It's important to understand what problem drug testing is supposed to address. In this segment, we will look first at substance use in the United States, and then in the second module, we'll look at substance use in the workplace. I want to start with a summary of the data that we will see in the slides going ahead. They address the question, what are the factors that influence the prevalence and the abuse of illegal drugs? The most important is age. Drug use starts early in high school and grade school. It peaks between 18 and 26, and then it decreases with age. Education is definitely a factor, especially as people graduate from college and enter a workforce where drug testing is prevalent. There are wide geographic distributions by regions in the United States, both for illicit drug use and for heavy alcohol use. And of course, a significant factor is the type of drugs that people are using, and we'll look at how frequently people use different kinds. But marijuana is the most commonly misused, and then of illegal drugs, amphetamines, and then opiates. Gender is a factor. Males in every age category are more likely to be using and abusing drugs than females. And in the next segment, we will address work status, occupation, and other factors. One key epidemiologic question is, how do we know the prevalence of drug use, both in the U.S. and in the workplace? And there are three main sources of data. We'll spend most of our time looking at data from the National Survey on Drug Use and Health, which is sponsored by the Substance Abuse and Mental Health Services Administration. It consists of an annual household interview survey of people 12 years and older, and we have data going back for 20 years. The second is a survey called Monitoring the Future, which annually surveys a sample of 8th, 10th, and 12th grade students and is done through the Institute for Social Research at the University of Michigan and sponsored by NIDA. And the third is a report that comes from reviewing emergency department records called the Drug Abuse Warning Network, also sponsored by SAMHSA. And they selectively go through emergency departments looking at medical records. The data was collected up through 2011, and so I'll show you some data that is fairly old, but it was reinstituted recently, so we'll be continuing to see new data as time goes on. You're not going to be tested on the details of this data, but I want you to look at it carefully and understand the key points. So let's start out with a definition of current use. The household survey defines current use as using a drug one or more times during the past 30 days. And here you see that in terms of the percent of use in the last 30 days, those who are 12 to 17 in high school, the average percent in 2016 was 7.9%. That rose to 23%, almost a quarter among 18 to 25, and then it dropped to just under 9% among those 26 or older. Illicit drug use means use of one of the five categories of drugs tested under the federal testing panel. And here you see that education is a factor. Those who have had some college are most likely to be using an illicit drug, but as I said, college graduates, as they enter the workforce, tend to significantly drop their use of recreational drugs. Geographic differences are absolutely fascinating. And here, looking at these five classes of illicit drugs, you see that the Pacific Northwest, all the way up to and including Alaska, are much more likely to be using drugs that are illegal. And the lowest level is in the Midwest. The picture is quite different with regard to binge drinking, which is defined as having had five or more drinks on one occasion. And here you see the area of heaviest use is in the upper Midwest, North and South Dakota, Iowa, Wisconsin, Illinois, Minnesota, and also in Massachusetts. The trends over time are also very interesting. In 1979, when we started reporting this data, 25 million Americans were currently using an illegal drug. And I watched that go down to 15 million as drug testing kicked in. But then with the growth of medical marijuana laws and then recreational marijuana laws, you see that the current use has now gone up significantly. As for the substances most frequently used, marijuana and hashish are clearly the most prevalent, and that represents the most significant proportion of drug use. Cocaine has remained relatively stable around 2 million users for as long as we've been teaching this course. And heavy alcohol use, which is defined as drinking five or more drinks on five or more occasions during the last 30 days, is just under the level of marijuana use. Among prescription medications, clearly the big focus on misuse has been on pain relievers with a secondary emphasis on tranquilizers. Here are the most recent available data. And I know this is a complex slide, and I just want to emphasize a couple of key points. Notice on the left, in the blue part of the circle, that in the past month, 60% of Americans have used one or more substances. So about 40% are not using a substance, 60% are using a substance. Now what are the substances that they most frequently use? Well, clearly alcohol by far is the largest amount. About half of people drink alcohol. Tobacco, about 20% of the public is smoking tobacco. And then you see at about half that level is marijuana. And then the other drugs go down from there. And we'll look at these in more detail. This slide shows the other drugs that are commonly used in more detail. You'll notice that marijuana has been rising over the years. The use of prescription medication, that is psychotherapeutic drugs, is the second most commonly used. Then cocaine, the hallucinogens, which is a large family, then methamphetamines, inhalants, and heroin. You see here in the middle columns that marijuana use peaks among those 18 to 25, and that percentage has been increasing. What also of notice is the far right, people 26 years and older. For adults 26 and over, you'll see that there's been a steady increase over the last four recordable years of use during the past month. And notice on the right, the past year, daily or almost daily use. So you see that marijuana use is increasing. One of the major reasons that marijuana use has been increasing is its legalization. And you see the states in green that have not only medical marijuana laws, but also have legalized recreational use of marijuana. The states in blue have legalized medical marijuana use, but not recreational use. And then there are other states, many of which will allow the use, for example, of CBD for certain populations, such as children who have had childhood seizures. Only four states have no laws whatsoever allowing any kind of THC products. Because alcohol is so frequently used, a certain percentage of drinkers get into trouble and they become alcoholics or have alcohol use disorder. You can see that this also peaks in the age range of 18 to 25. And as we know, many state universities take pride in the fact that they may be, quote, professional drinking schools, unquote. But you also see in the right-hand columns that the heavy use of alcohol and alcohol use disorder is not uncommon among those beyond the age of 26. Now let's look at opioid products in some detail. Amazingly, the US, with 4.5% of the world's population, consumes 99% of all hydrocodone, 80% of all oxycodone, and again, very significant percentages of all of the synthetic and semi-synthetic opioids. The main reason that the United States uses so much of the world's opioids is because they have been so heavily promoted, especially by pharmaceutical companies. The old school was that opioids were to be used only for severe pain and always with a great deal of caution. I remember my father, a radiologist, telling me that he was treating people with terminal cancer whose doctors were hesitant to give them opioids because they did not want them to become addicted. Well, that philosophy changed, and a fifth vital sign was introduced, namely that of pain. And they were heavily promoted for the chronic use of non-cancer pain, and they were promoted as being safe and effective. There was the belief that no person should ever suffer needless pain for any acute or chronic condition. This book that you see the picture of, Responsible Opioid Prescribing, was funded by the manufacturers of opiates. It was distributed by the Federation of State Medical Boards for continuing medical education credit, and it strongly recommended opioids for pain relief. When opioid use began to be suspect, the U.S. Senate actually investigated this book and the Federation of Medical Boards in 2012. As opioids were heavily promoted, they replaced tranquilizers such as Xanax as the most frequently prescribed drugs in the U.S. In 2015, the average opioid use per resident in the United States was 17.4 days average, and sales exceeded $9 billion. The Centers for Disease Control and Prevention, which tracks morbidity and mortality, has been carefully watching the admissions and deaths of drug overdoses from all causes, and they, of course, have declared a national epidemic of opioid overdose. It's now become the leading cause of death under the age of 50, and you'll see that the peak in 2017 was above 70,000 total lethal drug overdoses. A large part of that was due to prescription medication, but an even more significant part of that was from drugs that were abused. The next three slides present data from CDC. The first shows the national deaths from any drug overdose, and you'll see how rapidly the curve has risen. You also see that males are much more subject to overdose deaths than females. The curve gets even steeper when you're looking at deaths from any of the opioid products, and again, you see males exceeding females. This last chart drills down on prescription opioid medication, and now you see that the lines that are highlighted are not for males and females, but the one at the top is for prescription opioids without any other synthetic narcotics, and that's been going down in the last few years because of the heavy emphasis on mandatory medical CME and caution about prescribing opioids. The bottom line, though, has gone up rather significantly, and that's for prescription opioids and other synthetic narcotics, so people were taking a second pill or there may have been some adulteration going on within the drugs that people were taking. This last curve dramatically shows that we're not just talking about an opioid epidemic, we're really talking about a drug abuse epidemic in this country. The only line that has gone down from 1999 to 2017 is methadone, but notice the rise in deaths due to methamphetamine, notice the steady increase in natural and semi-synthetic opioids, the more dramatic rise in cocaine, which is experiencing a new epidemic, and the most dramatic of all of these curves, of course, is the synthetic opioids other than methadone, and that would include fentanyl and fentanyl-like drugs. So opioids are not only frequently prescribed, but they're very frequently misused, and here you see a breakdown among the different types of drugs. The most common ones, and this is not unexpected, would be the misuse of buprenorphine and methadone, which are usually used for treating people who have substance abuse problems. But then you see right after that fentanyl, oxycodone, hydrocodone, and other opiates that are often prescribed for pain. The last slide that I'll show you from the National Survey on Drug Use and Health answers the question, where do people get the pain relievers that are being misused? And I've circled the three highlights of this slide. On the right-hand side, you see that by far the most common source was drugs that were given by, bought from, or taken from a friend or a relative, so that's more than half. On the left-hand side, you see that getting drugs through a prescription or stealing from a healthcare provider is almost 38%, and then finally, buying through a drug dealer or some stranger, that's 6.5%, and 5% were other. The second source of data that we rely upon is that that comes from the Monitoring the Future Survey. This is an annual random sample of high school students in the 8th, 10th, and 12th grades. This older data from 2017 emphasizes three key points among 12th graders who are about to graduate from high school. Almost half of them have used, experimented with some kind of illegal drug during their lifetime. Almost 40% have used one of these classes of drugs in the last year, and almost a quarter have been using it within the last 30 days. Also this newest data confirms that high school graduating seniors have used an illegal drug 38% of the time, and interestingly, 11.5% of the time, it was something other than marijuana. On the right-hand side, you can see that those other drugs include LSD, synthetic cannabinoids such as K2 or Spice, cocaine, MDMA, and a smaller number using heroin. Looking at younger students in the 8th and 10th grade, you can see that daily use of marijuana has also been increasing and is not insignificant. And as far as marijuana use in the past year, you see that more and more 10th graders and more and more 8th graders are using marijuana. Although alcohol use has been decreasing over the past decade, you see that half of seniors are drinking alcohol, 38% of 10th graders, and almost 20% of 8th graders. And binge drinking, which is defined as five or more drinks in a row in the past two weeks, is not insignificant. The last source of data on the prevalence of drug use in the U.S. comes from emergency departments. Here, a sample of emergency departments have their medical records carefully reviewed to see if there's any reference to drugs, legal or illegal, as far as reasons for the visit. I know this is a complicated and hard-to-read slide, but I just want to emphasize a couple of points. First, look for the reddish color. That represents people coming to the emergency room with reference to the use of marijuana or hashish. And you see that this has been steadily increasing from 1994 to 2011. I think the reason is because marijuana has become so much more potent. Only a few drags are enough to get a person high, and people who are marijuana-naive often smoke too much, they develop a panic attack, they think they're going to die, and they end up in the emergency room. You also see that cocaine levels have risen generally and are much higher than marijuana for being in emergency rooms. And lastly, you see that heroin and morphine are on the rise, so we have an increasing substance abuse problem, not just an opioid problem, and it definitely shows up with people being in emergency rooms. What is most striking to me is that if you add up the numbers, starting with the people who are in emergency room because of adverse effects of pharmaceuticals, and then add to that adverse effects of illicit drugs, and then illicit drugs plus alcohol, and alcohol, or all three, you see that this constitutes a very significant percentage of people who are going to emergency departments. This may not make common sense, but I can tell you, having made a number of visits over the past few years, this is not out of character. Going to an emergency department is an amazing experience of seeing people who are often very, very adversely affected by substances. These more recent data confirm the earlier findings, a very frequent visit to emergency rooms for problems involving any drugs, including opioids, non-heroin opioids, and heroin. Earlier I indicated that you're not going to be tested on all the details, but I just wanted to summarize the key takeaways before we move into the workplace. So first of all, it's clear that substances are widely used in this country, most commonly alcohol, tobacco, marijuana, and prescription painkillers. Secondly, there are many factors that influence unauthorized use. We've looked at some of them, and we'll continue to look at more of them. We know that the recreational use of marijuana has dramatically risen, particularly with the legalization of recreational marijuana. We know that we're in an epidemic of opioid overdoses and deaths, especially

substance use

United States

workplace

illegal drugs

prevalence

abuse