models), Phoenix, and Texas. Ketamine ("Special K") use in nightclubs has also been reported in several cities. A mixture of GHB, ketamine, and alcohol, called "Special K-lude" because of the similar effects produced by methaqualone (Quaalude), is reported in New York City. Flunitrazepam (Rohypnol) use continues in many areas of the country (with the exception of the Northeast), most notably in Texas and Florida. Its widespread availability has declined, however, since the Federal ban on its importation. Other medications from the same manufacturer are now being sold and abused as "roofies" in Miami, Minnesota, and Texas. These drugs include clonazepam (another pharmaceutical benzodiazepine, marketed in Mexico as Rivotril), which has the same distinguishing manufacturer's imprint as flunitrazepam. Clonazepam (marketed in the United States as Klonopin) is also used by addicts in Minneapolis/St. Paul and Atlanta to enhance the effects of methadone and other opiates.

Hallucinogens

According to field reports in numerous areas, such as Texas, Boston, Chicago, New York, Philadelphia, St. Louis, and Washington, D.C., phencyclidine (PCP) is often used in combination with other drugs. A frequently reported combination is joints or blunts containing marijuana mixed with or dipped into PCP. In other cities, such as Los Angeles and New Orleans, PCP is commonly purchased as a pre-dipped cigarette. In New York City, PCP is combined with crack in "spaceballs." PCP ED mentions increased in 10 cities, but rates remain relatively low. Lysergic acid diethylamide (LSD) remains widely available in most CEWG cities, especially in suburban and rural areas. Use of psilocybin mushrooms has also been reported among adolescents and young adults in Boston, Minneapolis/St. Paul, and Philadelphia.

Perceived Risk and Availability of Drugs

More than half of youths age 12-17 reported that marijuana was easy to obtain in 1996, and about one quarter reported that heroin was easy to obtain. Fifteen percent of youths reported being approached by someone selling drugs in the month prior to being surveyed. In addition to demonstrating the accessibility of illicit drugs, youths showed a decrease in their perception of the risk in using illicit drugs. The percentage of youths who perceived great risk in using cocaine once a month decreased from 63 percent in 1994 to 54 percent in 1996. The percent of youths age 12-17 that perceived great risk in using marijuana once a month decreased from 1990 (40 percent) to 1994 (33 percent), but remained level from 1994 to 1996.

* NHSDA is an annual survey conducted by the Substance Abuse and Mental Health Services Administration. Copies of the latest survey are available from the National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686.

Criteria for Substance Dependence Diagnosis

How can we tell if someone is abusing or addicted to drugs?

Diagnostic and Statistical Manual - III - R

[DSM-III-R is not currently used but has historical utility.] At least three of the following are necessary; some of the symptoms of the disturbance must have persisted for at least one month or have occurred repeatedly over a longer period of time:

Substance is often taken in larger amounts or over longer period than intended
Persistent desire or one or more unsuccessful efforts to cut down or control substance use
A great deal of time is spent in activities necessary to get the substance (e.g., theft), taking the substance (e.g., chain smoking), or recovering from its effects
Important social, occupational, or recreational activities given up or reduced because of substance abuse
Continued substance use despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by use of the substance
Marked tolerance: need for markedly increased amounts of the substance (> 500/ increase) in order to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount
Characteristic withdrawal symptoms
Substance often taken to relieve or avoid withdrawal symptoms
Frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations or when use is physically hazardous

Diagnostic and Statistical Manual - IV

A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

Substance is often taken in larger amounts or over longer period than intended
Persistent desire or unsuccessful efforts to cut down or control substance use
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
Important social, occupational, or recreational activities given up or reduced because of substance abuse
Continued substance use despite knowledge of having a persistent or recurrent psychological, or physical problem that is caused or exacerbated by use of the substance
Tolerance, as defined by either:
1. need for read amounts of the substance in order to achieve intoxication or desired effect; or
2. markedly diminished effect with continued use of the same amount
Withdrawal, as manifested by either:
1. characteristic withdrawal syndrome for the substance; or
2. the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms

International Classification of Diseases - 10

[ICD-10 research criteria differ from the clinical diagnostic guidelines listed here.] Three or more of the following must have been experienced or exhibited at some time during the previous year:

Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use
A strong desire or sense of compulsion to take the substance
Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects
Persisting with substance use despite clear evidence of overtly harmful consequences, depressive mood states consequent to heavy use, or drug related impairment of cognitive functioning
Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses
A physiological withdrawal state when substance use has ceased or been reduced, as evidence by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms

Commonly Abused Drugs

Substance: Category and Name	Examples of Commercial and Street Names	DEA Schedule/ How Administered*	Intoxication Effects/Potential Health Consequences
*Cannabinoids*			euphoria, slowed thinking and reaction time, confusion, impaired balance and coordination/cough, frequent respiratory infections; impaired memory and learning; increased heart rate, anxiety; panic attacks; tolerance, addiction
hashish	boom, chronic, gangster, hash, hash oil, hemp	I/swallowed, smoked
marijuana	blunt, dope, ganja, grass, herb, joints, Mary Jane, pot, reefer, sinsemilla, skunk, weed	I/swallowed, smoked
*Depressants*			reduced pain and anxiety; feeling of well-being; lowered inhibitions; slowed pulse and breathing; lowered blood pressure; poor concentration/confusion, fatigue; impaired coordination, memory, judgment; respiratory depression and arrest, addiction Also, for barbiturates—sedation, drowsiness/depression, unusual excitement, fever, irritability, poor judgment, slurred speech, dizziness for benzodiazepines—sedation, drowsiness/dizziness for flunitrazepam—visual and gastrointestinal disturbances, urinary retention, memory loss for the time under the drug's effects for GHB—drowsiness, nausea/vomiting, headache, loss of consciousness, loss of reflexes, seizures, coma, death for methaqualone—euphoria/depression, poor reflexes, slurred speech, coma
barbiturates	Amytal, Nembutal, Seconal, Phenobarbital; barbs, reds, red birds, phennies, tooies, yellows, yellow jackets	II, III, V/injected, swallowed
benodiazepines (other than flunitrazepam)	Ativan, Halcion, Librium, Valium, Xanax; candy, downers, sleeping pills, tranks	IV/swallowed
flunitrazepam***	Rohypnol; forget-me pill, Mexican Valium, R2, Roche, roofies, roofinol, rope, rophies	IV/swallowed, snorted
GHB***	gamma-hydroxybutyrate; G, Georgia home boy, grievous bodily harm, liquid ecstasy	under consideration/swallowed
methaqualone	Quaalude, Sopor, Parest; ludes, mandrex, quad, quay	I/injected, swallowed
*Dissociative Anesthetics*			increased heart rate and blood pressure, impaired motor function/memory loss; numbness; nausea/vomiting Also, for ketamine—at high doses, delirium, depression, respiratory depression and arrest for PCP and analogs—possible decrease in blood pressure and heart rate, panic, aggression, violence/loss of appetite, depression
ketamine	Ketalar SV; cat Valiums, K, Special K, vitamin K	III/injected, snorted, smoked
PCP and analogs	phencyclidine; angel dust, boat, hog, love boat, peace pill	I, II/injected, swallowed, smoked
*Hallucinogens*			altered states of perception and feeling; nausea/chronic mental disorders, persisting perception disorder (flashbacks) Also, for LSD and mescaline—increased body temperature, heart rate, blood pressure; loss of appetite, sleeplessness, numbness, weakness, tremors for psilocybin—nervousness, paranoia
LSD	lysergic acid diethylamide; acid, blotter, boomers, cubes, microdot, yellow sunshines	I/swallowed, absorbed through mouth tissues
mescaline	buttons, cactus, mesc, peyote	I/swallowed, smoked
psilocybin	magic mushroom, purple passion, shrooms	I/swallowed
*Opioids and Morphine Derivatives*			pain relief, euphoria, drowsiness/respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness, coma, tolerance, addiction Also, for codeine—less analgesia, sedation, and respiratory depression than morphine for heroin—staggering gait
codeine	Empirin with Codeine, Fiorinal with Codeine, Robitussin A-C, Tylenol with Codeine; Captain Cody, Cody, schoolboy; (with glutethimide) doors & fours, loads, pancakes and syrup	II, III, IV/injected, swallowed
fentanyl	Actiq, Duragesic, Sublimaze; Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, Tango and Cash	II/injected, smoked, snorted
heroin	diacetylmorphine; brown sugar, dope, H, horse, junk, skag, skunk, smack, white horse	I/injected, smoked, snorted
morphine	Roxanol, Duramorph; M, Miss Emma, monkey, white stuff	II, III/injected, swallowed, smoked
opium	laudanum, paregoric; big O, black stuff, block, gum, hop	II, III, V/swallowed, smoked
*Stimulants*			increased heart rate, blood pressure, metabolism; feelings of exhilaration, energy, increased mental alertness/rapid or irregular heart beat; reduced appetite, weight loss, heart failure Also, for amphetamine—rapid breathing; hallucinations/ tremor, loss of coordination; irritability, anxiousness, restlessness, delirium, panic, paranoia, impulsive behavior, aggressiveness, tolerance, addiction for cocaine—increased temperature/chest pain, respiratory failure, nausea, abdominal pain, strokes, seizures, headaches, malnutrition for MDMA—mild hallucinogenic effects, increased tactile sensitivity, empathic feelings, hyperthermia/impaired memory and learning for methamphetamine—aggression, violence, psychotic behavior/memory loss, cardiac and neurological damage; impaired memory and learning, tolerance, addiction for methylphenidate—increase or decrease in blood pressure, psychotic episodes/digestive problems, loss of appetite, weight loss for nicotine—tolerance, addiction;additional effects attributable to tobacco exposure - adverse pregnancy outcomes, chronic lung disease, cardiovascular disease, stroke, cancer
amphetamine	Biphetamine, Dexedrine; bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers	II/injected, swallowed, smoked, snorted
cocaine	Cocaine hydrochloride; blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot	II/injected, smoked, snorted
MDMA (methylenedioxy- methamphetamine)	DOB, DOM, MDA; Adam, clarity, ecstasy, Eve, lover's speed, peace, STP, X, XTC	I/swallowed
methamphetamine	Desoxyn; chalk, crank, crystal, fire, glass, go fast, ice, meth, speed	II/injected, swallowed, smoked, snorted
methylphenidate	Ritalin; JIF, MPH, R-ball, Skippy, the smart drug, vitamin R	II/injected, swallowed, snorted
nicotine	bidis, chew, cigars, cigarettes, smokeless tobacco, snuff, spit tobacco	not scheduled/smoked, snorted, taken in snuff and spit tobacco
*Other Compounds*
anabolic steroids	Anadrol, Oxandrin, Durabolin, Depo-Testosterone, Equipoise; roids, juice	III/injected, swallowed, applied to skin	no intoxication effects/hypertension, blood clotting and cholesterol changes, liver cysts and cancer, kidney cancer, hostility and aggression, acne; adolescents, premature stoppage of growth; in males, prostate cancer, reduced sperm production, shrunken testicles, breast enlargement; in females, menstrual irregularities, development of beard and other masculine characteristics
inhalants	Solvents (paint thinners, gasoline, glues), gases (butane, propane, aerosol propellants, nitrous oxide), nitrites (isoamyl, isobutyl, cyclohexyl); laughing gas, poppers, snappers, whippets	not scheduled/inhaled through nose or mouth	stimulation, loss of inhibition; headache; nausea or vomiting; slurred speech, loss of motor coordination; wheezing/unconsciousness, cramps, weight loss, muscle weakness, depression, memory impairment, damage to cardiovascular and nervous systems, sudden death

*Schedule I and II drugs have a high potential for abuse. They require greater storage security and have a quota on manufacturing, among other restrictions. Schedule I drugs are available for research only and have no approved medical use; Schedule II drugs are available only by prescription (unrefillable) and require a form for ordering. Schedule III and IV drugs are available by prescription, may have five refills in 6 months, and may be ordered orally. Most Schedule V drugs are available over the counter.

**Taking drugs by injection can increase the risk of infection through needle contamination with staphylococci, HIV, hepatitis, and other organisms.

***Associated with sexual assaults.

Principles of Drug Addiction Treatment

Ecstasy (MDMA).
A Not So Bright Idea.
Ecstasy injures brain neurons that are critical to regulating mood, emotion, learning, memory, sleep, and pain.

More than two decades of scientific research has yielded a set of 13 fundamental principles that characterize effective drug abuse treatment. These principles are detailed in NIDA's Principles of Drug Addiction Treatment: A Research-Based Guide.

1. No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each patient's problems and needs is critical.

2. Treatment needs to be readily available. Treatment applicants can be lost if treatment is not immediately available or readily accessible.

3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. Treatment must address the individual's drug use and associated medical, psychological, social, vocational, and legal problems.

4. At different times during treatment, a patient may develop a need for medical services, family therapy, vocational rehabilitation, and social and legal services.

5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The time depends on an individual's needs. For most patients, the threshold of significant improvement is reached at about 3 months in treatment. Additional treatment can produce further progress. Programs should include strategies to prevent patients from leaving treatment prematurely.

6. Individual and/or group counseling and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address motivation, build skills to resist drug use, replace drug-using activities with constructive and rewarding non-drug using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships.

Graph showing percentage of U.S. Population who have ever used drugs of abuse 7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethodol (LAAM) help persons addicted to opiates stabilize their lives and reduce their drug use. Naltrexone is effective for some opiate addicts and some patients with co-occurring alcohol dependence. Nicotine patches or gum, or an oral medication, such as buproprion, can help persons addicted to nicotine.

8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.

9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification manages the acute physical symptoms of withdrawal. For some individuals it is a precursor to effective drug addiction treatment.

10. Treatment does not need to be voluntary to be effective. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase treatment entry, retention, and success.

11. Possible drug use during treatment must be monitored continuously. Monitoring a patient's drug and alcohol use during treatment, such as through urinalysis, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that treatment can be adjusted.

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12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place them or others at risk of infection. Counseling can help patients avoid high-risk behavior and help people who are already infected manage their illness.

13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Participation in self-help support programs during and following treatment often helps maintain abstinence.

Treatment Trends

In Fiscal Year 1995, there were nearly 1.9 million admissions to publicly funded substance abuse treatment.

About 54 percent were alcohol treatment admissions; and nearly 46 percent were for illicit drug abuse treatment.
Men made up about 70 percent of individuals in treatment; and women 30 percent.
Fifty-six percent were White, followed in number by African Americans (26 percent), Hispanics (7.7 percent), Native Americans (2.2 percent), and Asians and Pacific Islanders (0.6 percent).
The largest number of illicit drug treatment admissions, were for cocaine (38.3 percent), followed by heroin (25.5 percent), and marijuana (19.1 percent).
Fifty-nine percent of admissions were to treatment in an ambulatory environment.