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Article |

The Changing Pattern of Substance Abuse in Urban Adolescents FREE

Cynthia Brasseux, MA; Lawrence J. D'Angelo, MD, MPH; Mark Guagliardo, PhD; Jocelyn Hicks, PhD
[+] Author Affiliations

From the Children's National Medical Center, Children's Research Institute, Center VI, Washington, DC.


Arch Pediatr Adolesc Med. 1998;152(3):234-237. doi:10.1001/archpedi.152.3.234.
Text Size: A A A
Published online

Objectives  To determine the prevalence of specific drug use in adolescents attending an adolescent health clinic and to compare current rates with a similar previous study.

Design  Blinded and anonymous urine samples obtained from patients presenting for routine health care were tested for the presence of cannabinoids, phencyclidine (PCP), amphetamines, opiates, and cocaine.

Setting  Adolescent medicine outpatient clinic.

Patients  Patients were between 12 and 21 years of age. Specimens from 1313 patients in 1995 to 1996 and 1312 patients in 1989 to 1990 were tested.

Main Outcome Measures  Current drug use rates were compared with a similar screening of patients conducted in 1989 to 1990. Comparisons between studies were made on the basis of specific drug, age, and sex.

Results  For the most recent patient group, 14% were positive for 1 or more drugs and 13% were positive for cannabinoids. Males were significantly more likely to test positive for drug use than females. The oldest adolescents were more likely to test positive for drug use than younger adolescents. Comparing the 2 study year cohorts, patients tested recently were significantly more likely to have urine tests positive for at least 1 drug and cannabinoids in particular and less likely to have urine tests positive for cocaine.

Conclusions  There has been an increase in positive urine tests in patients seen in our ambulatory clinic, with a strong shift toward cannabinoids and a shift away from cocaine. Practitioners need to be aware that drug use patterns in adolescents can shift relatively abruptly and counseling should be targeted to current drug use patterns.

THE USE of illicit drugs by adolescents in the United States has risen since reaching a nadir in the late 1980s and early 1990s. This increase was first noted in 1993 drug use surveys and the trend has continued through 1995.17 The use of illicit drugs has been shown to be associated with leading causes of morbidity and mortality as well as low educational achievement and increased levels of school dropout in this age group.810 The link between drug use and sexual risk-taking behaviors has been documented11,12 as has the association of drug use and increased risk for sexually transmitted diseases and human immunodeficiency virus infection.1317 For those caring for adolescent patients, a reduction in substance use is therefore a highly sought after clinical end point.

For adolescent health care providers to target care and counseling efforts to the current drug use environment, an evaluation of the prevalence of current drug use patterns as well as an identification of shifts in drug use trends is helpful. The purpose of this study was to determine the prevalence of specific drug use in adolescents attending our urban adolescent health clinic. It is based on blinded and anonymous urine testing and compares recent rates of use and substance "preference" with a similar, previous study.

In the course of routine care, urine specimens were obtained from 1313 patients seen in the Children's National Medical Center (CNMC) Adolescent Medicine Outpatient Clinic, Washington, DC, for a 1-year period (April 1995 to March 1996). Once the appropriate clinical evaluation of the patient was complete, discarded urine specimens had all identifying information removed and destroyed, were coded by age and sex, and assigned a unique study number. All specimens were then tested for the presence of 5 drugs (cannabinoids, phencyclidine [PCP], cocaine metabolites, amphetamines/methamphetamines, and opiates) via fluorescence polarization immunoassay (ADX, Abbott Laboratories, Abbott Park, Ill). Specimens that screened positive for any drug were sent to a reference laboratory for gas chromatography/mass spectrometry confirmation testing. A similar study took place between October 1989 and September 1990. In that study, urine specimens were obtained in a blinded fashion from 1312 patients and were analyzed by an Abbott ADX system for the presence of 4 drugs (amphetamines, cannabinoids, cocaine and PCP). Specimens that screened positive for any drug were set to a reference laboratory for gas chromatography confirmation testing.

Both studies were reviewed and approved by the CNMC Institutional Review Board. The most recent study was also approved by the National Institutes of Health Office for Protection From Research Risks, Rockville, Md. Patient consent was not required for either study.

Results from both years were grouped by substance tested, age, and sex. Statistical analyses were performed using BMDP Statistical Software, Release 7 (SPSS Inc, Chicago, Ill) and StatXact 3 for Windows (Cytel Software Corp, Cambridge, Mass). Descriptive χ2 analysis, tests of proportions, and 95% confidence intervals were reported as appropriate. Differences in drug use rates for sex and age groupings for each study year and differences in rates between study periods were analyzed. Differences in rates between study periods for sex and age groupings were also analyzed. The critical α level for all tests of significance was .05. Adjustments to the criteria for significance were made for multiple comparisons.

Between April 1995 and March 1996, 1313 patients presenting for routine health care in the CNMC Adolescent Medicine Outpatient Clinic were tested for the presence of 5 drugs in urine specimens. In this temporal cohort, males composed 33% of the population and females 67%; the mean±SD age of the patients was 16.07±2.14 years (Table 1). In a similar previous study (1989-1990), 1312 patients (Table 1) attending the CNMC clinic were tested for 4 drugs. Males composed 20% of the population and females 80%; the mean age of the population was 16.62±1.88 years.

Table Graphic Jump LocationTable 1. Demographic Features of Patients Enrolled in Urine Drug Study 1989-1990 and 1995-1996, Washington, DC

For the most recent patient group, 179 (14%) were confirmed to test positive for 1 or more drugs. Of those with a positive drug screen, 166 (13%) were confirmed to be positive for cannabinoids (Table 2). Males were significantly more likely to test positive for at least 1 drug than females (18% vs 11%; P<.001). Males were also significantly more likely to test positive for cannabinoids than females (17% vs 10%; P<.001) (Table 3). There was a significant association between age group and confirmed use of 1 or more drugs (P<.001). The 18- to 21-year-old group had a significantly higher rate of overall drug use than the 12- to 14-year-old group and the 15- to 17-year-old group. The 15- to 17-year-old group also has a significantly higher use rate than the 12- to 14-year-old group. There was a significant association between age group and cannabinoid use (P<.001). The 15- to 17-year-old and 18- to 21-year-old groups had significantly higher cannabinoid use rates than the 12- to 14-year-old group (P=.001 for both) (Table 4).

Table Graphic Jump LocationTable 2. Urine Drug Screening Results by Drug and Study Year
Table Graphic Jump LocationTable 3. Urine Drug Screening Results by Sex and Study Year
Table Graphic Jump LocationTable 4. Urine Drug Screening Results by Age and Study Year

In the earlier cohort, positive urine tests for 1 drug category were found for 65 (5%) of the specimens. Positive urine tests for cannabinoids were found for 30 (2%) of 1265 of the specimens and positive urine tests for cocaine were found for 41 (3%) of 1289 of the specimens (Table 2). There was no significant association between sex and overall drug use. Males, however, tended to have higher cocaine use than females (Table 3). There were significant associations between age group and the use of at least 1 drug, marijuana, and cocaine (P<.001). The oldest age group had significantly higher overall drug, cannabinoid, and cocaine use rates than the younger age groups (Table 4).

Comparing the 2 cohorts, there was a significant increase in the proportion of males and a significant decrease in mean age for the most recent study group (Table 1). Patients tested recently were significantly more likely to have confirmed positive urine test results for at least 1 drug (P<.001) and for cannabinoids in particular (P<.001), and significantly less likely to have urine specimens positive for cocaine than those patients screened in 1989 to 1990 (P<.001) (Table 2). To explore the effect of sex and age differences across study periods, sex and age groupings were analyzed individually to determine shifts in drug use between study years. The increase in overall drug use and cannabinoids in particular was consistent across both sex and age groupings. The decrease in cocaine use was also consistent across both sex and age groupings (Table 3 and Table 4).

This study demonstrates an increase in positive urine test results in patients seen in our adolescent ambulatory clinic between 1989 and 1990 and 1995 and 1996, with a strong shift toward cannabinoid use and a shift away from cocaine use; this shift was consistent across both sex and age groupings. This upward trend in marijuana usage is similar to reported drug-use trends reported by national surveys.6,7,18 In our patients, this increase in marijuana use has been offset by a significant decrease in cocaine use, even greater than that seen in national survey.5,6 The higher use of drugs in general and marijuana in particular by males and older adolescents found in our study is also similar to the findings of national surveys.13,57

The findings of this study are unique because the results are based on actual use rather than self-reported data. While most other studies use responses to anonymous surveys, it is our experience that such historical self-reports are not totally accurate.19 The body of available literature concerning the validity of self-reported substance abuse demonstrates variability in results. Factors such as type of drug, testing environment, and subject characteristics affected the outcome of validity testing.2024 Maisto et al,25 in a review of self-reported substance abuse literature, noted that the accuracy of drug abusers' self-report of drug use is typically not high. Using urinalysis in addition to self-reported substance use may provide a means for a more precise estimate of true prevalence. In addition, the development of more accurate self-report measurement instruments may be enhanced by validating these instruments with urinalysis.

However, with the advantage of direct measurement of drugs in the urine comes the disadvantage of the limitations imposed by our testing methods. Urine screening can usually detect drugs in the urine only for a specific period (7-30 days for marijuana, 1-3 days for cocaine, 1-4 days for opiates, and 2-5 days for frequent users of PCP).26

The significantly higher rates in overall drug use and marijuana use in particular are most disturbing, however, because of the particularly rapid rise in drug use by the youngest adolescents. Both the 12- to 14-year-old group and the 15- to 17-year-old group experienced a greater than 4-fold increase in the identification of any drug in their urine. This is troubling because it suggests that adolescents in our community are initiating drug use at an earlier age than a decade ago.

It is interesting that the overall increase in substance use has been somewhat "softened" in our patient population by the shift away from cocaine to marijuana. The cocaine epidemic of the late 1980s and early 1990s was felt to be linked to the spread of a number of sexually transmitted diseases, including syphilis and human immunodeficiency virus infection.13,14,16,17 Before we are able to take any solace from this shift, however, we must acknowledge that in the 1980s a similar increase in marijuana use in our patient population signaled an increase in all drug use, including cocaine.

Practitioners need to be aware that drug use patterns in adolescents can shift relatively abruptly and counseling should be targeted to current drug use patterns. The need for such counseling becomes increasingly important because of the established link of drug use to other health risk behaviors.810,27,28 It is likely that this also holds true for our patients and is of particular concern with our younger adolescent patients. Earlier initiation of risk behaviors will certainly increase the risk of adverse health outcomes. From the established level of documented substance use in our younger adolescents, it is clear that interventions seeking to reduce drug use, premature sexuality, and other risk behaviors must target elementary and junior high school aged children.29 This is a process that must go forward as soon as possible and be as broad-based as possible. The future of a whole generation is at stake.

Accepted for publication October 9, 1997.

This research was supported by grant R01 DA08019-03 from the National Institute of Drug Abuse, Washington, DC.

Editor's Note: One nice aspect of this study is the correlation between self-report and urine screen results; the not-so-nice part is the clear increase in substance abuse by adolescents. They use drugs but they tell the truth.—Catherine D. DeAngelis, MD

Reprints: Lawrence J. D'Angelo, MD, MPH, Children's National Medical Center, Adolescent and Young Adult Medicine, 111 Michigan Ave NW, Washington, DC 20010.

Centers for Disease Control and Prevention, Alcohol and other drug use among high school students—United States, 1990. JAMA. 1991;2663266- 3267
Link to Article
Centers for Disease Control and Prevention, Tobacco, alcohol, and other drug use among high school students—United States, 1991. JAMA. 1992;2681841- 1842
Centers for Disease Control and Prevention, Youth risk behavior surveillance—United States, 1993. Morb Mortal Wkly Rep. 1995;44 ((SS-1)) 8- 1338- 41
Oetting  ERBeauvais  F Adolescent drug use: findings of national and local surveys. J Consult Clin Psychol. 1990;58385- 394
Link to Article
O'Malley  PMJohnston  LDBachman  JG Adolescent substance use: epidemiology and implications for public policy. Pediatr Clin North Am. 1995;42241- 259
Substance Abuse and Mental Health Services Administration, National Household Survey on Drug Abuse: Population Estimates 1995.  Rockville, Md SAMHSA1996;DHHS publication No. (SMA) 96-3095
Johnston  LDO'Malley  PMBachman,  JG National Survey Results on Drug Use From the Monitoring the Future Study, 1975-1995, Vol 1: Secondary School Students.  Rockville, Md National Institute on Drug Abuse1996;
Donovan  JEJessor  RCosta  FM Syndrome of problem behavior in adolescence: a replication. J Consult Clin Psychol. 1988;56762- 765
Link to Article
Farrell  ADDanish  SJHoward  CW Relationship between drug use and other problem behaviors in urban adolescents. J Consult Clin Psychol. 1992;60705- 712
Link to Article
Burge  VFelts  MChenier  TParrillo  AV Drug use, sexual activity, and suicidal behavior in US high school students. J Sch Health. 1995;65222- 227
Link to Article
Mott  FLHaurin  RJ Linkages between sexual activity and alcohol and drug use among American adolescents. Fam Plann Perspect. 1988;20128- 136
Link to Article
Kandel  DB Early onset of adolescent sexual behavior and drug involvement. J Marriage Fam. 1990;52783- 798
Link to Article
Fullilove  REFullilove  MTBowser  BPGross  SA Risk of sexually transmitted disease among black adolescent crack users in Oakland and San Francisco, Calif. JAMA. 1990;263851- 855
Link to Article
Fullilove  MTGolden  EFullilove  RELennon  RPorterfield  DSchwarcz  S Crack cocaine and high-risk behaviors among sexually active black adolescents. J Adolesc Health. 1993;14295- 300
Link to Article
Hingson  RWStrunin  LBerlin  BMHeeren  T Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J Public Health. 1990;80295- 299
Link to Article
Marx  RAral  SORolfs  RTSterk  CEKahn  JG Crack, sex and STD. Sex Transm Dis. 1991;1892- 101
Link to Article
Schwarcz  SKBoland  GAFullilove  M  et al.  Crack cocaine and the exchange of sex for money or drugs: risk factors for gonorrhea among black adolescents in San Francisco. Sex Transm Dis. 1992;197- 13
Link to Article
Newcomb  MD Identifying high-risk youth: prevalence and patterns of adolescent drug abuse. Rahdert  ECzechowicz  Deds.Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions. Washington, DC National Institute on Drug Abuse1995;7- 38NIDA Research Monograph Series No 156
Clark  LRBrasseux  CRichmond  DGetson  PD'Angelo  LJ Are adolescents accurate in reporting condom use and frequency of sexually transmitted diseases? J Adolesc Health. In press
Magura  SGoldsmith  DCasriel  CGoldstein  PJLipton  DS The validity of methadone clients' self-reported drug use. Int J Addict. 1987;22727- 749
McNagny  SEParker  RM High prevalence of recent cocaine use and the unreliability of patent self-report in an inner-city walk-in clinic. JAMA. 1992;2671106- 1108
Link to Article
Falck  RSiegal  HAForney  MAWang  JCarlson  RG The validity of injection drug users' self-reported use of opiates and cocaine. J Drug Issues 1992;22823- 832
Maisto  SA Corroboration of drug abusers' self-reports through the use of multiple data sources. Am J Drug Alcohol Abuse. 1982;9301- 308
Link to Article
Dowling-Guyer  SJohnson  MEFisher  DG  et al.  Reliability of drug users' self-reported HIV risk behaviors and validity of self-reported recent drug use. Assess. 1994;1383- 392
Maisto  SAMcKay  JRConnors  GJ Self-report issues in substance abuse: state of the art and future directions. Behav Assess. 1990;12117- 134
Hardman  JGedLimbird  LEed Goodman and Gilman's The Pharmacological Basis of Therapeutics.  New York, NY McGraw Hill Publishing1996;
Rosenbaum  EKandel  DB Early onset of adolescent sexual behavior and drug involvement. J Marriage Fam. 1990;52783- 798
Link to Article
Kokotailo  P Physical health problems associated with adolescent substance abuse. Rahdert  ECzechowicz  Deds.Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions. Washington, DC National Institute on Drug Abuse1995;112- 129NIDA Research Monograph Series No 156
Lucas  WLGilham  SA Profiles of drug use and attitudes among young adolescents. J Child Adolesc Subst Abuse. 1995;441- 60
Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Demographic Features of Patients Enrolled in Urine Drug Study 1989-1990 and 1995-1996, Washington, DC
Table Graphic Jump LocationTable 2. Urine Drug Screening Results by Drug and Study Year
Table Graphic Jump LocationTable 3. Urine Drug Screening Results by Sex and Study Year
Table Graphic Jump LocationTable 4. Urine Drug Screening Results by Age and Study Year

References

Centers for Disease Control and Prevention, Alcohol and other drug use among high school students—United States, 1990. JAMA. 1991;2663266- 3267
Link to Article
Centers for Disease Control and Prevention, Tobacco, alcohol, and other drug use among high school students—United States, 1991. JAMA. 1992;2681841- 1842
Centers for Disease Control and Prevention, Youth risk behavior surveillance—United States, 1993. Morb Mortal Wkly Rep. 1995;44 ((SS-1)) 8- 1338- 41
Oetting  ERBeauvais  F Adolescent drug use: findings of national and local surveys. J Consult Clin Psychol. 1990;58385- 394
Link to Article
O'Malley  PMJohnston  LDBachman  JG Adolescent substance use: epidemiology and implications for public policy. Pediatr Clin North Am. 1995;42241- 259
Substance Abuse and Mental Health Services Administration, National Household Survey on Drug Abuse: Population Estimates 1995.  Rockville, Md SAMHSA1996;DHHS publication No. (SMA) 96-3095
Johnston  LDO'Malley  PMBachman,  JG National Survey Results on Drug Use From the Monitoring the Future Study, 1975-1995, Vol 1: Secondary School Students.  Rockville, Md National Institute on Drug Abuse1996;
Donovan  JEJessor  RCosta  FM Syndrome of problem behavior in adolescence: a replication. J Consult Clin Psychol. 1988;56762- 765
Link to Article
Farrell  ADDanish  SJHoward  CW Relationship between drug use and other problem behaviors in urban adolescents. J Consult Clin Psychol. 1992;60705- 712
Link to Article
Burge  VFelts  MChenier  TParrillo  AV Drug use, sexual activity, and suicidal behavior in US high school students. J Sch Health. 1995;65222- 227
Link to Article
Mott  FLHaurin  RJ Linkages between sexual activity and alcohol and drug use among American adolescents. Fam Plann Perspect. 1988;20128- 136
Link to Article
Kandel  DB Early onset of adolescent sexual behavior and drug involvement. J Marriage Fam. 1990;52783- 798
Link to Article
Fullilove  REFullilove  MTBowser  BPGross  SA Risk of sexually transmitted disease among black adolescent crack users in Oakland and San Francisco, Calif. JAMA. 1990;263851- 855
Link to Article
Fullilove  MTGolden  EFullilove  RELennon  RPorterfield  DSchwarcz  S Crack cocaine and high-risk behaviors among sexually active black adolescents. J Adolesc Health. 1993;14295- 300
Link to Article
Hingson  RWStrunin  LBerlin  BMHeeren  T Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. Am J Public Health. 1990;80295- 299
Link to Article
Marx  RAral  SORolfs  RTSterk  CEKahn  JG Crack, sex and STD. Sex Transm Dis. 1991;1892- 101
Link to Article
Schwarcz  SKBoland  GAFullilove  M  et al.  Crack cocaine and the exchange of sex for money or drugs: risk factors for gonorrhea among black adolescents in San Francisco. Sex Transm Dis. 1992;197- 13
Link to Article
Newcomb  MD Identifying high-risk youth: prevalence and patterns of adolescent drug abuse. Rahdert  ECzechowicz  Deds.Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions. Washington, DC National Institute on Drug Abuse1995;7- 38NIDA Research Monograph Series No 156
Clark  LRBrasseux  CRichmond  DGetson  PD'Angelo  LJ Are adolescents accurate in reporting condom use and frequency of sexually transmitted diseases? J Adolesc Health. In press
Magura  SGoldsmith  DCasriel  CGoldstein  PJLipton  DS The validity of methadone clients' self-reported drug use. Int J Addict. 1987;22727- 749
McNagny  SEParker  RM High prevalence of recent cocaine use and the unreliability of patent self-report in an inner-city walk-in clinic. JAMA. 1992;2671106- 1108
Link to Article
Falck  RSiegal  HAForney  MAWang  JCarlson  RG The validity of injection drug users' self-reported use of opiates and cocaine. J Drug Issues 1992;22823- 832
Maisto  SA Corroboration of drug abusers' self-reports through the use of multiple data sources. Am J Drug Alcohol Abuse. 1982;9301- 308
Link to Article
Dowling-Guyer  SJohnson  MEFisher  DG  et al.  Reliability of drug users' self-reported HIV risk behaviors and validity of self-reported recent drug use. Assess. 1994;1383- 392
Maisto  SAMcKay  JRConnors  GJ Self-report issues in substance abuse: state of the art and future directions. Behav Assess. 1990;12117- 134
Hardman  JGedLimbird  LEed Goodman and Gilman's The Pharmacological Basis of Therapeutics.  New York, NY McGraw Hill Publishing1996;
Rosenbaum  EKandel  DB Early onset of adolescent sexual behavior and drug involvement. J Marriage Fam. 1990;52783- 798
Link to Article
Kokotailo  P Physical health problems associated with adolescent substance abuse. Rahdert  ECzechowicz  Deds.Adolescent Drug Abuse: Clinical Assessment and Therapeutic Interventions. Washington, DC National Institute on Drug Abuse1995;112- 129NIDA Research Monograph Series No 156
Lucas  WLGilham  SA Profiles of drug use and attitudes among young adolescents. J Child Adolesc Subst Abuse. 1995;441- 60
Link to Article

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