"Globally, 1.03 billion (95% UI 0·851–1·19) males (35.1% [29.1–40.7] of the male population aged ≥15 years) and 312 million (199–432) females (10.5% [6.72–14.6] of the female population aged ≥15 years) consumed alcohol in amounts exceeding the NDE [Non-Drinker Equivalence] in 2020; the number and proportion of people consuming alcohol in excess of the NDE, along with the percentage change since 1990 in the proportion of people consuming alcohol in excess of the NDE, by age group, sex, and location is reported in table 1. Since 1990, the global proportion of drinkers consuming alcohol in excess of the NDE has not changed significantly. Although the proportion of the population consuming harmful amounts of alcohol stayed at the same level over the past three decades, the number of people consuming harmful amounts of alcohol increased from 983 million (718–1190) in 1990 to 1.34 billion (1.06–1.62) in 2020, driven by population growth. Overall, among individuals consuming harmful amounts of alcohol in 2020, 76.9% (73.0–81.3) were male."

The National Survey on Drug Use and Health (NSDUH) is conducted annually by the federal Substance Abuse and Mental Health Services Administration.

According to the NSDUH, in 2021:
138,790 people in the US aged 12 and older had used an illegal drug or marijuana in their lifetimes.
61,203 had used an illegal drug or marijuana in the previous year.
39,995 had used an illegal drug or marijuana in the previous month.

NSDUH also reported that in 2021:
128,016 people in the US aged 12 or older had used marijuana in their lifetimes.
52,454 had used marijuana in the previous year.
36,363 had used marijuana in the previous month.

• Table: Marijuana Use and Illegal Drug Use: Lifetime, Past Year, and Past Month Use by People in the US Aged 12 and Over

"The 2021 NSDUH assessed the use and misuse of psychotherapeutic drugs currently or recently available by prescription in the United States, including prescription stimulants, tranquilizers or sedatives (e.g., benzodiazepines), and pain relievers. In NSDUH, misuse of prescription drugs was defined as use in any way not directed by a doctor, including use without a prescription of one’s own; use in greater amounts, more often, or longer than told to take a drug; or use in any other way not directed by a doctor. Misuse of over-the-counter (OTC) drugs was not included.

"Among people aged 12 or older in 2021, 5.1 percent (or 14.3 million people) misused prescription psychotherapeutic drugs in the past year (Table A.7B). The percentage was highest among young adults aged 18 to 25 (7.4 percent or 2.5 million people), followed by adults aged 26 or older (5.0 percent or 10.9 million people), then by adolescents aged 12 to 17 (3.3 percent or 851,000 people).

"Of the prescription drugs presented in this report, prescription pain relievers were the most commonly misused prescription drug by people aged 12 or older. The 14.3 million people in 2021 who misused prescription psychotherapeutic drugs in the past year included 8.7 million people who misused prescription pain relievers, 4.9 million people who misused prescription tranquilizers or sedatives (including 3.9 million past year misusers of benzodiazepines), and 3.7 million people who misused prescription stimulants (Figure 14)."

"Substance use disorders (SUDs) are characterized by impairment caused by the recurrent use of alcohol or other drugs (or both), including health problems, disability, and failure to meet major responsibilities at work, school, or home. The 2021 NSDUH included a series of questions to estimate the percentage of the population aged 12 or older who had at least one SUD in the past 12 months (subsequently referred to as “an SUD” or “a past year SUD”).

"The SUD questions assess the presence of an SUD in the past 12 months based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).^61,62 Respondents were asked SUD questions for any alcohol or drugs they used in the 12 months prior to the survey. Drugs include marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, methamphetamine, and any use of prescription stimulants, tranquilizers or sedatives (e.g., benzodiazepines), and pain relievers.¹⁸ Unlike in the section on Illicit Drug Use in the Past Year, the DSM-5 SUD criteria for prescription drugs apply to people who used but did not misuse prescription drugs in the past year, in addition to people who misused them.

"A Clinical Validation Study (CVS) was conducted in early 2020 to assess NSDUH SUD questions that were revised to be consistent with the DSM-5 criteria discussed as follows.⁶³ For the 2021 NSDUH, the SUD questions from the CVS replaced the SUD questions in the 2020 questionnaire. Also beginning in 2021, NSDUH respondents who reported any use of prescription psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, or sedatives) in the past year (i.e., not just misuse of prescription drugs) were asked the respective SUD questions for that category of prescription drugs.

"DSM-5 includes the following SUD criteria (as measured in the 2021 NSDUH):

"1. The substance is often taken in larger amounts or over a longer period than intended.

"2. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

"3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.

"4. There is a craving, or a strong desire or urge, to use the substance.

"5. There is recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

"6. There is continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of the substance.

"7. Important social, occupational, or recreational activities are given up or reduced because of substance use.

"8. There is recurrent substance use in situations in which it is physically hazardous.

"9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

"10. There is a need for markedly increased amounts of the substance to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount of the substance (i.e., tolerance).

"11. There are two components of withdrawal symptoms, either of which meet the overall criterion for withdrawal symptoms:
"a. There is a required number of withdrawal symptoms that occur when substance use is cut back or stopped following a period of prolonged use.64
"b. The substance or a related substance is used to get over or avoid withdrawal symptoms.⁶⁵

"Table 1 shows how these 11 DSM-5 SUD criteria apply to substances in NSDUH. For prescription pain relievers, tranquilizers, stimulants, and sedatives, Table 1 also shows how these criteria apply if respondents misused prescription drugs or if they simply used but did not misuse prescription drugs in the past year. For consistency with the DSM-5 criteria, NSDUH respondents were classified as having an SUD if they met two or more of the applicable criteria in a 12-month period.

"For alcohol, marijuana, cocaine, heroin, and methamphetamine in Table 1, respondents were classified as having an SUD if they met 2 or more of the 11 criteria in a 12-month period. However, respondents were classified as having a hallucinogen use disorder or an inhalant use disorder if they met 2 or more of the first 10 criteria in the past 12 months; the withdrawal criterion does not apply to hallucinogens and inhalants.

"For the use or misuse of prescription drugs in Table 1, the number of applicable DSM-5 criteria for classifying respondents as having a prescription drug use disorder depends on whether respondents misused prescription drugs, or they used prescription drugs in the past year, but they did not misuse them. If respondents misused prescription drugs in the past year, they were classified as having a prescription drug use disorder if they met 2 or more of the 11 criteria shown in Table 1. However, if respondents used prescription drugs in the past year but did not misuse them, they were classified as having a prescription drug use disorder if they met two or more of the first nine criteria shown in Table 1. Criteria 10 (tolerance) and 11 (withdrawal) do not apply to respondents who used but did not misuse these prescription drugs in the past year; tolerance and withdrawal can occur as normal physiological adaptations when people use these prescription drugs appropriately under medical supervision.⁶⁶"

"In 2018, an estimated 269 million people worldwide had used drugs at least once in the previous year (range: 166 million to 373 million). This corresponds to 5.4 per cent of the global population aged 15–64 (range: 3.3 to7.5 per cent), representing nearly 1 in every 19 people.

"Over the period 2009–2018, the estimated number of past-year users of any drug globally increased from 210 million (range: 149 million to 272 million) to 269 million (range: 166 million to 373 million) – in other words, by more than a quarter (28 per cent) – partly as a result of growth in the global population. Consequently, the prevalence of drug use increased by over 12 per cent, from 4.8 per cent (range: 3.4 to 6.2 per cent) of the adult population in 2009 to 5.4 per cent (range: 3.3 to 7.5 per cent) in 2018. However, considering the wide uncertainty intervals of these estimates and that in any given year the global estimates represent the best available data, any comparison of the estimates over time should be undertaken with caution."

In 2019, among people aged 12 and older in the United States:
An estimated 35,803,000 people were past-month users of any illicit drug.
An estimated 31,606,000 people were past-month users of marijuana or hashish.
An estimated 3,101,000 people were past-month users any opioid (including heroin and prescription pain relievers).
An estimated 1,998,000 people were past-month users of cocaine.
An estimated 58,074,000 people were past-month users of tobacco products.
An estimated 139,727,000 people were past-month alcohol users, of whom 65,845,000 were "binge drinkers" (binge drinking is defined as five or more drinks (for males) or four or more drinks (for females) on the same occasion on at least one day in the past 30 days), of whom 16,044,000 were "heavy" alcohol users (heavy alcohol use is defined as binge drinking on the same occasion on each of five or more days in the past 30 days).

Table: Estimated Prevalence of Past-Month Substance Use in US by Those Aged 12 and Older (Numbers In Thousands)

"Consistent with the results of previous researchers,² there was no evidence that the legalization of medical marijuana encourages marijuana use among youth. Moreover, the estimates reported in the Table showed that marijuana use among youth may actually decline after legalization for recreational purposes. This latter result is consistent with findings by Dilley et al⁴ and with the argument that it is more difficult for teenagers to obtain marijuana as drug dealers are replaced by licensed dispensaries that require proof of age.⁶"

"For a number of years, 12th grade African-American students reported lifetime, annual, 30-day, and daily prevalence levels for nearly all drugs that were lower – sometimes dramatically so – than those for White or Hispanic 12th graders. That is less true today, with levels of drug use among African Americans more similar to the other groups. This narrowing of the gap between African Americans and other two racial/ethnic groups is also seen in 8th and 10th grade, indicating that this narrowing in 12th grade is almost certainly not due primarily to differential dropout rates.

"• Whites have the lowest levels of annual marijuana use in 8th grade, at 8% compared to 11.6% and 14.3% for African American and Hispanic students, respectively. In 10th and 12th grade annual marijuana use differs little by race/ethnicity.

"• A number of drugs are much less popular among African-American teens than among White teens, particularly at the higher grades. These include nicotine vaping, marijuana vaping, use of hallucinogens, nonmedical use of sedatives (barbiturates), tranquilizers, LSD, MDMA (ecstasy, Molly), nonmedical use of amphetamines, narcotics other than heroin, cocaine, and cocaine other than crack.

"• By 12th grade, White students have the highest lifetime and annual prevalence levels among the three major racial/ethnic groups for many substances, including alcohol use, being drunk, vaping nicotine, vaping marijuana, LSD, hallucinogens other than LSD, MDMA (ecstasy, Molly), and nonmedical use of narcotics other than heroin, amphetamines, and tranquilizers. Not all of these findings are replicated at lower grade levels, however. See Tables 4-5 and 4-6 for specifics.

"• Hispanics in 2019 had the highest annual prevalence at all three grade levels for synthetic marijuana, cocaine, crack, and cocaine other than crack. It bears repeating that Hispanics have a considerably higher dropout rate than Whites or African Americans, based on Census Bureau statistics, which should tend to diminish any such differences by 12th grade, yet there remain sizeable differences even in the upper grades.

"• In 8th grade – before most dropping out occurs – Hispanics had the highest levels of use of almost all substances, whereas by 12th grade Whites have the highest levels of use of most. Certainly the considerably higher dropout rate among Hispanics could help explain this shift. Another explanation worth consideration is that Hispanics may tend to start using drugs at a younger age, but Whites overtake them at older ages. These explanations are not mutually exclusive, of course, and to some degree both explanations may hold true.

"• Table 4-8 shows that White students have by far the highest prevalence of daily cigarette smoking while African American and Hispanic students are fairly close to each other among all three grades, for example, 12th grade Whites have a 3.5% daily smoking prevalence, Hispanics, 1.9%, and African Americans, 1.8%.

"• Thirty-day prevalence of smokeless tobacco use is highest among White students in 10th and 12th grade. The difference is quite pronounced in 12th grade, with prevalence rates of 5.6% for White students versus 1.5% for Hispanic and 1.3% for African American students.

"• African-American students have the lowest 30-day prevalence for alcohol use in all three grades. They also have the lowest prevalence for self-reports of having been drunk during the prior 30 days. The differences are largest at 12th grade, with 22% of Whites reporting having been drunk, 12% of Hispanics, and 11% of African Americans.

"• Recent binge drinking (having five or more drinks in a row during the prior two weeks) is also lowest among African Americans in all three grades; in 12th grade, their level of use is 6.7% versus 18% for Whites and 11% for Hispanics. The corresponding prevalence levels for 10th grade are 4.2% for African Americans vs. 9.7% for Whites and 9.3% for Hispanics. In 8th grade, Hispanics have the highest prevalence at 5.3% compared to 3.4% for Whites and 1.9% for African Americans.

"• Hispanic students have markedly lower levels of use for drugs used to treat ADHD than do White and African American students. In 2019 prevalence of use for either stimulant or non-stimulant prescription ADHD drugs was 5.5% among Hispanic students as compared to 12% for White students and 15% for African American students. Use of either of these drugs in the past 30 days is also much lower for Hispanic students, who have a prevalence level of 1.9% as compared to 5.8% for White students and 5.0% for African American students. As to why Hispanic students are less likely to be treated with ADHD drugs than White and African American students, possible contributing factors include Hispanic families being less likely to get access to, or be able to afford, professional assessment and treatment.

"• Levels of past-year use for diet pills did not differ much by race/ethnicity in 2019. They varied between a narrow range of 1.5% for Hispanic students and 2.5% for African American students, with White students in the middle at 2.0%."

"Crack cocaine use spread rapidly from the early to mid-1980s. Still, among 12th graders, the use of crack remained relatively low during this period (3.9% annual prevalence in 1987). Clearly, crack had quickly attained a reputation as a dangerous drug, and by the time of our first measurement of perceived risk in 1987, it was seen as the most dangerous of all drugs. Annual prevalence dropped sharply in the next few years, reaching 1.5% by 1991, where it remained through 1993. Perceived risk began a long and substantial decline after 1990 – again serving as a driver and leading indicator of use. (The decline in perceived risk in this period may well reflect generational forgetting of the dangers of this drug.)

"Annual prevalence among 12th graders rose gradually after 1993, from 1.5% to 2.7% by 1999. It finally declined slightly in 2000 and then held level through 2007. Since then, some additional decline has occurred. In 2016, annual prevalence for crack cocaine was at 0.8%.

"Among 8th and 10th graders, crack use rose gradually in the 1990s: from 0.7% in 1991 to 2.1% by 1998 among 8th graders, and from 0.9% in 1992 to 2.5% in 1998 among 10th graders. And, as just discussed, use among 12th graders peaked in 1999 at 2.7% and among young adults at 1.4%. Since those peak years, crack use has declined appreciably -- more than half among 8th, 10th, and 12th graders -- yet it held fairly steady among college students and young adults, at least until 2007, when use among college students finally began to decline. The 2016 prevalence levels for this drug were relatively low – less than 1% in all five groups. Twelfth graders had the highest prevalence. Annual crack prevalence among the college-bound has generally been considerably lower than among those not bound for college. Among 12th graders, the levels of use in 2016 were 0.7% for college-bound and 1.2% for noncollege-bound.

"We believe that the particularly intense and early media coverage of the hazards of crack cocaine likely had the effect of capping an epidemic early by deterring many would-be users and motivating many experimenters to desist use. As has been mentioned, when we first measured crack use in 1987, it had the highest level of perceived risk of any illicit drug. Also, it did not turn out to be “instantly addicting” upon first-time use, as had been widely reported. In some earlier years, 1994 and 1995 for example, 3% of 12th graders reported ever trying crack; however, only about 2% used in the prior 12 months and only about 1.0% used in the prior 30 days. It thus appears that, among the small numbers of 12th graders who have ever tried crack, the majority of those who tried it did not establish a pattern of continued use, let alone develop an addiction."

"Crack, a form of cocaine that comes in small chunks or 'rocks,' can be smoked to produce a rapid and intense but short-lasting high. In 2015 it had lifetime prevalence levels of under 2% in all three grade levels: 1.0% for 8th, 1.1% for 10th, and 1.7% for 12th graders.
"Of all students reporting any cocaine use in their lifetime, significant proportions have some experience with crack: Nearly two thirds of 8th-grade cocaine users (63%), two fifths of 10th-grade users (41%) and more than two fifths of 12th-grade users (43%) reported having used crack (data derivable from Table 4-1)."

"Trends in Substance Use
"Past month alcohol use, binge alcohol use, and illicit drug use remained relatively stable among black adults between 2002 and 2008 (Figure1).^4,5

"Past Month Alcohol and Illicit Drug Use
"Combined 2004 to 2008 data indicate that, in the past month, 44.3 percent of black adults used alcohol, 21.7 percent reported binge alcohol use, and 9.5 percent used an illicit drug (Figure 2).

"Rates of past month alcohol use and binge alcohol use were lower among black adults than the national averages. The rate of past month illicit drug use among black adults, however, was higher than the national average.

"Substance Use among Young Adults (Aged 18 to 25)
"Rates of past month and binge alcohol use were considerably lower among young black adults than the national average of young adults (48.6 vs. 61.1 percent and 25.3 vs. 41.6 percent, respectively) (Figure 3).

"Past month illicit drug use among young black adults was slightly lower than the national average (18.7 vs. 19.7 percent).

"Substance Use among Older Adults (Aged 65 or Older)
"Older black adults had a rate of past month alcohol use that was considerably lower than the national average of older adults (20.3 vs. 38.3 percent) (Figure 4). Their rates of binge alcohol use and past month illicit drug use, however, did not differ significantly from the national averages.

"Substance Use among Women
"Compared with the national averages, adult black females had lower rates of past month alcohol use and binge alcohol use and a slightly higher rate of past month illicit drug use (Table 1). Patterns varied by age group.

"Among women aged 18 to 44 who were pregnant at the time of the survey interview, blacks had a higher rate of binge alcohol use than the national average (8.1 vs. 3.6 percent) (Figure 5). As for past month alcohol use and past month illicit drug use, the rates appear to have been higher than the national average of pregnant women, but the differences were not statistically significant.

"Substance Use among Men
"Compared with the national averages, adult black males had lower rates of past month alcohol use and binge alcohol use and a slightly higher rate of past month illicit drug use (Table 2). Patterns varied by age group."

"Fifty-two percent of Hispanic youth report using illicit drugs in the past year (vs. 42 percent for African-American youth and 40 percent for Caucasian teens). They are also more likely than other teens to have used prescription medicine, Ecstasy or cocaine/crack to get high.
"Marijuana use levels are of significant concern among Hispanic youth. Half of Hispanic teens report smoking marijuana in the past year (43 percent more than Caucasian teens and 25 percent more than African-American youth)."

"UNODC, UNAIDS, WHO and the World Bank jointly estimate that some 11.2 million persons worldwide injected drugs in 2020. There has been no measurable change in the estimated global prevalence of injecting drug use from the previous estimate for 2019, which was also 0.22 per cent of the population aged 15–64. However, any trend data must be viewed with caution as the methodologies used to produce national or subnational PWID population size estimations may have changed.

"Approximately 59 per cent of PWID worldwide reside in East and South-East Asia, Eastern Europe and North America. Injecting drug use remains particularly prevalent in Eastern Europe and, to a lesser extent, Central Asia and Transcaucasia, and North America, with rates that are 5.8, 2.6 and 2.5 times the global average, respectively."

"PWID [People Who Inject Drugs] accounted for 9 per cent of new adult HIV infections worldwide in 2020, with the proportion rising to 20 per cent outside sub-Saharan Africa, where HIV disproportionately affects adolescent girls and young women.⁹¹ UNODC, UNAIDS, WHO and the World Bank jointly estimated that in 2020 approximately one in every eight (12.4 per cent, down from 12.6 per cent in 2019) PWID worldwide were living with HIV, amounting to 1.4 million people.

"The latest UNAIDS estimates suggest that in 2020, PWID had a risk of acquiring HIV that was 35 times greater than that of people who do not inject drugs.⁹² This underlines the greater vulnerability of PWID to HIV infection than have other key population groups more likely to be exposed to HIV or to transmit it.^{93, 94}

"As a tool to monitor progress in the testing and treatment of HIV, UNAIDS established the 90-90-90 targets in 2014 with the aim that by 2020, 90 per cent of people living with HIV would know their HIV status, 90 per cent of those diagnosed would be receiving antiretroviral treatment, and 90 per cent of those receiving treatment would have achieved viral suppression.⁹⁵ The sub-population of PWID living with HIV seems to be particularly far from these targets as shown by a study in selected countries in Europe and Central Asia.⁹⁶

"Eastern Europe and South-West Asia continue to be the subregions with the highest estimated prevalence of HIV among PWID, with more than one in four PWID in those two regions living with HIV. According to UNAIDS, Eastern Europe and Central Asia (as defined geographically by UNAIDS) is the region with the world’s fastest growing HIV epidemic, with the annual number of new adult HIV infections increasing by an estimated 43 per cent between 2010 and 2020. This is in contrast to a 31 per cent decline in the annual number of new adult HIV infections globally in the same period.⁹⁷"

"It is estimated that 61.3 million people (range: 36.5 million–78.1 million) had used opioids in the past year worldwide in 2020. This includes people who use opiates and people who use pharmaceutical opioids for non-medical purposes and corresponds to 1.2 per cent of the global population aged 15–64. The majority of people who use opioids are men – an estimated 85% based on data from 26 countries.

"Since 2017, both quantitative and qualitative information have pointed to a moderate increase in opioid use, with possible stabilization in 2020. Qualitative reporting suggests that between 2010 and 2017 most countries observed decreases in opioid use. However, it is challenging to confirm long-term trends in opioid use by means of quantitative estimates, since it is not always possible to determine if changes were the result of actual phenomena or merely the result of improved data. For example, global estimates show a sharp increase in use between 2016 and 2017, but this mainly represents new estimates made available for Asia and Africa.

"About half of the users of opioids had used opiates, mainly heroin and opium, in the past year. Opiate use includes, most often, the use of heroin and opium, but also non medical use of codeine and morphine. Opiate use constitutes part of overall opioid use and follows similar trends."

"Approximately 59 per cent of PWID worldwide reside in East and South-East Asia, Eastern Europe and North America. Injecting drug use remains particularly prevalent in Eastern Europe and, to a lesser extent, Central Asia and Transcaucasia, and North America, with rates that are 5.8, 2.6 and 2.5 times the global average, respectively."

"Our findings show that past-year and past-month cannabis use among non-Hispanic White respondents ages 21 years or older consistently increased following recreational cannabis legalization, while past-year and past-month use remained unchanged among non-Hispanic Black participants. No changes in use were observed for any racial or ethnic group among individuals aged 12 to 20, for whom cannabis use remains illegal. Nevertheless, Black people were still 1.72 times more likely to be arrested for cannabis possession in states that legalized cannabis before 2018,⁹ indicating that racist and discriminatory targeting of Black people persists despite changing policies.^9,10"

"• In 2013, 5.7 million persons aged 12 or older used marijuana on a daily or almost daily basis in the past 12 months (i.e., on 300 or more days in that period), which was an increase from the 3.1 million daily or almost daily users in 2006 (Figure 2.15). The number of daily or almost daily users of marijuana in 2013 represented 17.4 percent of past year users.
"• In 2013, 8.1 million persons aged 12 or older used marijuana on 20 or more days in the past month, which was an increase from the 5.1 million daily or almost daily past month users in 2005 to 2007 (Figure 2.15). The number of daily or almost daily users in 2013 represented 41.1 percent of past month marijuana users."

"In this report, estimates of the use of cocaine include use of crack cocaine. Estimates also are presented separately for crack use. In 2015, the estimate of about 1.9 million people aged 12 or older who were current users of cocaine (Figure 1) included about 394,000 current users of crack. These numbers correspond to about 0.7 percent of the population aged 12 or older who were current users of cocaine (Figure 7) and 0.1 percent who were current users of crack (Table A.1B in Appendix A). The 2015 estimate for current cocaine use was similar to the estimates in most years between 2007 and 2013, but it was higher than the estimate in 2014. The 2015 estimate of crack use was similar to the estimates in most years from 2008 to 2014. The 2015 estimates of both cocaine and crack use were lower than most of the estimates between 2002 and 2006."

"Data on people in drug treatment who mentioned cocaine products as their primary drug are limited to 26 countries, 20 of them in Europe, and show an increasing trend over the past decade. However, 70 per cent of the countries reported a decrease in the number of such patients in 2020, compared with the previous year, possibly confirming the general decrease in treatment delivery during the pandemic rather than a decrease in the number of people with cocaine use disorders.

"Wastewater-based epidemiology offers an additional source of information on trends in consumption of cocaine,^d although this method is limited to a relatively small number of cities, concentrated in Europe, followed by Oceania and Asia.⁴⁰ Long-term trend data with relatively good subregional coverage is only available for Western and Central Europe, although there were available paired data points for 2019 and 2020 for 66 cities across various regions. On average, the standardized quantity of findings of benzoylecgonine, the metabolite that signals the passing of cocaine through the human body, in wastewater dropped by 13 per cent from 2019 to 2020. However, the number of cities witnessing increased benzoylecgonine levels was almost identical to the number of cities experiencing decreases. As data became available for 2021, the trend seems to have returned to its pre-pandemic increasing trajectory. Overall, a 17 per cent increase in average loads was observed in 66 locations with available paired measurements. While 19 locations have recorded a decline and 9 locations a stable situation,^e 38 locations witnessed increases between 2020 and 2021.^f"

"• Table 8-8 lists the proportions of 12th graders in 2019 who favor various legal consequences for marijuana use. The proportion who believe it should be entirely legal was 51%, the highest level recorded by the survey. As the percentage favoring legality increased, the percentage believing marijuana use should be a crime decreased and in 2019 was 9%, the lowest level recorded by the survey, having fallen from a peak of 53% in 1990.

"• Asked whether they thought it should be legal to sell marijuana if it were legal to use it, about two in three (67%) said “yes,” matching the historic high of 67% set in 2017. However, about 87% of those answering “yes” (58% of all respondents) would permit sale only to adults. A small minority (9%) favored the sale to anyone, regardless of age, while 20% said that sale should not be legal even if use were made legal, and 13% said they “don’t know.” Thus, while the majority now subscribe to the idea of legal sale, if use is allowed, the great majority agree with the notion that sale to underage people should not be legal.

"• Most 12th graders felt that they would be little affected personally by the legalization of either the sale or the use of marijuana. Forty-three percent of the 2019 respondents said that they would not use the drug even if it were legal to buy and use, while others indicated that they would use it about as often as they do now (17%) or less often (1%). Only 10% said they would use it more often than they do at present, while 17% thought they would try it. Another 12% said they did not know how their behavior would be affected if marijuana were legalized. Still, this amounts to 27% of all 12th graders, or about one in four, who thought that they would try marijuana, or that their use would increase, if marijuana were legalized.

"• A study of the effects of decriminalization by several states during the late 1970s, based on MTF data, found no evidence of any impact on the use of marijuana among young people, nor on attitudes and beliefs concerning its use.18 However, it should be noted that decriminalization falls well short of the full legalization posited in the questions here. Moreover, the situation today is very different from the one in the late 1970s, with more peer disapproval and more rigorous enforcement of drug laws, at least until recently. Some more recent studies suggest that there might be an impact of decriminalization, because “youths living in decriminalized states are significantly more likely to report currently using marijuana.”¹⁹ One study using MTF data shows that prevalence of marijuana use among 12th grade Californian students significantly increased in the two years after decriminalization went into effect in 2011, and youth attitudes also became significantly more permissive.²⁰ As more states approve full legalization of recreational use for adults (as has occurred in California, Illinois, Massachusetts, Michigan, Nevada, Maine, Colorado, Washington, Oregon, Alaska, Vermont, and Washington, DC), it is possible that attitudes about, and use of, marijuana will change. Declines in perceived risk and disapproval of marijuana would seem the most likely attitudinal changes, and such changes may well lead to increased use among youth."

"• The prevalence of past month illicit drug use among adult full-time workers was 8.2 percent (Figure 2.3 and Tables 2.2 and 2.3).
"• Nearly one out of five (19.0 percent) workers aged 18 to 25 used illicit drugs during the past month. This was a higher percentage than among the 26-to-34 (10.3 percent), 35-to-49 (7.0 percent), and 50-to-64 (2.6 percent) age groups (Figure 2.3 and Table 2.2).
"• Males were more likely than females to report past month illicit drug use (9.7 vs. 6.2 percent). Males accounted for about two thirds (6.4 million) of the workers who reported past month illicit drug use (Figure 2.4 and Table 2.2).
"• The prevalence of past month illicit drug use for white adults was 8.8 percent, higher than the prevalence for Asian (2.2 percent) or Hispanic (6.7 percent) adults, and lower than that reported for adults who reported two or more races (13.5 percent). The prevalence of past month illicit drug use by Asians was lower than that reported by all other racial/ethnic groups reported here (Figure 2.5 and Table 2.2)."

"• The number and percentage of persons aged 12 or older who were current nonmedical users of stimulants in 2013 (1.4 million or 0.5 percent) were similar to those in 2012 (1.2 million or 0.5 percent), but were higher than the estimates in 2011 (970,000 or 0.4 percent)."

"• Approximately 3 million full-time workers (2.6 percent) aged 18 to 64 met the criteria for past year illicit drug dependence or abuse (Figure 2.3 and Table 2.4).

"• Approximately 7.5 percent of 18- to 25-year-old workers had past year illicit drug dependence or abuse. This was higher than among all other age groups studied (26- to 34-year-olds [3.3 percent], 35- to 49-year-olds [1.9 percent], and 50- to 64-year-olds [0.7 percent]) (Figure 2.3 and Table 2.4).

"• Males were nearly twice as likely as females to meet the criteria for past year illicit drug dependence or abuse (3.3 vs. 1.8 percent) (Figure 2.4 and Table 2.4).

"• Hispanics (3.2 percent) had a higher prevalence of past year illicit drug dependence or abuse than non-Hispanics (2.6 percent) (Figure 2.8 and Table 2.4).

"• Within non-Hispanic subgroups, Asians had the lowest prevalence of past year illicit drug dependence or abuse (1.1 percent). This was lower than non-Hispanic white adults (2.5 percent), black (2.9 percent) adults, American Indian or Alaska Native (4.5 percent) adults, and adults reporting two or more races (4.3 percent) (Figure 2.8 and Table 2.4)."

"Antidepressants were the third most common prescription drug taken by Americans of all ages in 2005–2008 and the most frequently used by persons aged 18–44 years. From 1988–1994 through 2005–2008, the rate of antidepressant use in the United States among all ages increased nearly 400%."

"In 2004, 6.0 million persons were current users of psychotherapeutic drugs taken nonmedically (2.5 percent). These include 4.4 million who used pain relievers, 1.6 million who used tranquilizers, 1.2 million who used stimulants, and 0.3 million who used sedatives. These estimates are all similar to the corresponding estimates for 2003.
"There were significant increases in the lifetime prevalence of use from 2003 to 2004 in several categories of pain relievers among those aged 18 to 25. Specific pain relievers with statistically significant increases in lifetime use were Vicodin®, Lortab®, or Lorcet® (from 15.0 to 16.5 percent); Percocet®, Percodan®, or Tylox® (from 7.8 to 8.7 percent); hydrocodone products (from 16.3 to 17.4 percent); OxyContin® (from 3.6 to 4.3 percent); and oxycodone products (from 8.9 to 10.1 percent)."

"With between 9.4 million and 28.2 million estimated past-year users in 2012, its use declined globally in the period 2010-2012, mainly in Western and Central Europe. Nevertheless, Oceania (2.9 per cent), North America (0.9 per cent) and Europe (0.5 per cent) remain regions with prevalence rates higher than the global average of 0.4 per cent."

Alcohol and Tobacco

"• Slightly more than half (52.2 percent) of Americans aged 12 or older reported being current drinkers of alcohol in the 2013 survey, which was similar to the rate in 2012 (52.1 percent). This translates to an estimated 136.9 million current drinkers in 2013.
"• Nearly one quarter (22.9 percent) of persons aged 12 or older in 2013 were binge alcohol users in the 30 days prior to the survey. This translates to about 60.1 million people. The rate in 2013 was similar to the rate in 2012 (23.0 percent).
"• In 2013, heavy drinking was reported by 6.3 percent of the population aged 12 or older, or 16.5 million people. This percentage was similar to the rate of heavy drinking in 2012 (6.5 percent)."

"• In 2013, an estimated 66.9 million Americans aged 12 or older were current (past month) users of a tobacco product. This represents 25.5 percent of the population in that age range (Figure 4.1). Also, 55.8 million persons (21.3 percent of the population) were current cigarette smokers; 12.4 million (4.7 percent) smoked cigars; 8.8 million (3.4 percent) used smokeless tobacco; and 2.3 million (0.9 percent) smoked tobacco in pipes.

"• Between 2002 and 2013, past month use of any tobacco product among persons aged 12 or older decreased from 30.4 to 25.5 percent, and past month cigarette use declined from 26.0 to 21.3 percent (Figure 4.1). Past month cigar use decreased from 5.4 percent in 2002 to 4.7 percent in 2013. Rates of past month use of smokeless tobacco and pipe tobacco were similar in 2002 and 2013."

"In 2002 and 2003, an estimated 88.2 percent of persons aged 21 or older (175.6 million) were lifetime alcohol users, whereas an estimated 11.8 percent (23.5 million) were lifetime nondrinkers. Over half of lifetime alcohol users (52.7 percent) had used one or more illicit drugs at some time in their life, compared to 8.0 percent of lifetime nondrinkers. Among persons who had used an illicit drug in their lifetime, the average age at first illicit drug use was 19 years for lifetime alcohol users, versus 23 years for lifetime nondrinkers."

"• As was the case in prior years, the level of alcohol use was associated with illicit drug use in 2013. Among the 16.5 million heavy drinkers aged 12 or older, 33.7 percent were current illicit drug users. Persons who were not current alcohol users were less likely to have used illicit drugs in the past month (4.3 percent) than those who reported current use of alcohol but no binge or heavy use (7.3 percent), binge use but no heavy use (18.5 percent), or heavy use of alcohol (33.7 percent).

"• Alcohol consumption levels also were associated with tobacco use in 2013. Among heavy alcohol users aged 12 or older, 53.1 percent smoked cigarettes in the past month compared with 16.2 percent of non-binge current drinkers and 15.5 percent of persons who did not drink alcohol in the past month. Smokeless tobacco use and cigar use also were more prevalent among heavy drinkers (12.1 and 15.4 percent, respectively) than among non-binge drinkers (2.0 and 3.9 percent) and persons who were not current alcohol users (2.0 and 1.8 percent)."

"Overall, supply reduction—that is, reducing the availability of drugs—does not appear to have played as major a role as many had assumed in four of the five most important downturns in illicit drug use that have occurred to date, namely, those for marijuana, cocaine, crack, and ecstasy (see, for example, Figures 8-4, 8-5, and 8-6). The case of cocaine is particularly striking, as perceived availability actually rose during much of the period of downturn in use that began in the mid- 1980s. (These data are corroborated by data from the Drug Enforcement Administration on trends in the price and purity of cocaine on the streets.⁸) For marijuana, perceived availability has remained very high for 12th graders since 1976, while use dropped substantially from 1979 through 1992 and has fluctuated considerably thereafter. Perceived availability for ecstasy did increase in parallel with increasing use in the 1990s, but the decline phase for use appears to have been driven much more by changing beliefs about the dangers of ecstasy than by any sharp downturn in availability. Similarly, amphetamine use declined appreciably from 1981 to 1992, with only a modest corresponding change in perceived availability. Finally, until 1995, heroin use had not risen among 12th graders even though availability had increased substantially.

"• What did change dramatically were young peoples’ beliefs about the dangers of using marijuana, cocaine, crack, and ecstasy. We believe that increases in perceived risk led to a decrease in use directly through their impact on young people’s demand for these drugs and indirectly through their impact on personal disapproval and, subsequently, peer norms. Because the perceived risk of amphetamine use was changing little when amphetamine use was declining substantially (1981–1986), other factors must have helped to account for the decline in demand for that class of drugs—quite conceivably some displacement by cocaine. Because three classes of drugs (marijuana, cocaine, and amphetamines) have shown different patterns of change, it is highly unlikely that a general factor (e.g., a broad shift in attitudes about drug use) can explain their various trends.

"• The increase in marijuana use in the 1990s among 12th graders added more compelling evidence to this interpretation. It was both preceded and accompanied by a decrease in perceived risk. (Between 1991 and 1997, the perceived risk of regular marijuana use declined 21 percentage points.) Perceived peer disapproval dropped sharply from 1993 through 1997, after perceived risk began to change, consistent with our interpretation that perceived risk can be an important determinant of disapproval as well as of use. Perceived availability remained fairly constant from 1991 to 1993 and then increased seven percentage points through 1998.⁹

"• We do think that the expansion in the world supply of heroin, particularly in the 1990s, had the effect of dramatically raising the purity of heroin available on the streets, thus allowing for new means of ingestion, such as snorting and smoking. The advent of new forms of heroin, rather than any change in respondents’ beliefs about the dangers associated with injecting heroin, very likely contributed to the fairly sharp increase in heroin use in the 1990s. Evidence from this study, showing that a significant portion of the self-reported heroin users in recent years are using by means other than injection, lends credibility to this interpretation. The dramatic decline in LSD use in the early to mid 2000s is also not explainable by means of concurrent changes in perceived risk or disapproval; but availability did decline sharply during this period and very likely played a key role in reducing the use of that drug.

"We should also note that other factors, such as price, could play an important role for some drugs. Analyses of MTF data have shown, for example, that price probably played an important role in the decline of marijuana use in the 1980s, and in changes in cigarette use in the 1990s.^10,11 However, price does not appear to have the same influence in all periods for all drugs, as the dramatic reduction in cocaine prevalence during the late 1980s took place at the same time that the price of cocaine decreased,¹² contrary to the supply/demand model."

"The prevalence of heroin use is extremely difficult to estimate despite the fact that harm to society associated with heroin marketing and use is substantial. A disproportionate number of heroin users are part of the nonsampled populations in general prevalence surveys (persons with no fixed address, prison inmates, etc.) Also, heroin users are believed to represent less than one half of one percent of our total population, making heroin usage a relatively rare event. Sample surveys are not sensitive enough to measure rare events reliable. Data from the National Household Survey on Drug Abuse (which is considered to produce conservative estimates), indicated that 1.9 percent of blacks, 1.6 percent of Hispanics, and 1.4 percent of whites had ever tried heroin. As will be noted later in this report, the data available from hospital emergency rooms and from drug abuse treatment programs indicated that heroin use is a more serious problem among blacks than whites and Hispanics."

"Marijuana, the most widely used of the illicit drugs, did not show any significant change in annual prevalence this year in any of the three grades, nor in the three grades combined. After rising for several years, the annual prevalence of marijuana has more or less leveled out since about 2010.
"This year, 12 percent of 8th ­graders, 25 percent of 10th ­graders and 35 percent of 12th ­graders reported using marijuana at least once in the prior 12 months. Of more importance, perhaps, is their daily or near-­daily marijuana use (defined as smoking marijuana on 20 or more occasions in the past 30 days). These rates stand at 1.1 percent, 3.0 percent and 6.0 percent in 8th, 10th and 12th grades, respectively.
"In other words, one in every 16 or 17 high school seniors is smoking marijuana daily or near daily. These rates have changed rather little since 2010, but are from three-­to-­six times higher than they were at their low point in 1991.
"'The proportion of our young people smoking marijuana this frequently remains a matter of concern,' Johnston said.[2],[3]
"He notes that the percent of students who see regular marijuana use as carrying a great risk of harm has declined substantially since about 2005, and is still declining. Over the past 10 years, the percent seeing a great risk in regular marijuana use has fallen among 8th ­graders from 74 percent to 58 percent, among 10th ­graders from 66 percent to 43 percent and among 12th­graders from 58 percent to 32 percent."

"• Support for laws prohibiting consumption of marijuana in private has been in substantial decline since 1990 and has fallen by more than half from a high of 56% (in 1990) to 21% in 2019, the lowest level recorded by the survey. This trend is almost a mirror image of the pattern before 1990, when the proportion who believed private marijuana use should be prohibited more than doubled, from 25% in 1978 to its level of 56% in 1990 – also a dramatic shift. The trend for prohibition of marijuana use in public follows very closely the same overall pattern seen for private use, with support for prohibition of public use running about 30 percentage points higher in every year. In 2019 it was 49%, the second lowest level ever recorded by the survey (the lowest was in 2018 at 48%).

"• In 2019 the proportions of 12th grade students agreeing that use of LSD, heroin, and amphetamines in private should be prohibited by law continued their long declines and were near historic lows (Table 8-7). The decline has been weakest for heroin, which seems to have maintained its reputation as a very dangerous drug, and support for legal prohibitions against its use in private stood at 68% in 2019. Steeper declines have been apparent for LSD and amphetamines. For all three drugs, the trends for support of legal prohibitions against public use are similar to their trends for private use, although levels of support of legal prohibitions against public use are higher and are 60% or above in all years. Specifically, in 2019 all three drugs – LSD, heroin, and amphetamines – were at or near the lowest levels recorded by the survey.

"• The proportion of 12th graders who said smoking cigarettes “in certain specified public places” should be prohibited by law was 36% in 2019, a historic low. The proportion has dipped below the 40% level where it had hovered since 2013. In earlier years level of support hovered at around 45% since the 1980s and showed surprisingly little change given the steady decline in smoking prevalence over the course of the survey. Given recent widespread prohibitions of smoking in many public and private places, it is possible that the assumed definition of “certain specified public places” has expanded in the minds of many 12th graders.

"• Attitudes about the legality of drunkenness in public significantly declined in 2019 to 41%, a historic low. In the past decade the percentage of 12th grade students favoring prohibition of public drunkenness had varied within the narrow range of 46% to 50%. This historic low in 2019 joins historic lows in attitudes toward both smoking cigarettes and marijuana use in public, suggesting a growing, general opposition to legal prohibition of public drug use, at least for the most commonly used substances. For private drunkenness, support for a prohibition ranged from 19% to 23% over the past decade, and in 2019 registered at 21%."

"Cannabis is perceived to be the easiest illicit substance to get hold of, with around one third of ESPAD students (32 %) rating cannabis as easily obtainable. More students in the Netherlands, Denmark, Czechia, Slovenia and Slovakia than in the other ESPAD countries perceived cannabis to be easily available (rates from 45 % to 51 %). The countries with the lowest perceived availability of cannabis were Kosovo (11 %), Ukraine (13 %), Romania (16 %) and North Macedonia (19 %). Boys were more likely than girls to consider cannabis to be easily available (ESPAD average: 34 % for boys versus 30 % for girls).

"Compared with cannabis, perceived availability was low for ecstasy (MDMA) (14 %), cocaine (13 %), amphetamine (10 %) and methamphetamine (8.5 %). These drugs were perceived to be more easily available in Bulgaria, Sweden and Denmark than elsewhere in Europe.

"The perceived availability of ecstasy was highest (over 20 %) in Slovakia, Czechia, Slovenia and the Netherlands, whereas for cocaine it was highest in Denmark and Ireland (22 % each). The countries with the lowest perceived availability of nearly all illicit drugs were Kosovo, Georgia and Romania.

"On average, 2.4 % of the ESPAD students reported having used cannabis for the first time at age 13 or younger. The highest proportions were found in France (4.5 %), Italy (4.4 %), Latvia (3.8 %), Cyprus (3.6 %) and Estonia (3.5 %). Rates of early onset of amphetamine/methamphetamine use were lower (ESPAD average: 0.5 %), with the highest proportion in Bulgaria (1.8 %). Boys were more likely than girls to have used cannabis or amphetamine/ methamphetamine at age 13 or younger. Similar results were found for early onset of ecstasy and cocaine use.

"The average prevalence of lifetime use of illicit drugs was 17 %, with considerable variation across ESPAD countries. It should be noted that this mainly relates to cannabis use (average lifetime prevalence of 16 %). The highest proportions of students reporting lifetime use of any illicit drug were found in Czechia (29 %), Italy (28 %), Latvia (27 %) and Slovakia (25 %). Particularly low levels (10 % or less) of lifetime illicit drug use were noted in Kosovo, Iceland, North Macedonia, Ukraine, Serbia, Sweden, Norway, Greece and Romania."

"Illicit drug use in 2011 varied by the educational status of adults aged 18 or older, with the rate of current illicit drug use lower among college graduates (5.4 percent) than those with some college education (10.4 percent), high school graduates (8.9 percent), and those who had not graduated from high school (11.1 percent)."

"In the 2010 Census, 97 percent of all respondents (299.7 million) reported only one race (see Table 1).¹⁰ The largest group reported White alone (223.6 million), accounting for 72 percent of all people living in the United States.¹¹ The Black or African-American alone population was 38.9 million and represented 13 percent of the total population.¹² There were 2.9 million respondents who indicated American Indian and Alaska Native alone (0.9 percent). Approximately 14.7 million (about 5 percent of all respondents) identified their race as Asian alone."

"• Among adults aged 50 to 64, the rate of current illicit drug use increased from 2.7 percent in 2002 to 6.0 percent in 2013. For adults aged 50 to 54, the rate increased from 3.4 percent in 2002 to 7.9 percent in 2013 (Figure 2.10). Among those aged 55 to 59, the rate of current illicit drug use increased from 1.9 percent in 2002 to 5.7 percent in 2013. Among those aged 60 to 64, the rate of current illicit drug use increased from 1.1 percent in 2003 and 2004 to 3.9 percent in 2013."

Substance Use in the Military

"The prevalence of any reported illicit drug use (including prescription drug misuse) during the past 30 days declined sharply from 28% in 1980 to 3% in 2002. In 2005, the prevalence of illicit drug use for the past 30 days was 5% and in 2008 it was 12%. Improved question wording in 2005 and 2008 may partially account for the higher observed rates, which are largely attributable to reported increases in misuse of prescription pain medications (see Section 3.3.2 for additional discussion). Because of wording changes, data from 2005 and 2008 are not comparable to data from prior surveys and are not included as part of the trend line. An additional line from 2002 to 2008 shows estimates of illicit drug use excluding prescription drug misuse. As shown, those rates were very low (2% in 2008) and did not change across these three iterations of the survey."

"• In the 2018 HRBS [Health Related Behaviors Survey], 34.0 percent of all service members reported binge drinking in the past 30 days (Table 5.1).

"• In the most recent comparable U.S. general population estimate of adults age 18 and above from the 2018 NSDUH, 26.5 percent of adults reported binge drinking in the past 30 days (Substance Abuse and Mental Health Services Administration, 2019c, Table 2.30B). Some of the disparity between the military and general populations is likely due to the high percentage of men and young adults in the armed forces; both groups are more likely to binge drink within the U.S. general population (Substance Abuse and Mental Health Services Administration, 2019c, Tables 2.30B and 2.32B).

"• The HP2020 [Health People 2020] target for binge drinking in the general population is for 24.2 percent or less of adults to engage in binge drinking (Healthy People, 2020o), which is well below the 2018 HRBS estimate.

"• Across all services, 9.8 percent of personnel reported heavy drinking in the past 30 days (Table 5.1). In the U.S. adult population in 2018, 6.6 percent reported heavy drinking in the past month (Substance Abuse and Mental Health Services Administration, 2019c, Table 2.31B); however, as noted, this is not a direct comparison due to variations in definitions between the 2018 HRBS and the 2018 NSDUH. Using the recalculated variation of the 2017 NSDUH heavy drinking rates, we found that 8.9 percent (CI: 8.4–9.3) of the U.S. adult population in 2017 reported heavy drinking.

"• Binge drinking and heavy drinking varied substantially by service branch. Both binge drinking and heavy drinking were highest in the Marine Corps and Navy, with Marines reporting significantly higher rates of both binge drinking and heavy drinking than all other services except the Navy, and the Navy reporting significantly higher rates of binge drinking and heavy drinking than all other services except the Marines. The Air Force had the lowest percentages of binge drinking and heavy drinking (Table 5.1).

"• Binge drinking and heavy drinking varied by pay grade. For binge drinking, senior officers (O4–O6) reported significantly lower rates of binge drinking than all other pay grades except warrant officers. Junior officers reported significantly higher rates than senior enlisted personnel. For heavy drinking, senior officers (O4–O6) again reported significantly lower rates of heavy drinking than all other pay grades except warrant officers. Junior enlisted personnel (E1–E4) reported significantly higher rates than junior officers (O1–O3) and senior officers (O4–O6). Noncommissioned officers (NCOs; E5–E6) also reported higher rates of heavy drinking than junior and senior officers. (Table 5.2).

"• Binge drinking and heavy drinking were more common among men than among women (Table 5.3). For example, the rate of heavy drinking was nearly double among men than among women.

"• For age, progressively higher percentages of binge drinking and heavy drinking were present with decreasing age (Appendix Table D.22). For race/ethnicity, there were no significant differences between groups for either binge drinking or heavy drinking (Appendix Table D.21)."

"For the DoD services, the percentage of military personnel who smoked cigarettes in the past 30 days decreased significantly from 51% in 1980 to 30% in 1998. It increased significantly from 1998 (30%) to 2002 (34%), and while not showing significant declines in 2005 (32%) and in 2008 (31%), has been slowly trending downward since 2002."

"Military personnel aged 18 to 25 showed significantly higher rates of heavy drinking (26%) than did civilians (16%).
"Likewise, military personnel aged 26 to 35 showed higher rates of heavy drinking (18%) than did their civilian counterparts (11%). For those aged 36 to 45, this rate was slightly higher for military personnel than civilians (10% vs. 8%) though this difference did not reach statistical significance.
"Among those aged 46 to 64, military personnel exhibited lower rates of heavy alcohol use (4%) than did civilians (9%).
"Across all age groups, military personnel showed significantly higher rates of heavy drinking (20%) than did civilians (14%)."

Sociopolitical Research

"There were little or no differences in the probability of employment by lifetime alcohol and drug use patterns. Men who had an alcohol disorder at some point in their life were equally likely as men who had never drunk alcohol to be currently employed (.91) and only slightly less likely than moderate alcohol users (.91 vs. .92, p=.09). Similarly, men who had a drug disorder at some point in their life were somewhat less likely (.90 vs. 92, p=.07) to be currently employed, but there was no statistically difference between moderate drug users and non-users. Differences among men by their current (last 12 months) alcohol and, especially, drug use patterns were greater. Current moderate alcohol drinkers were actually more likely than those who had not drunk alcohol in the last year to be employed (.93 vs. 91), while those with a current alcohol problem were less likely to be employed than either moderate or nondrinkers (.89). In contrast to moderate alcohol users, current moderate drug users were less likely to be employed than nonusers (.88 vs. .92). Men with a current drug problem were substantially less likely to be employed (.82) than either moderate or non drug users."

(Use Unrelated to Enforcement) "Opponents of drug policy reform commonly argue that drug use would increase if health-based models were emphasized over drug law enforcement,¹⁴ but we are unaware of any research to support this position. In fact, a recent World Health Organization study demonstrated that international rates of drug use were unrelated to how vigorously drug laws were enforced, concluding that 'countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones.'¹⁵"

"In conclusion, this study found that chronic drug use was significantly related to employment status for men and women. On the other hand, male chronic drug users were less likely to participate in the labor force, but no significant relationship existed between chronic drug use and labor force participation for females. Perhaps the most important finding of this study, however, was the lack of any significant relationships between nonchronic drug use, employment, and labor force participation. An implication of this finding is that employers and policy makers should focus on problematic drug users in the same way that they focus on problematic alcohol users."

"We conclude that there is an association between substance use and occupational injury. This association is stronger for males and in certain industries, such as manufacturing and construction, and may also be stronger for younger workers, though future research is needed on this last point. The proportion of injuries caused by substance use, however, is relatively small. Instead, there is mounting evidence that harmful substance use is one of a constellation of behaviors exhibited by certain individuals who may avoid work-related safety precautions and take greater work-related risks. Thus, we suspect that it is more likely that risk-taking dispositions, often termed deviance proneness, and other omitted factors can explain most empirical associations between substance use and injuries at work."

"Legal and illegal use of drugs was most strongly associated with age, sex, and income. Higher income was associated with a greater likelihood of drug use for all drug types examined, which is perhaps not surprising given that drug use requires disposable income. Relationship status was linked to illegal (but not legal) drug use: both cocaine and cannabis use were more likely among persons who had never been married or previously been married."

"The use of drugs seems to be a feature of more affluent countries. The US, which has been driving much of the world’s drug research and drug policy agenda, stands out with higher levels of use of alcohol, cocaine, and cannabis, despite punitive illegal drug policies, as well as (in many US states), a higher minimum legal alcohol drinking age than many comparable developed countries. The Netherlands, with a less criminally punitive approach to cannabis use than the US, has experienced lower levels of use, particularly among younger adults. Clearly, by itself, a punitive policy towards possession and use accounts for limited variation in nation level rates of illegal drug use."

"Some scientists have recently turned to the sewer to develop a more accurate estimate of drug use. They examine tiny samples of raw sewage for the presence of illicit drugs and their metabolites in a science known as sewer epidemiology.⁴ These samples are essentially a diluted urine test collected from an entire community,⁵ making them akin to a “community urinalysis.”⁶ The basic science is simple: nearly every drug ingested into the body is eventually excreted and finds its way into the sewer system, allowing scientists to profile a community’s drug use based on objective data."

"Marijuana use declined in the early 2000s, but subsequently rebounded before leveling in the past couple of years. In 2014 the percentage of youth who used marijuana in the past year among students in 12th, 10th, and 8th grade was 35.1%, 27.3%, and 11.7%, respectively.
"It is important to note that 8th grade students were the first to show the two major shifts in marijuana prevalence — an increase at the start of the 1990s and a decrease by the end of the 1990s. As mentioned above, this suggests that 8th graders may be the most immediately responsive to changing influences in the larger social environment. The lag in the decline in the later grades likely reflects some cohort effects (i.e., lingering effects of changes in use that occurred when the students were in lower grades).
"Levels of annual marijuana use today are considerably lower than the historic highs observed in the late 1970s, when more than half of U.S. 12th graders had used marijuana in the past year. This high point marked the pinnacle of a rise in marijuana use from relatively negligible levels before the 1960s.²
"Important changes in young people’s attitudes and beliefs about marijuana use have occurred over the study period, and these changes can account for much of the long-term decline in use, as well as the increase in use during the 1990s drug relapse. Chapter 8 contains a more thorough discussion of this issue.
"• Figure 5-4a and Table 5-5d provide trends in daily marijuana use. These trends depart somewhat from the typical pattern seen for drug use because, among 12th graders, today’s level of use is actually higher than it was at the end of the 1990s relapse period. Although daily use of marijuana declined somewhat in 2014 as compared to the previous year, the average level since 2010 (i.e., 2011–2014 combined) is the highest recorded in the past two decades. (See Chapter 10 for additional information on the cumulative amount of daily marijuana use among 12th graders. It shows that the proportion using marijuana daily for a month or more at any time in the past is considerably higher than the proportion reporting daily marijuana use during just the past month.) The overall trends follow a similar pattern in 12th, 10th, and 8th grade, and in 2014 prevalence levels of daily marijuana use were 5.8%, 3.4%, and 1.0%, respectively. About one in every 17 twelfth-grade high school students in 2014 was a daily or near-daily marijuana user.
"Still, the percentage of youth using marijuana on a daily basis today is substantially lower than its peak in the late 1970s, when it reached a high of 10.7% among 12th grade students. As we will discuss in Chapter 8, we think much of the decline from this peak is attributable to a very substantial increase in teens’ concerns about possible adverse effects from regular use and to a growing perception that peers disapproved of marijuana use, particularly regular use. The recent surge in daily marijuana use since 2009 among 12th-grade students tracks with concurrent, decreasing levels of perceived harmfulness and disapproval of regular marijuana use.
"• In 2014 marijuana use showed a one-year, slight decline in lifetime, annual, thirty-day, and daily use in all three grades. This finding is unexpected in light of the positive publicity marijuana has received in recent years prior to the data collection in 2014, with several states allowing medical marijuana use and two states (Colorado and Washington) legalizing recreational use for adults. Further, perceived risk of marijuana use among adolescents has declined in recent years (discussed in more detail in Chapter 8), which also supports an expectation for an increase in marijuana use this year. The study results point to the need for further qualitative and quantitative research to analyze why marijuana use has not increased in the last two or three years as expected."

"Any prescription drug misuse includes use of narcotics, sedatives, tranquilizers, and/or amphetamines without medical supervision. It has been of considerable public health concern in recent years, because most of these drugs showed a substantial increase in use in the 1990s, which then continued into the first decade of the 2000s, when many of the illegal drugs already were in decline.
"Only 12th-graders report on their use of all of these drugs; they show a statistically significant decline between 2013 and 2014, from 16 percent to 14 percent, saying that they used one or more of these prescription drugs in the 12 months prior to the survey. The gradual turnaround began after 2005, when 17 percent indicated misuse of any of these drugs.
"'It's not as much progress as we might like to see, but at least the number of students using these dangerous prescription drugs is finally declining,' Johnston said.
"Narcotic drugs other than heroin—among the most dangerous of the prescription drugs—have been declining in use by 12th-graders since 2009, when 9 percent indicated using them without medical supervision in the prior 12 months. Their use continued to drop significantly, from 7 percent in 2013 to 6 percent in 2014. Use of these drugs is reported only for 12th grade; students are reporting that these drugs are increasingly difficult to obtain.
"Use in the prior 12 months of the specific narcotic analgesic OxyContin also declined this year, significantly so in 8th grade. OxyContin use reached a recent peak among adolescents around 2009 and use has declined since then in all three grades. The 2014 reports of use in the past 12 months stand at 1.0 percent, 3.0 percent and 3.3 percent in grades 8, 10 and 12, respectively."

"• Substantial differences were found in perceived availability of the various drugs. In general, the more widely used drugs are reported to be available by higher proportions of the age group, as would be expected (see Tables 9-6, 9-7, and 9-8). Also, older age groups generally perceive drugs to be more available. For example, in 2013, 39% of 8th graders said marijuana would be fairly easy or very easy to get (which we refer to as 'readily available'), versus 70% of 10th graders and 81% of 12th graders. In fact, compared to 8th graders, the proportion of 12th graders indicating that drugs are available to them is two to four times as high for other drugs included in the study and five times as high for narcotics other than heroin. (Tranquilizers, on the other hand, are reported as only a little less available by 8th graders.) Both associations are consistent with the notion that availability is largely attained through friendship circles. (A section in Chapter 10 documents where 12th graders obtain prescription drugs that are not medically prescribed, and friends clearly are the leading source.) The differences among age groups may also reflect less willingness and/or motivation on the part of those who deal drugs to establish contact with younger adolescents. Because many inhalants — such as glues, butane, and aerosols — are universally available, we do not ask about their availability. See Table 9-8 for the full list of drugs included in the questions for 12th graders; a few of these drugs were not asked of the younger students (see Tables 9-6 and 9-7).
"• Measures on the availability of cigarettes are not included in the 12th-grade questionnaires because we have assumed that they are almost universally available to this age group. However, data on this measure are collected from 8th and 10th graders, which clearly show that cigarettes are readily available to most of them. In 2013, 50% of 8th graders and 71% of 10th graders thought that cigarettes would be fairly easy or very easy for them to get if they wanted some.
"• The great majority of teens also see alcohol as readily available: In 2013, 56% of 8th graders, 77% of 10th graders, and 90% of 12th graders said it would be fairly easy or very easy to get."

Table: Annual Prevalence of Use of Various Drugs by US Youth in Grades 8, 10, and 12 Combined, 1998-2014