"The prevalence of lifetime substance use among adolescents in 2018 was 26.3% (95% CI, 25.4-27.2) for alcohol, 15.4% (95% CI, 14.7-16.1) for cannabis, and 13.4% (95% CI, 12.7-14.1) for tobacco; among young adults in 2018, prevalence of lifetime substance use was 79.7% (95% CI, 78.9- 80.5) for alcohol, 51.5% (95% CI, 50.4-52.6) for cannabis, and 5.0% (95% CI, 53.9-56.1) for tobacco. Prevalence of SUDs differed by substance, age group, and time since initiation. Adjusted prevalence of cannabis use disorder was higher among adolescents than among young adults within 12 months of initiation (10.7%; 95% CI, 9.3-12.3 vs. 6.4%; 95% CI, 5.2-7.9) and at more than 36 months (20.1% [95% CI, 18.0-22.3] vs. 10.9% [95% CI, 10.3-11.4]) (Table). Prevalence of alcohol use disorder and nicotine dependence did not differ between the 2 groups within 12 months of initiation but was higher for young adults in subsequent periods.

"Among young adults, prevalence of lifetime cocaine, methamphetamine, and heroin use in 2018 was 11.4% (95% CI, 10.7-12.1), 2.5% (95% CI, 2.2-2.8), and 1.3% (95% CI, 1.1-1.5), respectively. Within 12 months of initiation, adjusted prevalence was higher for methamphetamine use disorder (24.8% [95% CI, 16.8-34.9]) and heroin use disorder (30.9% [95% CI, 20.6-43.4]) than for cocaine use disorder (5.6% [95% CI, 4.2-7.4]). Estimates for adolescents were not reported owing to limited samples.

"Prevalence of lifetime misuse of prescription drugs in 2014 was 9.2% (95% CI, 8.7-9.7) among adolescents and 26.3% (95% CI, 25.4-27.2) among young adults. Among the population with lifetime misuse, adjusted prevalence of prescription opioid use disorder, prescription stimulant use disorder, and prescription tranquilizer use disorder were consistently higher for adolescents than for young adults (Figure). Prevalence since time of initiation for adolescents was stable for prescription opioid use disorder and decreased for prescription stimulant use disorder and prescription tranquilizer use disorder, whereas for young adults, prevalence increased for prescription opioid use disorder and was stable for prescription stimulant use disorder and prescription tranquilizer use disorder."

"Among people aged 12 or older in 2019, 60.1 percent (or 165.4 million people) used a substance (i.e., tobacco, alcohol, kratom, or an illicit drug) in the past month. In particular, 50.8 percent (or 139.7 million people) drank alcohol in the past month, 21.1 percent (or 58.1 million people) used a tobacco product in the past month, and 13.0 percent (or 35.8 million people) used an illicit drug in the past month. In addition, 0.3 percent (or 825,000 people) used kratom in the past month."

"• Among people aged 12 or older, the percentage with a past year substance use disorder (SUD) (i.e., alcohol use disorder, illicit drug use disorder, or both) remained stable between 2015 and 2019. Among the 20.4 million people aged 12 or older with a past year SUD in 2019, 71.1 percent (or 14.5 million people) had a past year alcohol use disorder, 40.7 percent (or 8.3 million people) had a past year illicit drug use disorder, and 11.8 percent (or 2.4 million people) had both an alcohol use disorder and an illicit drug use disorder in the past year.

"• Among people aged 12 or older, the percentage with a past year alcohol use disorder declined from 7.7 percent (or 18.1 million people) in 2002 to 5.3 percent (or 14.5 million people) in 2019. Over that same period, the percentage with a past year cocaine use disorder declined from 0.6 percent (or 1.5 million people) to 0.4 percent (or 1.0 million people).

"• Among people aged 12 or older, the percentage with a past year prescription pain reliever use disorder decreased from 0.8 percent (or 2.0 million people) in 2015 to 0.5 percent (or 1.4 million people) in 2019. Over that same period, the percentage with a past year opioid use disorder also decreased from 0.9 percent (or 2.4 million people) to 0.6 percent (or 1.6 million people).

"• Among adolescents aged 12 to 17, the percentage with a past year marijuana use disorder declined from 4.3 percent (or 1.1 million people) in 2002 to 2.8 percent (or 699,000 people) in 2019. Among adults aged 26 or older, however, the percentage with a past year marijuana use disorder increased from 0.8 percent (or 1.4 million people) in 2002 to 1.0 percent (or 2.2 million people) in 2019.

"• Among adults aged 26 or older, the percentage with a past year methamphetamine use disorder increased from 0.3 percent (or 539,000 people) in 2016 to 0.4 percent (or 904,000 people) in 2019. The percentage with a past year prescription pain reliever use disorder decreased from 0.7 percent (or 1.5 million people) in 2015 to 0.5 percent (or 1.1 million people) in 2019."

"• Figure 5-4a and Table 5-5d provide trends in daily marijuana use, defined as using marijuana on 20 or more occasions in the prior 30 days. Among 12th grade students, the 2019 level of 6.4% is the highest level recorded by the survey since 2013. About one in every 16 twelfth grade students in 2019 was a daily or near-daily marijuana user. Daily marijuana use significantly increased in 8th and 10th grade in 2019, to 1.3% and 4.8%, respectively.

"In context, the percentage of youth using marijuana on a daily or near-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, or about one in every nine students. As discussed 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. In recent years teens have reported less concern about marijuana’s potential adverse effects and less disapproval of it (reported in Chapter 8), and daily use has risen considerably since the early 1990s.

"• Table 5-4 presents trend data on lifetime daily marijuana use for a month or more (this question is asked only of 12th grade students and on only one form). Prevalence in 2019 (15%) is between the high of 21% (set in 1982, when first measured by the survey) and the low of 8% (set in 1992, just before the 1990s drug relapse). Before 2011, prevalence hovered at around 16% since 1996, then rose in 2011 and 2012 along with current daily use, before declining some and then remaining stable in recent years. In a pattern seen with many other drugs, prevalence increased considerably during the 1990s relapse (from 1992 to 1997) having decreased considerably prior to the relapse.

"• Medical marijuana prescriptions for adolescents have been surveyed since 2017 and are rare. In all grades and in all years, fewer than 1.5% of adolescents reported that they had ever used marijuana because a doctor told them to do so.

"• Annual prevalence of synthetic marijuana has decreased dramatically since it was first tracked by Monitoring the Future in 2011 for 12th graders and 2012 for 8th and 10th graders (Table 5-5b and Figure 5-4b). For 12th graders, annual prevalence declined from 11.4% in 2011 to 3.3% in 2019, a drop of more than two-thirds. For 10th graders, annual prevalence declined from 8.8% in 2012 to 2.6% in 2019. For 8th graders the decline was from 4.4% in 2012 to 2.12 in 2019.

"The current 2.7% level in 8th grade reflects a significant 1.1 percentage point increase in 2019, which is concerning. It may be that 8th graders are confusing synthetic marijuana with marijuana vaping, which increased significantly in 2019 (discussed below). This could explain the unusual finding of a slightly higher prevalence among 8th as compared to 10th grade students."

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)

"Of the estimated 585,000 deaths attributed to drug use in 2017, half are attributed to liver cancer, cirrhosis and other chronic liver diseases related to hepatitis C, which remains mostly untreated among PWID. Deaths attributed to drug use disorders (167,000) account for 28 per cent of all deaths resulting from drug use; 110,000 or 66 per cent of those deaths are attributable to opioids. Over the past decade, the total number of deaths attributed to drug use has increased by a quarter, with a major increase in deaths caused by opioid use disorders (71 per cent increase), followed by cirrhosis and other chronic liver diseases (55 per cent increase) and liver cancer (46 per cent) resulting from hepatitis C.

"The comparison of deaths attributed to drug use among men and women over the past decade shows that the number of deaths attributed to drug use disorders, in particular opioid use disorders, has increased disproportionately among women, with a 92 per cent increase in deaths attributed to opioid use disorders among women compared with a 63 per cent increase among men."

"The illicit drugs with the largest number of recent initiates in 2016 were marijuana (2.6 million new users), prescription pain relievers (2.1 million new misusers), prescription tranquilizers (1.4 million new misusers), prescription stimulants (1.4 million new misusers), hallucinogens (1.2 million new users), and cocaine (1.1 million new users). In addition, there were 4.6 million new users of alcohol, 1.8 million people who tried a cigarette for the first time in the past year, and 1.2 million people who first used smokeless tobacco in the past year.³⁴

"Figure 12 provides an overview of the average age at first use (or first misuse for prescription drugs) in 2016 among recent initiates aged 12 to 49. For many substances, the average age at initiation in 2016 was younger than age 20, with average ages of 17.4 years for alcohol, 18.0 years for cigarettes, 18.2 years for inhalants, 19.3 years for marijuana, and 19.6 years for any hallucinogen. However, some substances had older average initiation ages, such as methamphetamine (24.6 years) and heroin (25.5 years). The average ages at initiation for prescription drug misuse were in the early to mid-20s (23.9 years for prescription tranquilizers, 24.3 years for prescription stimulants, 24.4 years for prescription pain relievers, and 24.8 years for prescription sedatives)."

"In 2018, an estimated 164.8 million people aged 12 or older used a substance (i.e., tobacco, alcohol, or an illicit drug) in the past month (Figure 1). This number of current substance users corresponds to 60.2 percent of the population. About 2 out of 5 people aged 12 or older (108.9 million, or 39.8 percent) did not use substances in the past month.

"The 164.8 million current substance users in 2018 include 139.8 million people who drank alcohol, 58.8 million people who used a tobacco product, and 31.9 million people who used an illicit drug (2018 DT 7.3). These numbers are not mutually exclusive because respondents could have used more than one type of substance (e.g., tobacco products and alcohol) in the past month.

"Although about half of the people aged 12 or older (51.1 percent) drank alcohol in the past month and 1 in 5 (21.5 percent) used a tobacco product, use of illicit drugs was less common (Table A.1B). About 1 in 9 people aged 12 or older (11.7 percent) used an illicit drug in the past month."

"In 2015, 138.3 million Americans aged 12 or older reported current use of alcohol, 66.7 million reported binge alcohol use in the past month, and 17.3 million reported heavy alcohol use in the past month (Figure 21). Thus, nearly half of current alcohol users reported binge alcohol use (48.2 percent), and about 1 in 8 current alcohol users reported heavy alcohol use (12.5 percent). Among binge alcohol users, about 1 in 4 (26.0 percent) were heavy users.

"Current Alcohol Use
"The estimate of 138.3 million current alcohol users aged 12 or older in 2015 (Figure 21) corresponds to alcohol use in the past month by slightly more than half (51.7 percent) of people aged 12 or older (Figure 22). The 2015 estimate of past month alcohol use was similar to the estimate in 2005 to 2013, but it was lower than the 2014 estimate."

"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."

"• In 2013, among persons aged 12 or older, the rate of current illicit drug use was 3.1 percent among Asians, 8.8 percent among Hispanics, 9.5 percent among whites, 10.5 percent among blacks, 12.3 percent among American Indians or Alaska Natives, 14.0 percent among Native Hawaiians or Other Pacific Islanders, and 17.4 percent among persons reporting two or more races.
"• There were no statistically significant differences in the rates of current illicit drug use between 2012 and 2013 for any of the racial/ethnic groups. Between 2002 and 2013, the rate of current illicit drug use increased from 8.5 to 9.5 percent for whites. Among blacks, the rate increased from 8.7 percent in 2003 and 2004 to 10.5 percent in 2013 (Figure 2.12)."

"The estimate of current heroin use in 2015 among people aged 12 or older was higher than the estimates in most years between 2002 and 2009, but it was similar to the estimates between 2010 and 2014 (Figure 8). However, even when there was a statistically significant difference between the 2015 estimate and prior years, the percentages were approximately the same, except for the estimate in 2014 (0.2 percent). For example, all of these estimates for current heroin use rounded to 0.1 percent. In 2014, the estimate of current heroin use was higher than in all previous years; however, the 2015 estimate does not provide strong support that the increase in 2014 signaled the start of a change in the trend. Future survey years will be useful for monitoring this trend.
"The estimate of past year heroin use in 2015 (0.3 percent) was also higher than the estimates for most years between 2002 and 2008, but it was similar to the estimates between 2009 and 2014 (Figure 9). This shift in heroin use among people aged 12 or older reflects changes in heroin use by adults aged 26 or older and, to a lesser extent, smaller increases in heroin use among young adults aged 18 to 25."

"As noted in the illicit drug use section, an estimated 22.2 million Americans aged 12 or older in 2015 were current users of marijuana (Figure 1). This number of past month marijuana users corresponds to 8.3 percent of the population aged 12 or older (Figure 3). The percentage of people aged 12 or older who were current marijuana users in 2015 was similar to the percentage in 2014, but it was higher than the percentages from 2002 to 2013. This increase in marijuana use among people aged 12 or older reflects the increase in marijuana use by adults aged 26 or older and, to a lesser extent, increases in marijuana use among young adults aged 18 to 25."

"Worldwide, there were an estimated 192 million past-year users of cannabis in 2018, corresponding to 3.9 per cent of the global population aged 15–64. The past-year use of cannabis is substantially higher than the global average in North America (14.6 per cent), Australia and New Zealand (10.6 per cent) and West and Central Africa (9.3 per cent).

"In 2009, cannabis use was reported to be stabilizing or declining in countries with established cannabis markets, such as in Western and Central Europe, North America and Australia and New Zealand, but that trend was offset by increasing use in many countries in Africa and Asia.²¹ A decade later, cannabis use in Western and Central Europe has remained stable overall and has increased considerably in North America, Africa and Asia.²²"

"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."

"Globally, an estimated 19 million people were past-year users of cocaine in 2018, corresponding to 0.4 per cent of the global population aged 15–64. The main cocaine markets continue to be North America and Western and Central Europe, with a prevalence of use of 2.1 per cent and 1.4 per cent, respectively, while the highest prevalence of past-year cocaine use is in Australia and New Zealand, at 2.2 per cent of the population aged 15–64. Cocaine use is also higher than the global average in Central America (0.7 per cent) and South America (1.0 per cent)."

"In 2018, 57.8 million people globally were estimated to have used opioids in the past year, a figure that includes those who had used opiates (30.4 million) and those who had misused pharmaceutical opioids.32 This corresponds to a past-year prevalence of opioid use of 1.2 per cent of the global population aged 15–64. The use of opioids is higher than the global average in North America (3.6 per cent), Australia and New Zealand (3.3 per cent), the Near and Middle East and South-West Asia (2.6 per cent) and South Asia (2.0 per cent). The population of South Asia accounts for approximately 20 per cent of the global population aged 15–64 and more than one third of the estimated number of opioid users worldwide live in that subregion.

"The past-year prevalence of opiate use is higher than the global average (0.6 per cent) in the Near and Middle East and South-West Asia (1.8 per cent) and South Asia (1.1 per cent), two subregions that together account for almost 60 per cent of the estimated number of opiate users worldwide.

"Although global estimates are not available, the nonmedical use of pharmaceutical opioids is reported in many countries, in particular in countries in West and North Africa and the Near and Middle East (tramadol), and in North America (hydrocodone, oxycodone, codeine, tramadol and fentanyl)."

"Injecting drug use is estimated to account for approximately 10 per cent of HIV infections worldwide and 30 per cent of all HIV cases outside Africa,¹¹³ while in the eastern countries of the WHO European Region¹¹⁴ more than 80 per cent of all HIV infections occur among PWID.¹¹⁵ PWID are estimated to be 22 times more likely than people in the general population to be living with HIV.¹¹⁶

"The 2018 joint UNODC/WHO/UNAIDS/World Bank estimate of the global prevalence of HIV among PWID is 12.6 per cent, amounting to 1.4 million PWID living with HIV. This estimate is based on reporting of the prevalence of HIV among PWID by 121 countries, covering 96 per cent of the estimated global number of PWID. Data on HIV prevalence were available for all PWID in North America, South-West Asia, South Asia, Eastern Europe and South-Eastern Europe, but only for 33 and 32 per cent of all PWID in Central America and the Caribbean, respectively. Of all the countries that provided details of the methodology used to collect their data and estimate the prevalence of HIV, almost three quarters (reports from 89 countries) could be graded as “class A methodology” (seroprevalence study).¹¹⁷ In 2018, new or updated estimates of HIV among PWID were available for a total of 40 countries."

Amphetamine-Type Stimulants

"In 2014, the estimated 1.6 million people aged 12 or older who were current nonmedical users of stimulants included 569,000 people who were current methamphetamine users (Figure 8). Thus, almost two thirds of current nonmedical users of stimulants in 2014 who were aged 12 or older reported current nonmedical use of prescription stimulants but not methamphetamine.
"These numbers of nonmedical users of stimulants and methamphetamine users represent 0.6 percent of the population aged 12 or older who were current nonmedical users of stimulants (Figure 9) and 0.2 percent who were current users of methamphetamine in 2014 (Figure 10). The percentage of the population aged 12 or older in 2014 who were current nonmedical users of stimulants was higher than the percentages for most years between 2005 and 2012. Meanwhile, the percentage of the population aged 12 or older in 2014 who were current users of methamphetamine was similar to the percentages for most years between 2002 and 2013."

"• 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)."

"About 1.0 percent of people aged 12 or older (2.7 million) had a prescription drug use disorder in the past year, including 2.0 million people with a pain reliever use disorder, 688,000 with a tranquilizer use disorder, 426,000 with a stimulant use disorder, and 154,000 with a sedative use disorder. In 2015, as part of their most recent substance use treatment, 822,000 people received treatment for the misuse of pain relievers, 293,000 people received treatment for tranquilizer misuse, 139,000 received treatment for stimulant misuse, and 116,000 received treatment for sedative misuse.
"Among people aged 12 or older who misused prescription pain relievers in the past year, the most commonly reported reason for their last misuse was to relieve physical pain (62.6 percent). Among past year misusers of tranquilizers, the most commonly reported reasons were to relax or relieve tension (44.9 percent) or to help with sleep (20.4 percent). Commonly reported reasons for misuse among stimulant misusers were to help be alert or stay awake, help concentrate, or help study (26.8, 26.5, and 22.5 percent, respectively). Among past year sedative misusers, the most common reason was to help with sleep (71.7 percent). Even if people misused prescription drugs for conditions for which these drugs are typically prescribed (e.g., for pain relief or to help with sleep), use without one’s own prescription or use more often or at a higher dosage than prescribed nevertheless constitutes misuse.
"Among people aged 12 or older who misused pain relievers in the past year, the most common source for the last pain reliever that was misused was from a friend or relative (53.7 percent), and about one third misused a prescription from one doctor. About 1 in 20 people who misused pain relievers bought the last pain reliever they misused from a drug dealer or stranger."

"• 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)."

"• Nonmedical use of psychotherapeutics includes nonmedical use of any prescription-type pain relievers, tranquilizers, stimulants, or sedatives. Over-the-counter substances are not included. In 2013, there were approximately 2.0 million persons aged 12 or older who used psychotherapeutics nonmedically for the first time within the past year, which averages to about 5,500 initiates per day. The number of new nonmedical users of psychotherapeutics in 2013 was lower than the estimates for prior years from 2002 through 2012 (ranging from 2.3 million to 2.8 million).
"• In 2013, the numbers of initiates were 1.5 million for pain relievers, 1.2 million for tranquilizers, 603,000 for stimulants, and 128,000 for sedatives (Figure 5.6).
"• The number of new nonmedical users of pain relievers in 2013 (1.5 million) was lower than the numbers in 2002 through 2012 (ranging from 1.9 million to 2.5 million) (Figure 5.6). The number of past year initiates for nonmedical use of tranquilizers has been fairly stable from 2002 to 2013 (ranging from 1.1 million to 1.4 million). The number of initiates for nonmedical use of stimulants in 2013 was similar to the numbers in 2003, 2005, and in 2007 to 2012 (ranging from 602,000 to 715,000), but was lower than the numbers in 2002, 2004, and 2006 (ranging from 783,000 to 846,000). The number of initiates for nonmedical use of sedatives in 2013 was similar to the numbers in 2002, 2003, 2007 to 2009, 2011, and 2012 (ranging from 159,000 to 209,000), but was lower than the numbers in 2004 to 2006 and in 2010 (ranging from 240,000 to 267,000).
"• In 2013, the average age at first nonmedical use of any psychotherapeutics among recent initiates aged 12 to 49 was 22.4 years. Average ages at first nonmedical use were 21.6 years for stimulants, 21.7 years for pain relievers, 25.0 years for sedatives, and 25.4 years for tranquilizers. All of these 2013 estimates were similar to the corresponding estimates in 2012.
"• In 2013, the number of new nonmedical users of OxyContin® aged 12 or older was 436,000, which was similar to the estimates for prior years from 2004 through 2012. The average age at first use of OxyContin® among past year initiates aged 12 to 49 was similar in 2012 and 2013 (22.0 and 23.6 years, respectively)."

"• Among young adults aged 18 to 25, the rate of current nonmedical use of psychotherapeutic drugs in 2013 (4.8 percent) was similar to the rates in 2011 (5.0 percent) and 2012 (5.3 percent), but it was lower than the rates in 2002 to 2010 (ranging from 5.5 to 6.5 percent) (Figure 2.9). The rate of current nonmedical use of pain relievers among young adults in 2013 (3.3 percent) was lower than the rates in 2012 (3.8 percent) and in 2002 to 2010 (ranging from 4.1 to 5.0 percent), but it was similar to the rate in 2011 (3.6 percent)."

"In the United States, there are indications of an increase in NPS use among certain user groups between 2009 and 2013; the prevalence of lifetime use of a 'novel psychoactive substance' among the population aged 12-34 was 1.2 per cent in 2013.²³⁵ There are signs of declining use of synthetic cannabinoids among secondary school students in the United States. The prevalence of past-year use of synthetic cannabinoids among twelfth-grade students decreased from 11.4 per cent in 2011 to 5.2 per cent in 2015.²³⁶ This is associated with an increase, over the same period, in the perceived risk of taking synthetic cannabinoids among the same group. The use of NPS with stimulant effects (reported as “bath salts“) among twelfth graders remained stable at 1 per cent in 2015. The prevalence of the use of synthetic cannabinoids among eighth, tenth and twelfth graders has declined to the lowest levels since the collection of such data began. However, the large amount of synthetic cannabinoids seized between 2012 and 2014 (more than 93 tons) and the large number of calls to poison centres for problems related to the use of synthetic cannabinoids (3,682 in 2014 and 7,779 in 2015)²³⁷ indicate the continued presence and use of this NPS group in the United States."

"• The number and percentage of persons aged 12 or older who were current users of hallucinogens in 2013 (1.3 million or 0.5 percent) were similar to those in 2012 (1.1 million or 0.4 percent), but were higher than in 2011 (1.0 million or 0.4 percent) (Figure 2.2)."

"• An estimated 8.8 percent, or 10.1 million, of full-time workers reported past month heavy alcohol use (Figure 2.3 and Tables 2.2 and 2.3).

"• Past month heavy alcohol use was related to age. Among younger workers (18 to 25 years old), 16.3 percent reported past month heavy alcohol use compared with 10.4 percent of 26- to 34-year-olds, 8.1 percent of 35- to 49-year-olds, and 4.7 percent of 50- to 64-year-olds (Figure 2.3 and Table 2.2).

"• Males were three times as likely as females to be past month heavy alcohol users (12.3 vs. 4.1 percent) (Figure 2.4 and Table 2.2).

"• An estimated 10.1 percent of white adults reported heavy alcohol use in the past month. This was higher than the percentage among black adults (5.4 percent), Asian adults (2.9 percent), Hispanic adults (6.9 percent), and adults reporting two or more races (7.5 percent) (Figure 2.5 and Table 2.2).

"• Residents of noncore rural counties had a lower prevalence of past month heavy alcohol use (7.5 percent) compared with residents of micropolitan statistical area (9.2 percent), small MSA (9.8 percent), and large MSA (8.1 percent) counties (Table 2.3).

"• Workers with a college education had a lower prevalence of past month heavy alcohol use compared with those without a college education. Past month heavy alcohol use was lower among those with higher levels of education than those with less education (college graduate [6.7 percent] vs. less than high school [10.8 percent]) (Figure 2.6 and Table 2.3)."

"Lifetime alcohol users aged 21 or older had a significantly higher rate of past year illicit drug use (13.7 percent) compared with lifetime nondrinkers (2.7 percent). In addition, lifetime alcohol users had significantly higher rates of past year use across all illicit drug categories, with the exception of inhalants (Table 1). Nonmedical use of pain relievers was the illicit drug used most often by lifetime nondrinkers, whereas lifetime alcohol users reported using marijuana most frequently."

"Global estimates suggest that past-month prevalence of tobacco use (25 per cent of the population aged 15 and above) is 10 times higher than past-month prevalence of illicit drug use (2.5 per cent). Annual prevalence of the use of alcohol is 42 per cent (the use of alcohol being legal in most countries), which is eight times higher than annual prevalence of illicit drug use (5.0 per cent). Heavy episodic weekly drinking is eight times more prevalent than problem drug use. Drug use accounts for 0.9 per cent of all disability-adjusted life years lost at the global level, or 10 per cent of all life years lost as a result of the consumption of psychoactive substances (drugs, alcohol and tobacco)."

"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."

"• Among current drinkers, 39.6% reported binge drinking in the past month, with the Marine Corps reporting the highest prevalence of binge drinking (56.7%), and the Air Force reporting the lowest prevalence (28.1%).
"• When examining levels of drinking across all services, 9.9% were classified abstainers, 5.7% were former drinkers, and 84.5% were current drinkers; 58.6% of all personnel were classified as infrequent/light drinkers, 17.5% were moderate drinkers, and 8.4% were classified as heavy drinkers.
"• Heavy drinkers were more often in the Marine Corps (15.5%), had a high school education or less (12.6%), 21-25 years old (13.2%), unmarried (11.9%), and stationed OCONUS (9.9%).
"• In general, active duty personnel who were heavy drinkers, initiated alcohol use at earlier ages, or drank at work more often reported higher work-related productivity loss, serious consequences from drinking, began drinking at older ages, or did not drink at work.
"• Across all drinking levels, 11.3% of active duty personnel were classified as problem drinkers (AUDIT ≥), with 58.4% of heavy drinkers considered problem drinkers compared to 22.6% of moderate drinkers and 3.5% of infrequent/light drinkers."

"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."

"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."

(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"

"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