Saying Yes to Drugs?

Part I: Confronting the Reality

It is 12:30 AM. Three teen boys are out in the garage, smoking pot and drinking Bud Lights.  The parents of the oldest who resides at the home went to bed a couple of hours ago.  Although his parents don’t “necessarily approve” of the illicit activities occurring out their back window, they reasoned a long time ago that it was better to have the teens drinking and smoking on their property instead of having them at someone else’s house, or even worse, driving impaired.  And so, their house became one of the spots where local youth knew that they could hang out and unwind while they drank a brew and smoked a joint.  But tonight, one of the visitors had brought something new that he had found in his grandmother’s closet.  It wasn’t the first time the boys had tried pain pills, and it certainly wouldn’t be the last.  If only they could just get through the semester and pass their classes; then a summer of fun awaited.

 In 1996, OxyContin came into the market and was advertised as a non-addictive pain reliever.  Eighty MG was approved initially, but a 160 MG tablet was later approved in 2000.  Prescription rates quickly skyrocketed as they did for other opioids.  In 1991, 76 million  prescriptions were given; in 2013, the number was 207 million.  In 1998, Joint Commission declared that pain was the “fifth vital sign” and that every patient in a hospital had to be asked about pain.  Whether a patient had a hang nail or an amputation, it was determined that pain treatment must be offered even if the patient did not initially voice a complaint.  Although many non-pharmacological methods existed to relieve pain (e.g., physical therapy, massage, acupuncture), physicians quickly began prescribing opioids given their quick acting, readily-available qualities.  Today, as noted by Joseph Garbely, director of the Caron Treatment Centers based in Wernersville, Pennsylvania, the US uses 80% of the world’s opioids despite only constituting 4.6% of the world’s population.  99% of the world’s hydrocodone (e.g., Vicodin) is prescribed here; so is 81% of Oxycodone (e.g., Percocet).  As he noted, there is no difference in the way the brain processes heroin and opioids.  Both ultimately result in a pleasurable, warm feeling called euphorigenesis. When people experience this positive sensation, they associate it with pain relief; however, the pain relief actually occurs through a psychological effect, not a physiological change.

Recently, Tim Everly of the Evansville Police Department addressed staff at St. Mary’s Medical Center. He noted that 80% of illicit drugs in the world make it into the US at some point.  Crystal methamphetamine was noted as the #1 drug in this area, but many other drugs, including illegally used prescriptions, are on the rise.  Nationwide, illicit drug use increased by 8.2% from 2002 to 2013.  Everly noted an increasing presence of the local drug scene, whether exposed through YouTube postings of “Zombieville” or various gangs that utilize drug dealing as a means of financial support.  It was also noted that the drugs of today are not just the same ole drugs of previous decades.  In 1970, a joint equaled ¼ gram of weed at 1% THC (THC is the psychoactive compound in marijuana).  Today, a blunt contains 1 gram of weed at 20% THC.

Nationwide, over 35% of high school seniors reported in a 2014 survey that they have used marijuana. Two-thirds of these seniors felt that they didn’t consider marijuana use to be harmful despite continued research to indicate the opposite.  Consistent findings have indicated that when youth use marijuana, they are at increased risk for the following: respiratory problems, decreased processing speed and decision-making skills, impaired driving, psychiatric issues (including psychotic symptoms), reduced academic functioning and job performance, relationship difficulties, and increased likelihood of using other drugs.

All of this news presents an uncomfortable and dangerous situation for our families. And I haven’t even mentioned the high rates of alcohol use that occur in underage youth and young adults.  As someone who routinely works with adolescents enrolled in both public and private schools, I have ready access to firsthand accounts of the illegal drug and alcohol culture that exists with our youth, regularly sanctioned (or allowed) by parents who struggle to understand the best options available.  I also remember it myself as a teen.  Not all underage users struggle academically and/or socially.  Some persist as good students and/or excellent athletes and may find themselves in leadership positions.  Others are not so fortunate, and find their grades slipping, extra-curricular activities either revoked or no longer a priority, and on their way to eventual alternate options or dropout.

Whatever the course we find our youth taking, a few things are clear. One, we as a society have a serious drug/alcohol problem that doesn’t seem to be getting better.  And two, both parents and students are repeatedly influenced to make decisions that they don’t feel are the right ones, and settle for a tenuous position that serves to muddle and confuse everyone about what should be done.  In the hope of preventing the worst (e.g., fatal accident involving impaired teen drivers), many find themselves sacrificing the best, or even the better.  I completely understand the desire to protect teens against their own worst decisions.  Yet, despite the horror of what impaired driving can do, I don’t believe that operating under the pretense of avoiding tragedy justifies enabling a systemic issue that contributes to a national crisis.  I think it is time to acknowledge that in doing so, each parent involved inherits some culpability when it comes to the growing the drug use.  Parents should also realize that early drug/alcohol use is a significant predictor of later abuse.  A majority of individuals with substance dependence/abuse started using prior to age 18.  For those who start drinking by the age of 14, over 15 percent will develop alcohol abuse or dependence compared to 2.1 percent for those who wait until they are 21 or older.

Recently, I had a teen mention that one of his teachers told his class that if any of them were drinking in high school and didn’t have a sober ride, they shouldn’t hesitate to call her. She had previously revealed to them that a close family member had been killed by a drunk driver.  As my patient was saying this to me, I found myself pulled in two directions.  The first was a sense of appreciation that this teacher would be willing to do this for her students (and others on the roadway) as a way of translating a horrible experience into a helpful response.  But my second reaction was a sense of discomfort that this message was sent to 8^th graders with a sense that they would likely drink well before the legal age.

And why shouldn’t they? Many of them are surrounded by adults who never show up at a party without a cooler of their own, and who still espouse alcohol as the one guarantee of a good time while their kids listen on.  Forty year old men still brag about how much they drink as if it is a prize to be had while more than 10 percent of U.S. children live with at least one parent with serious alcohol problems. A quarter of the U.S. population 18 and older reported at least one binge drinking episode in the past month.  Meanwhile, a plethora of online sites describe how pot isn’t that bad, and many adults locally look the other way (or smoke themselves) as the “seemingly benign drug” creates its own culture of experimentation and dependence throughout the schools.

I must admit the situation reeks of a society “settling” for something that is only sliding further south. I am not opposed to legal use of substances, such as alcohol, done in a responsible manner.  But does anyone else feel like the bigger message being sent to young and old alike is that “fun and stress relief can’t be had unless we get buzzed, wasted, or high?”  Although you might consider me idealistic, it sure seems like a much richer, much clearer, much more meaningful world when all of us—starting with parents—send a message that fun and stress relief can be had without psychologically and physiologically fooling our brain through use of substances.  Many other options abound, all of which leave our brains and nervous systems intact.

But as the movement across this country surges to legalize pot (and reduce the drinking age), I can’t help but feel that it is one more way in which we are acting as if we can’t survive, or even thrive, without another “quick fix.” Seems a bit like rats in a maze looking for the next lever to push in search of a pellet.  Sorry for the negative tone, but I just have grave concerns about where this is headed as I believe others do.  I will speak more specifically about options for change in part II and III.  But for now, it would be great if parents and teachers who might feel a similar way started talking about possible solutions, and not just turn a blind eye to the illegal parties and activities that are going on in their own neighborhoods, backyards, and homes.  Otherwise, we are in essence welcoming a growing drug trade into our communities and our lives.

Part II: Changing the Answer to No

As our communities work to effectively curb illicit drug use, underage drinking, and alcohol abuse, countless factors loom large. But none loom bigger than the idea that most substance issues start early, and any attempt to truly make a difference must do the same.  As a starter, the National Institute on Drug Abuse (NIDA) has published a report entitled Preventing Drug Abuse Among Children and Adolescents.  I will focus much of Part II on highlighting important findings before moving onto other issues.  The report begins by noting five significant risk factors for early substance use and opposing protective factors (in parentheses) that can decrease risk.  Risk factors include the following:  early aggressive behavior (self-control development), poor parental supervision (parental monitoring), peer substance abuse (academic competence), drug availability (anti-drug use policies at school), and poverty (strong neighborhood attachment).  Each of potential risk factors, and protective factors, spans from an individual source all the way up through the community.

Within these overall domains, further risk factors for later drug use, beyond inconsistent/permissive parenting, include having a parent that uses substances and poor attachment between youth and parents in general. Academic failure and poor classroom behaviors are also further threats. But of all factors, it appears that consistent association with drug-using peers may be the most immediate risk factor for early delinquent behavior and substance use.   The reality of peer pressure is something that parents can ill afford to ignore, especially when youth increasingly spend time with substance-using individuals in and out of school.

Youth seem particularly susceptible to substance use during transitions in their lives. For most youth, this occurs as they move through the different stages of school, including moving onto college.  But transitions can also include a move to a different city, divorce, death of a family member, or many other circumstances that may significantly alter a youth’s existence.  Vulnerability emerges during these times for many reasons, but especially because youth find themselves searching for new peers that can help them feel secure and grounded in uncertain times; therefore, they may be willing to supersede moral, logical, and/or legal boundaries in search of perceived security and acceptance.  Substance in early adolescence typically involves alcohol, tobacco, marijuana, prescription meds, and inhalants.  If use persists into late adolescence, continued alcohol/tobacco use typically coincides with heavier marijuana use and a shift into other illicit drugs, such as heroin and cocaine.

NIDA recommends five steps in developing a community plan for addressing illicit substance use/abuse. It includes 1) Identifying the most pressing substance issues among youth in the community 2) Building on current available programs 3) Developing short-term goals using research-based programs 4) Projecting long-term goals to provide for logistical and financial infrastructure, and 5) Assessing how effective programs become.  Various methods of increasing community engagement around this issue include creating anti-drug coalitions, developing public education campaigns, and attracting individuals/organizations willing to sponsor various activities.  Research has consistently found that media used strategically can be an effective tool in reducing substance use.

Prevention programs should ultimately be geared to minimize known risk factors and promote what we know creates resiliency. Programs can occur anywhere, from schools to churches to broader community agencies.  They can target all youth (universal), those at-risk (e.g., failing academically), or even those who have already started to experiment.  But ultimately, it is clear that they must at least partially be geared towards strengthening families and improving parenting, which remains the first defense against substance use.  In school, programs should focus on areas such as peer relations, improving decision-making and self-control in the presence of temptations, and helping students avert failure and subsequent dropout (given its association with drug use).  Programs also must correct misleading information that may serve to increase drug use, such as the idea that “everyone is doing it.”  Caution should be placed in putting high-risk teens together in groups, as this has been shown to often increase drug use, not curb it.

Community-based programs have the opportunity to develop policy and establish media campaigns in addition to other mass efforts; evidence has shown that overall, reaching youth on multiple fronts is associated with decreased drug use. Much more specific information about effective programs is available on the NIDA website.  However, one important note should be made.  Repeated evidence has indicated that simply providing information about drug abuse, including potential negative outcomes, is not effective by itself in reducing substance use.  Just as findings have indicated that smokers routinely overestimate the average number of years that a person dies early due to smoking, so knowledge about risks and pitfalls regarding other substance issues is simply not a strong enough motivator for most to prevent or stop other drug/alcohol use.  Knowledge is power, but only if it is combined with procedure, policy, and positive, pro-active measures on multiple fronts.

To many of you reading, the aforementioned information may be neither new nor particularly profound. But I think if we all take a closer look, themes emerge that are critical to transform our community into a place that truly says no to drugs.  For starters, the available evidence suggests that information, conversations, relationships, and the like must start early.  Even in elementary school, we must be aware of the messages our kids are receiving (face to face, digitally, or online) and work to be smarter, savvier, and more energetic than those who are promulgating messages that contradict our values and our goals.  Complacency is a huge enemy to promoting a substance-free, or even a substance-limited, environment.

Secondly, we as parents have to realize that when raising kids, being good people is not enough. I have known many faithful, fervent parents whose kids went on to use drugs not because anything went horribly wrong, but because these parents admittedly struggled with critical parenting tasks.  Similarly, I have known loving, compassionate parents whose kids grew up in a warm, safe environment, but whose limited supervision and lack of direct, honest feedback was associated with negative consequences.  I want to be very clear as a father of six kids not yet in adolescence.  There is no guarantee that what I or anyone else does as a parent will deter kids from serious substance issues, especially as peer and media influence looms so large.  But I do know that we must parent with consciousness, intention, and humility on this and other matters; otherwise, we might be caught blindsided one day by what our youth has been doing for some time.

Finally, as a community, I think it time that we depart from our silos and really consider ourselves as part of a collective unit that all have a part in raising children. Studies have shown that when people in neighborhoods and schools work to hold everyone accountable through honest, well-intentioned (although often not comfortable) reporting of illicit or suspicious affairs, youth and neighborhoods benefit. But increasingly, we live in a society that tends to look the other way, and not police our streets as I believe we should.  If neighbors see a kid smoking (pot or otherwise) in the nearby woods, a phone call should be made—first to their parents, and then to the police if the behavior continues.  None of the circumstances make for easy decisions or discussions, but if we as fellow citizens aren’t engaged in this enough to forego understandable discomfort and awkwardness that might result, then I am not sure who will be.  Police, probation officers, and anyone else in an official law enforcement capacity are only as helpful as the people they serve.

All this being said, though, there are deeper seeded factors that must be addressed before real change will occur. We can talk a good game, intend a good game, but actually performing in the arena of substance use is a whole different matter that involves assessing and altering critical factors for what they are.  I will begin this conversation in Part III.

Part III: Starting with New Questions

In 1995, I graduated from Mater Dei High School. Blessed with a wonderful education and conscientious, loving parents, I was well prepared for college and beyond.  High school was a time of much growth and development, and many people played an important role during this time.  In a few years, Amy and I look forward to sending our kids to MD and providing the same gift of faith formation and strong academics to them.

Beneath the positivity, though, I experienced challenges that are not exclusive to Mater Dei, but certainly were a challenge there. Although I was fortunate to not experience drug use directly while in high school (although I was aware of individuals engaging in it), underage drinking was a constant presence.  Parties at homes, outdoor areas, river camps, etc. regularly involved significant amounts of alcohol, and presented numerous challenges for those who wanted to be socially connected, but also did not have a desire to use substances to any (or even some) degree.  Today, consistent with the growing use nationally of marijuana and prescription pills, I have good reason to believe that all of our major high schools in town have a strong alcohol/drug subculture as I consistently hear from youth, parents, and teachers throughout the area.

Yet what is even more concerning is that much of this subculture is not only somewhat ignored by parents and others in various positions, but at times even enabled and supplied. As I mentioned in the first segment, it is often done under the auspices of “keeping impaired teens” off the streets.  But enabling illicit substance use not only supports a national crisis, it enables dependence/abuse for entire lives.  Consider this.  If we as a society curbed early substance use through more assertive means, then even if certain teens engage in impaired driving (which some will anyway), we theoretically reduce the tremendous risk incurred by a lifelong substance abuser who drives impaired for up to fifty years or more.  However, if we allow or promote early substance abuse, then we are in effect increasing the percentages of individuals who will never stop abusing drugs and alcohol, and will be (driving) on our streets for a long period of time.

I recently spoke with a parent of a youth from a high-achieving local high school who indicated that a large party was held for freshman in which a number of illicit activities occurred while the host’s parents were present. This parent described the awkward, difficult position in which the youth was placed, and how in many ways, there is a sense that this teen must forego many future social engagements if the desire to “stay clean” is honored. This isn’t a new problem.  But it is a serious one.  There is no doubt that youth will (and always have) experimented to some point.  But when this experimentation is sanctioned by parents and/or high-standing members of society, it creates a really confusing situation for youth in deciding what is right and wrong, and what should be done.  Especially when these youth often have up to a decade of brain development—corresponding to areas of impulse control, emotional regulation, and higher-order thinking—left to go.

Growing up on the West Side of Evansville, I was exposed to the alcohol culture that was often associated (fairly and unfairly) with the German Catholics of today. Whether extended family members or close family friends, I came to realize how indoctrinated alcohol use was into many people’s daily lives.  It was often the butt of jokes or the shrug of shoulders, but unfortunately for many, it severely affected lives and led many of those in subsequent generations to adopt its ways.  So many of the people that I dearly love have paid a significant price—one that did not have to be paid.

So if we are to make any real changes in the trends of today, we all have to begin with a simple question posed in reverse: Does my substance use, or sanctioning of illegal substance use, send a message that contradicts the values and laws of our land?  If so, am I willing to take difficult steps to change what I do, and to have conversations with others about doing the same?  If parents and families don’t take these questions seriously, then I firmly believe that no amount of high-quality initiatives or policies will really make a sustained difference.  We have to be motivated as a collective community of people invested in the future of our youth to make a difference.  And wouldn’t that be nice.

If we are in the business of really making change, then we also have to consider a few others factors at play. It is critical to understand that just as media can be an agent of good decisions, it really can be an agent of bad ones as well.  Any parent who doesn’t think that it is a big deal that their youth is watching movies with adult content (or engaging in any type of similar viewing) at any early age is fooling themselves, especially when it comes to substance use.  Just as new fashion lines are often launched through a single popular flick, so also are substance trends influenced in what is seen as “cool” and “edgy”.  Anyone remember the Joe Camel campaign?  In 1991, the Journal of the American Medical Association published a study indicating that nearly as many 6-year-old children could identify Joe Camel with cigarettes as could Mickey Mouse with Disney.  Despite R.J. Reynold’s denial that they were marketing children, almost 33% of cigarettes sold to underage youth were Camels, up from less than 1% previously.

We all have some say about the advertising that occurs in our town. But we have a much greater say about the content that is viewed in our homes.  Whether direct or embedded advertising (e.g., a bottle of Budweiser sitting on a table in a movie), our youth are exposed to millions of influential messages in their lives.  Want a simple way to reduce risk of substance abuse from the earliest of ages?  Limit screen access.  All kinds of screen access.  Including commercials.  If all parents made an effort to do so during those early years of formative brain development, it would really provide a great start.  Instead of completing the sentence “This ____ for you” with “Bud’s,” youth unconsciously might start considering that this phrase opens up many other potentials.

If we started with these two factors, then it would certainly give us a “leg up” in considering other needed changes, such addressing parenting/familial challenges, peer issues, academic failure, and other risk factors. But until we begin to create better awareness and mobilization regarding the role of media and the familial/generational influence of substances, it is unlikely that much change will occur.  These two factors are so deeply imbedded, so unconsciously ingrained into daily life that you can literally see youth or young adults fall into substance patterns with almost no conscious thought.  Almost as easy as sliding a beer into a coozy or swallowing a pain med.  Goes down smooth until life starts getting harder and harder each day.  Then substances can go from a regular pleasure to a constant need in order to deal with the challenges.  And that’s when addiction really sets in.

Consider one final comparison. Many people addicted to substances benefit from various rehabilitation programs, including 12-step programs such as AA.  However, the long-term success rates of these programs vary widely depending on which report is accepted.  At best, it is 50% for those who complete them in full; at worst, it is no better than 5-10% and this doesn’t even address the significant time and expense incurred.  Attrition rates are up to 90-95% for voluntary programs, and it is estimated that up to 90% of those who need treatment for substance issues never actually get it.  Now, contrast this with the statistic that I noted in the first part of this series:  2.1 percent of those who wait until 21 will develop alcohol abuse and dependence in their lifetime. That means almost 98% will not.  Evidence suggests similar results for those who don’t use other drugs until this age, too.  I think it is fair to say that this is the success rate we all desire.

Is there any question that an ounce of prevention is worth a pound of cure? Or maybe 12 ounces in this case?  Regardless of what you think of the ideas put forth, imagine our homes, schools, and roadways if the trends were going away from, not towards, substance use and abuse.  I know it’s complicated.  I know there are a lot of competing factors.  But just for a second, imagine all the people…