2003
National Survey on Drug
Use & Health: Results
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Office of Applied Studies
Acknowledgments
This report was prepared by the Division of Population Surveys, Office of Applied Studies, SAMHSA, and by RTI International, a trade name of Research Triangle Institute, Research Triangle Park, North Carolina. Work by RTI was performed under Contract No. 283989008. Contributors and reviewers at RTI listed alphabetically include Jeremy Aldworth, Katherine R. Bowman, Walter R. Boyle, Janice M. Brown, Jessica Duncan Cance, Patrick Chen, James R. Chromy, Andrew Clarke, Elizabeth Copello, David B. Cunningham, Teresa R. Davis, Steven L. Emrich, Ralph E. Folsom, Jr., Misty Foster, G. G. Frick, Eric A. Grau, Jennie L. Harris, David C. Heller, Erica Hirsch, Laurel Hourani, Susan Hunter, Jennifer J. Kasten, Larry A. Kroutil, Judith T. Lessler, Amy Licata, Mary Ellen Marsden, Christine Murtha, Brian Newquist, Dawn Odom, Lisa E. Packer, Michael R. Pemberton, Kristine L. Rae, Avinash C. Singh, Thomas G. Virag (Project Director), Michael Vorburger, and Jill Webster. Contributors at SAMHSA listed alphabetically include Peggy Barker, Joan Epstein, Joseph Gfroerer, Joe Gustin, Arthur Hughes (Project Officer), Joel Kennet, Dicy Painter, and Doug Wright. At RTI, Richard S. Straw edited the report with assistance from K. Scott Chestnut and Kathleen B. Mohar. Also at RTI, Diane G. Caudill prepared the graphics; Brenda K. Porter and Keri V. Kennedy formatted the tables; Joyce Clay-Brooks and Danny Occoquan formatted and word processed the report; and Pamela Couch Prevatt, Teresa F. Gurley, Kim Cone, David Belton, and Shari B. Lambert prepared its press and Web versions. Final report production was provided by Beatrice A. Rouse, Coleen Sanderson, and Jane Feldmann at SAMHSA.
Public Domain Notice
All material appearing in this report is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration. However, this publication may not be reproduced or distributed for a fee without specific, written authorization of the Office of Communications, SAMHSA, U.S. Department of Health and Human Services. Citation of the source is appreciated. Suggested citation:
Substance Abuse and Mental Health Services Administration. (2004). Results from the 2003 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H25, DHHS Publication No. SMA 043964). Rockville, MD.
2. Illicit Drug Use
Age
Gender
Pregnant Women
Race/Ethnicity
Education
College Students
Employment
Geographic Area
Criminal Justice Populations
Frequency of Use
Association with Cigarette and Alcohol Use
Driving Under the Influence of Illicit Drugs
How Marijuana Is Obtained
3. Alcohol Use
Age
Underage Alcohol Use
Gender
Pregnant Women
Race/Ethnicity
Education
College Students
Employment
Geographic Area
Association with Illicit Drug and Tobacco Use
Driving Under the Influence of Alcohol
4. Tobacco Use
Age
Gender
Pregnant Women
Race/Ethnicity
Education
College Students
Employment
Geographic Area
Frequency of Cigarette Use
Association with Illicit Drug and Alcohol Use
Usual Brand of Cigarettes Smoked
Youth Access to Cigarettes
Nicotine Dependence
6. Youth Prevention-Related Measures
Perceptions of Risk
Availability
Parental Disapproval of Substance Use
Attitudes about School
Delinquent Behavior
Participation in Religious and Other Activities
Exposure to Prevention Messages and Programs
This report presents the first information from the 2003 National Survey on Drug Use and Health (NSDUH). This survey, formerly called the National Household Survey on Drug Abuse (NHSDA), is a project of the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services. This survey was initiated in 1971 and is the primary source of information on the use of illicit drugs, alcohol, and tobacco by the civilian, noninstitutionalized population of the United States aged 12 years old or older. The survey interviews approximately 67,500 persons each year.
Illicit Drug Use
In 2003, an estimated 19.5 million Americans, or 8.2 percent of the population aged 12 or older, were current illicit drug users. Current illicit drug use means use of an illicit drug during the month prior to the survey interview.
There was no change in the overall rate of illicit drug use between 2002 and 2003. In 2002, there were an estimated 19.5 million illicit drug users (8.3 percent).
The rate of current illicit drug use among youths aged 12 to 17 did not change significantly between 2002 (11.6 percent) and 2003 (11.2 percent), and there were no changes for any specific drug. The rate of current marijuana use among youths was 8.2 percent in 2002 and 7.9 percent in 2003. There was a significant decline in lifetime marijuana use among youths, from 20.6 percent in 2002 to 19.6 percent in 2003. There also were decreases in rates of past year use of LSD (1.3 to 0.6 percent), Ecstasy (2.2 to 1.3 percent), and methamphetamine (0.9 to 0.7 percent).
Marijuana is the most commonly used illicit drug, with a rate of 6.2 percent (14.6 million) in 2003. An estimated 2.3 million persons (1.0 percent) were current cocaine users, 604,000 of whom used crack. Hallucinogens were used by 1.0 million persons, and there were an estimated 119,000 current heroin users. All of these 2003 estimates are similar to the estimates for 2002.
The number of current users of Ecstasy (i.e., MDMA) decreased between 2002 and 2003, from 676,000 (0.3 percent) to 470,000 (0.2 percent). Although there were no significant changes in the past month use of other hallucinogens, there were significant declines in past year use of LSD (from 1 million to 558,000) and in past year overall hallucinogen use (from 4.7 million to 3.9 million) between 2002 and 2003, as well as in past year use of Ecstasy (from 3.2 million to 2.1 million).
An estimated 6.3 million persons were current users of psychotherapeutic drugs taken nonmedically. This represents 2.7 percent of the population aged 12 or older. An estimated 4.7 million used pain relievers, 1.8 million used tranquilizers, 1.2 million used stimulants, and 0.3 million used sedatives. The 2003 estimates are all similar to the corresponding estimates for 2002.
There was a significant increase in lifetime nonmedical use of pain relievers between 2002 and 2003 among persons aged 12 or older, from 29.6 million to 31.2 million. Specific pain relievers with statistically significant increases in lifetime use were Vicodin®, Lortab®, or Lorcet® (from 13.1 million to 15.7 million); Percocet®, Percodan®, or Tylox® (from 9.7 million to 10.8 million); Hydrocodone (from 4.5 million to 5.7 million); OxyContin® (from 1.9 million to 2.8 million); methadone (from 0.9 million to 1.2 million); and Tramadol (from 52,000 to 186,000).
Rates of current illicit drug use varied significantly among the major racial/ethnic groups in 2003. Rates were highest among American Indians or Alaska Natives (12.1 percent), persons reporting two or more races (12.0 percent), and Native Hawaiians or Other Pacific Islanders (11.1 percent). Rates were 8.7 percent for blacks, 8.3 percent for whites, and 8.0 percent for Hispanics. Asians had the lowest rate at 3.8 percent.
An estimated 18.2 percent of unemployed adults aged 18 or older were current illicit drug users in 2003 compared with 7.9 percent of those employed full time and 10.7 percent of those employed part time. However, most drug users were employed. Of the 16.7 million illicit drug users aged 18 or older in 2003, 12.4 million (74.3 percent) were employed either full or part time.
Alcohol Use
An estimated 119 million Americans aged 12 or older were current drinkers of alcohol in 2003 (50.1 percent). About 54 million (22.6 percent) participated in binge drinking at least once in the 30 days prior to the survey, and 16.1 million (6.8 percent) were heavy drinkers. These 2003 numbers are all similar to the corresponding estimates for 2002.
The highest prevalence of binge and heavy drinking in 2003 was for young adults aged 18 to 25, with the peak rate of both measures occurring at age 21. The rate of binge drinking was 41.6 percent for young adults aged 18 to 25 and 47.8 percent at age 21. Heavy alcohol use was reported by 15.1 percent of persons aged 18 to 25 and by 18.7 percent of persons aged 21.
About 10.9 million persons aged 12 to 20 reported drinking alcohol in the month prior to the survey interview in 2003 (29.0 percent of this age group). Nearly 7.2 million (19.2 percent) were binge drinkers and 2.3 million (6.1 percent) were heavy drinkers. These 2003 rates were essentially the same as those obtained from the 2002 survey.
An estimated 13.6 percent of persons aged 12 or older drove under the influence of alcohol at least once in the 12 months prior to the interview in 2003 (a decrease from 14.2 percent in 2002). These percentages represent 32.3 million persons in 2003 and 33.5 million persons in 2002.
Tobacco Use
An estimated 70.8 million Americans reported current (past month) use of a tobacco product in 2003. This is 29.8 percent of the population aged 12 or older, similar to the rate in 2002 (30.4 percent). There were 60.4 million (25.4 percent) who smoked cigarettes in the past month, 12.8 million (5.4 percent) who smoked cigars, 7.7 million (3.3 percent) who used smokeless tobacco, and 1.6 million (0.7 percent) who smoked tobacco in pipes. These 2003 rates all remained unchanged from 2002.
Young adults aged 18 to 25 reported the highest rate of past month cigarette use (40.2 percent). This was similar to the rate among young adults in 2002 (40.8 percent).
Among those aged 12 or older, a higher proportion of males than females smoked cigarettes in 2003 (28.1 vs. 23.0 percent). Among youths aged 12 to 17, however, girls (12.5 percent) were as likely as boys (11.9 percent) to smoke. There was no change in cigarette use among boys aged 12 to 17 between 2002 and 2003. However, among girls, cigarette use decreased from 13.6 percent in 2002 to 12.5 percent in 2003.
An estimated 35.7 million Americans aged 12 or older in 2003 were classified as nicotine dependent in the past month because of their cigarette use (15.0 percent of the total population). These estimates are similar to the estimates for 2002.
Trends in Initiation of Substance Use (Incidence)
There were an estimated 2.6 million new marijuana users in 2002. This means that each day an average of 7,000 Americans tried marijuana for the first time. About two thirds (69 percent) of these new marijuana users were under age 18, and about half (53 percent) were female.
The annual number of marijuana initiates generally increased from 1965 until about 1973. From 1973 to 1978, the annual number of marijuana initiates remained level at over 3 million per year. After that, the number of initiates declined, reaching a low point in 1990, then rose again until 1995. From 1995 to 2002, there was no consistent trend, with estimates varying between 2.4 million and 2.9 million per year.
Decreases in initiation of both LSD (from 631,000 to 272,000) and Ecstasy (from 1.8 million to 1.1 million) were evident between 2001 and 2002, coinciding with an overall drop in hallucinogen incidence from 1.6 million to 1.1 million.
Pain reliever incidence increased from 1990 (573,000 initiates) to 2000 (2.5 million). In 2001 and 2002, the number also was 2.5 million.
The number of new daily cigarette smokers decreased from 2.0 million in 1997 to 1.4 million in 2002. Among youths under 18, the number of new daily smokers decreased from 1.1 million per year between 1997 and 2000 to 734,000 in 2002. This corresponds to a decrease from about 3,000 to about 2,000 new youth smokers per day.
Youth Prevention-Related Measures
The percentage of youths aged 12 to 17 indicating that smoking marijuana once a month was a great risk increased from 32.4 percent in 2002 to 34.9 percent in 2003. There were no changes between 2002 and 2003 in the percentages of youths perceiving a great risk associated with using cigarettes, alcohol, cocaine, heroin, and LSD.
The percentage of youths reporting that it would be easy to obtain marijuana declined slightly between 2002 and 2003, from 55.0 to 53.6 percent. The percentage of youths reporting that LSD would be easy to obtain also decreased between 2002 and 2003, from 19.4 to 17.6 percent.
Most youths (89.4 percent) reported that their parents would strongly disapprove of their trying marijuana once or twice. Among these youths, only 5.4 percent had used marijuana in the past month. However, among youths who perceived that their parents would only somewhat disapprove or neither approve nor disapprove of their trying marijuana, 28.7 percent used marijuana.
Substance Dependence or Abuse
An estimated 21.6 million Americans in 2003 were classified with substance dependence or abuse (9.1 percent of the total population aged 12 or older). Of these, 3.1 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.8 million were dependent on or abused illicit drugs but not alcohol, and 14.8 million were dependent on or abused alcohol but not illicit drugs.
Between 2002 and 2003, there was no change in the number of persons with substance dependence or abuse (22.0 million in 2002 and 21.6 million in 2003).
In 2003, an estimated 17.0 percent of unemployed adults aged 18 or older were classified with dependence or abuse, while 10.2 percent of full-time employed adults and 10.3 percent of part-time employed adults were classified as such. However, most adults with substance dependence or abuse were employed either full or part time. Of the 19.4 million adults classified with dependence or abuse, 14.9 million (76.8 percent) were employed.
Treatment and Treatment Need for Substance Problems
An estimated 3.3 million people aged 12 or older (1.4 percent of the population) received some kind of treatment for a problem related to the use of alcohol or illicit drugs in the 12 months prior to being interviewed in 2003. Of these, 1.2 million persons received treatment at a rehabilitation facility as an outpatient, 752,000 at a rehabilitation facility as an inpatient, 729,000 at a mental health center as an outpatient, 587,000 at a hospital as an inpatient, 377,000 at a private doctor's office, 251,000 at an emergency room, and 206,000 at a prison or jail. (Note that the estimates of treatment by location include persons reporting more than one location.)
Between 2002 and 2003, there were decreases in the number of persons who received treatment for a substance use problem at a hospital as an inpatient, at a rehabilitation facility as an inpatient, at a mental health center as an outpatient, and at an emergency room.
In 2003, the estimated number of persons aged 12 or older needing treatment for an alcohol or illicit drug problem was 22.2 million (9.3 percent of the total population), about the same as in 2002 (22.8 million). The number needing but not receiving treatment also did not change between 2002 (20.5 million) and 2003 (20.3 million). However, a decline in the number receiving specialty treatment, from 2.3 million to 1.9 million, was statistically significant. This decline was driven by a decrease in treatment among adults aged 26 or older, from 1.7 million in 2002 to 1.2 million in 2003.
Of the 20.3 million people who needed but did not receive treatment in 2003, an estimated 1.0 million (5.1 percent) reported that they felt they needed treatment for their alcohol or drug problem. Of the 1.0 million persons who felt they needed treatment, 273,000 (26.3 percent) reported that they made an effort but were unable to get treatment and 764,000 (73.7 percent) reported making no effort to get treatment.
Among the 1.0 million people who needed but did not receive treatment and felt they needed treatment, the most often reported reasons for not receiving treatment were not ready to stop using (41.2 percent), cost or insurance barriers (33.2 percent), reasons related to stigma (19.6 percent), and did not feel the need for treatment (at the time) or could handle the problem without treatment (17.2 percent).
The number of persons needing treatment for an illicit drug problem in 2003 (7.3 million) was similar to the number needing treatment in 2002 (7.7 million). However, the number receiving treatment for drug abuse at a specialty facility was lower in 2003 (1.1 million) than in 2002 (1.4 million).
Serious Mental Illness among Adults
In 2003, there were an estimated 19.6 million adults aged 18 or older with serious mental illness (SMI). This represents 9.2 percent of all adults and is higher than the rate of 8.3 percent in 2002. Rates of SMI were highest for young adults aged 18 to 25 (13.9 percent) and lowest for persons aged 50 or older (5.9 percent). The percentage of females with SMI was higher than the percentage of males (11.5 vs. 6.7 percent).
Adults who used illicit drugs were more than twice as likely to have SMI as adults who did not use an illicit drug. In 2003, 18.1 percent of adult past year illicit drug users had SMI in that year, while the rate was 7.8 percent among adults who had not used an illicit drug.
Co-Occurrence of Serious Mental Illness and Substance Use Disorders
SMI was highly correlated with substance dependence or abuse. Among adults with SMI in 2003, 21.3 percent (4.2 million) were dependent on or abused alcohol or illicit drugs, while the rate among adults without SMI was only 7.9 percent. Among adults with substance dependence or abuse, 21.6 percent had SMI compared with 8.0 percent among those who did not have dependence or abuse.
Treatment for Mental Health Problems
In 2003, an estimated 28 million adults (13.2 percent) received treatment for mental health problems in the 12 months prior to the interview. These 2003 estimates are similar to the 2002 estimates.
The most prevalent type of treatment for mental health problems in the adult population in 2003 was prescription medication (10.9 percent), followed by outpatient treatment (7.2 percent). An estimated 1.8 million adults (0.8 percent) were hospitalized for mental health problems at some time within the past 12 months.
Among the 5.5 million adults who did not receive treatment but perceived an unmet need for treatment for mental health problems in the past year, the most commonly reported reasons for not receiving treatment were cost or insurance issues (45.1 percent), not feeling a need for treatment (at the time) or thinking the problem could be handled without treatment (40.6 percent), not knowing where to go for services (22.9 percent), perceived stigma associated with receiving treatment (22.8 percent), and did not have time (18.1 percent).
Among the 19.6 million adults with SMI in 2003, 9.3 million, or 47.3 percent, received treatment for a mental health problem in the 12 months prior to the interview. This estimate is similar to the estimate in 2002 (47.9 percent). The rate of inpatient treatment among adults with SMI increased between 2002 and 2003 (from 3.8 to 5.6 percent).
Among the 4.2 million adults with co-occurring SMI and a substance use disorder in 2003, 47.3 percent (about 2.0 million) received treatment for mental health problems and 11.2 percent (0.5 million) received specialty substance use treatment, including 7.5 percent (0.3 million) who received both types of treatment.
In 2003, an estimated 5.1 million youths aged 12 to 17 (20.6 percent) received treatment or counseling for emotional or behavior problems in the year prior to the interview. This is higher than the 2002 estimate of 4.8 million (19.3 percent).
1. Introduction
This report presents the first information from the 2003 National Survey on Drug Use and Health (NSDUH), an annual survey of the civilian, noninstitutionalized population of the United States aged 12 years old or older. Prior to 2002, the survey was called the National Household Survey on Drug Abuse (NHSDA). This initial report on the 2003 data presents national estimates of rates of use, numbers of users, and other measures related to illicit drugs, alcohol, and tobacco products. Measures related to mental health problems also are included. State-level estimates from NSDUH will be presented in a separate report.
A major focus of this report is changes in substance use between 2002 and 2003. Because of improvements to the survey in 2002, the 2002 data constitute a new baseline for tracking trends in substance use and other measures. Therefore, estimates from the 2002 and 2003 NSDUHs should not be compared with estimates from the 2001 and earlier NHSDAs to assess changes in substance use over time.
1.1. Summary of NSDUH
NSDUH is the primary source of statistical information on the use of illegal drugs by the U.S. population. Conducted by the Federal Government since 1971, the survey collects data by administering questionnaires to a representative sample of the population through face-to-face interviews at their places of residence. The survey is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services and is planned and managed by SAMHSA's Office of Applied Studies (OAS). Data collection is conducted under contract with RTI International, Research Triangle Park, North Carolina.1 This section briefly describes the survey methodology; a more complete description is provided in Appendix A.
NSDUH collects information from residents of households, noninstitutional group quarters (e.g., shelters, rooming houses, dormitories), and civilians living on military bases. Persons excluded from the survey include homeless persons who do not use shelters, military personnel on active duty, and residents of institutional group quarters, such as jails and hospitals. Appendix D describes surveys that cover populations outside the NSDUH sampling frame.
Since 1999, the NSDUH interview has been carried out using computer-assisted interviewing (CAI). Most of the questions are administered with audio computer-assisted self-interviewing (ACASI). ACASI is designed to provide the respondent with a highly private and confidential means of responding to questions to increase the level of honest reporting of illicit drug use and other sensitive behaviors. Less sensitive items are administered by interviewers using computer-assisted personal interviewing (CAPI).
Consistent with the 2002 survey, the 2003 NSDUH employed a 50State sample design with an independent, multistage area probability sample for each of the 50 States and the District of Columbia. The eight States with the largest population (which together account for 48 percent of the total U.S. population aged 12 or older) were designated as large sample States (California, Florida, Illinois, Michigan, New York, Ohio, Pennsylvania, and Texas). For these States, the design provided a sample sufficient to support direct State estimates. For the remaining 42 States and the District of Columbia, smaller, but adequate, samples were selected to support State estimates using small area estimation (SAE) techniques. The design also oversampled youths and young adults, so that each State's sample was approximately equally distributed among three major age groups: 12 to 17 years, 18 to 25 years, and 26 years or older.
Nationally, 130,605 addresses were screened for the 2003 survey, and 67,784 completed interviews were obtained. The survey was conducted from January through December 2003. Weighted response rates for household screening and for interviewing were 90.72 and 77.39 percent, respectively. See Appendix B for more information on NSDUH response rates.
1.2. Trend Measurement
Although the design of the 2002 and 2003 NSDUHs is similar to the design of the 1999 through 2001 surveys, there are important methodological differences that impact comparability of 2002 and 2003 estimates with estimates from prior surveys. In addition to the name change, each NSDUH respondent is now given an incentive payment of $30. These changes, both implemented in 2002 and continued in 2003, resulted in a substantial improvement in the survey response rate. The changes also affected respondents' reporting of many critical items that are the basis of prevalence measures reported by the survey each year. Comparability also could be affected by improved data collection quality control procedures that were introduced in the survey beginning in 2001, and by incorporating new population data from the 2000 decennial census into NSDUH sample weighting procedures. Analyses of the effects of each of these factors on NSDUH estimates have shown that 2002 and 2003 data should not be compared with 2001 and earlier NHSDA data to assess changes over time. Therefore, this report presents data only from the 2002 and 2003 NSDUHs.
Using only the 2002 and 2003 data, however, limited trend assessment can be done using information collected in NSDUH on prior substance use. Specifically, questions on age at first use of substances, in conjunction with respondents' ages and interview dates, provide data that can be used to estimate the rates of first-time use (incidence) for years prior to 2002 and 2003. Trends for 1965 to 2002 in these incidence measures for youths and young adults are discussed in Chapter 5. Estimates of lifetime prevalence rates for years prior to 2002 were produced from 2002 NSDUH data on age at first use and included in last year's NSDUH report (OAS, 2003). However, a recent evaluation assessing the validity of those estimates determined they were subject to significant bias (Gfroerer, Hughes, Chromy, Heller, & Packer, 2004). Therefore, they are not included in this report. Further discussion of incidence estimates is given in Chapter 5 and Appendix B.
1.3. Format of Report and Explanation of Tables
The results from the 2003 NSDUH are given in this report, which has separate chapters that discuss the national findings on seven topics: use of illicit drugs; use of alcohol; use of tobacco products; trends in initiation of substance use; prevention-related issues; substance dependence, abuse, and treatment; and mental health. A final chapter summarizes the results and discusses key findings in relation to other research and survey results. Technical appendices describe the survey (Appendix A), provide technical details on the statistical methods and measurement (Appendix B), offer key NSDUH definitions (Appendix C), discuss other sources of related data (Appendix D), list the references cited in the report (as well as other relevant references) (Appendix E), and present selected tabulations of estimates (Appendices F and G).
Tables, text, and figures present prevalence measures for the population in terms of both the number of substance users and the rate of use for illicit drugs, alcohol, and tobacco products. Tables show estimates of drug use prevalence by lifetime (i.e., ever used), past year, and past month use. Analyses focus primarily on past month use, which also is referred to as "current use." Tables and figures have footnotes indicating whether the 2003 and 2002 estimates were significantly different.
Data are presented for racial/ethnic groups in several categorizations, based on current standards for collecting and reporting race and ethnicity data (Office of Management and Budget [OMB], 1997) and on the level of detail permitted by the sample. Because respondents were allowed to choose more than one racial group, a "two or more races" category is presented that includes persons who reported more than one category among the seven basic groups listed in the survey question (white, black/African American, American Indian or Alaska Native, Native Hawaiian, Other Pacific Islander, Asian, Other). It should be noted that, except for the "Hispanic or Latino" group, the racial/ethnic groups discussed in this report include only non-Hispanics. The category "Hispanic or Latino" includes Hispanics of any race. Also, more detailed categories describing specific subgroups were obtained from survey respondents if they reported either Asian race or Hispanic ethnicity. Data on Native Hawaiians and Other Pacific Islanders are combined in this report.
Data also are presented for four U.S. geographic regions and nine geographic divisions within these regions. These regions and divisions, defined by the U.S. Bureau of the Census, consist of the following groups of States:
Northeast Region - New England Division: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont; Middle Atlantic Division: New Jersey, New York, Pennsylvania.
Midwest Region - East North Central Division: Illinois, Indiana, Michigan, Ohio, Wisconsin; West North Central Division: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota.
South Region - South Atlantic Division: Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia; East South Central Division: Alabama, Kentucky, Mississippi, Tennessee; West South Central Division: Arkansas, Louisiana, Oklahoma, Texas.
West Region - Mountain Division: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming; Pacific Division: Alaska, California, Hawaii, Oregon, Washington.
Geographic comparisons for 2002 and 2003 also are made based on county type, which reflects different levels of urbanicity and metropolitan area inclusion of counties. For this purpose, counties are grouped based on the 2003 rural-urban continuum codes. These codes were originally developed by the U.S. Department of Agriculture (Butler & Beale, 1994). Each county is either inside or outside a metropolitan statistical area (MSA), as defined by the OMB.
Large metropolitan areas have a population of 1 million or more. Small metropolitan areas have a population of fewer than 1 million. Nonmetropolitan areas are areas outside MSAs. Small metropolitan areas are further classified as having either fewer than or greater than 250,000 population. Counties in nonmetropolitan areas are classified based on the number of people in the county who live in an urbanized area, as defined by the Census Bureau at the subcounty level. "Urbanized" counties have 20,000 or more population in urbanized areas, "less urbanized" counties have at least 2,500 but fewer than 20,000 population in urbanized areas, and "completely rural" counties have fewer than 2,500 population in urbanized areas.
In June 2003, the OMB issued revised definitions for metropolitan areas (OMB, 2003), and these revised definitions are reflected in the county type variable used in this report. Counties no longer have to meet certain urban characteristics to be considered part of an MSA. Simplified commuting criteria concerning the percentage of residents who work in the central county of an MSA determine the metropolitan status for outlying counties. As a result of these changes, analyses based on county type information for 2003 are not fully comparable with analyses based on county type information in prior years. To make the analyses by county type presented in this report comparable for 2002 and 2003 data, county type classifications for both years are based on the 2003 rural-urban continuum codes. The 2002 county type analyses presented in this report are therefore not directly comparable with those presented in the 2002 NSDUH report (OAS, 2003).
1.4. Other NSDUH Reports
This report provides a comprehensive summary of the 2003 NSDUH, including results, technical appendices, and selected data tables. A companion report, Overview of Findings from the 2003 National Survey on Drug Use and Health, is a shorter, more concise report that highlights the most important findings of the survey and includes only a brief discussion of the methods. A report on State-level estimates for 2003 will be available in 2005.
In addition to the tables included in Appendices F and G of this report, a more extensive set of tables, including standard errors, is available upon request from OAS or through the Internet at http://www.oas.samhsa.gov. Additional methodological information on NSDUH, including the questionnaire, is available electronically at the same Web address. Brief descriptive reports and in-depth analytic reports focusing on specific issues or population groups also are produced by OAS. A complete listing of previously published reports from NSDUH and other data sources is available from OAS. Most of these reports also are available through the Internet (http://www.oas.samhsa.gov). In addition, OAS makes public use data files available to researchers through the Substance Abuse and Mental Health Data Archive (SAMHDA, 2004). Currently, files are available from the 1979 to 2002 surveys at http://www.icpsr.umich.edu/SAMHDA/index.html. The NSDUH 2003 public use file will be available by the end of 2004.
2. Illicit Drug Use
The National Survey on Drug Use and Health (NSDUH) obtains information on nine different categories of illicit drug use: marijuana, cocaine, heroin, hallucinogens, inhalants, and nonmedical use of prescription-type pain relievers, tranquilizers, stimulants, and sedatives. In these categories, hashish is included with marijuana, and crack is considered a form of cocaine. Several drugs are grouped under the hallucinogens category, including LSD, PCP, peyote, mescaline, mushrooms, and "Ecstasy" (MDMA). Inhalants include a variety of substances, such as amyl nitrite, cleaning fluids, gasoline, paint, and glue. The four categories of prescription-type drugs (pain relievers, tranquilizers, stimulants, and sedatives) cover numerous drugs available through prescriptions and sometimes illegally "on the street." Methamphetamine is included under stimulants. Over-the-counter drugs and legitimate uses of prescription drugs are not included. Respondents are asked to report only uses of drugs that were not prescribed for them or drugs they took only for the experience or feeling they caused. NSDUH reports combine the four prescription-type drug groups into a category referred to as "any psychotherapeutics."
Estimates of "any illicit drug use" reported from NSDUH reflect use of any of the nine substance categories listed above. Use of alcohol and tobacco products, while illegal for youths, are not included in these estimates, but are discussed in Chapters 3 and 4.
In 2003, an estimated 19.5 million Americans aged 12 or older were current illicit drug users, meaning they had used an illicit drug during the month prior to the survey interview. This estimate represents 8.2 percent of the population aged 12 years old or older.
There was no change in the overall rate of illicit drug use between 2002 and 2003. In 2002, there were an estimated 19.5 million illicit drug users (8.3 percent).
Marijuana is the most commonly used illicit drug (14.6 million past month users). In 2003, it was used by 75.2 percent of current illicit drug users. An estimated 54.6 percent of current illicit drug users used only marijuana, 20.6 percent used marijuana and another illicit drug, and the remaining 24.8 percent used an illicit drug but not marijuana in the past month (Figure 2.1).
Figure 2.1 Types of Drugs Used by Past Month Illicit Drug Users Aged 12 or Older: 2003
About 45.4 percent of current illicit drug users in 2003 (8.8 million Americans) used illicit drugs other than marijuana and hashish, either with or without using marijuana as well.
In 2003, an estimated 2.3 million persons (1.0 percent) were current cocaine users, 604,000 of whom used crack during the same time period (0.3 percent). Hallucinogens were used by 1.0 million persons (0.4 percent) (Figure 2.2). There were an estimated 119,000 current heroin users (0.1 percent). All of these estimates are similar to estimates for 2002.
Figure 2.2 Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
The number of current users of Ecstasy decreased between 2002 and 2003, from 676,000 (0.3 percent) to 470,000 (0.2 percent). Although there were no significant changes in the past month use of other hallucinogens, there were significant declines in past year use of LSD (from 1 million to 558,000) and in past year overall hallucinogen use (from 4.7 million to 3.9 million) between 2002 and 2003, as well as in past year use of Ecstasy (from 3.2 million to 2.1 million) (Figure 2.3).
Figure 2.3 Numbers (in Millions) of Past Year Users of Selected Hallucinogens among Persons Aged 12 or Older: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Of the 8.8 million current users of illicit drugs other than marijuana in 2003, 6.3 million were current users of psychotherapeutic drugs. This represents 2.7 percent of the population aged 12 or older. Of those who reported current use of any psychotherapeutics, 4.7 million used pain relievers, 1.8 million used tranquilizers, 1.2 million used stimulants, and 0.3 million used sedatives. These estimates are all similar to the corresponding estimates for 2002.
There was a significant increase in the number of persons aged 12 or older with lifetime nonmedical use of pain relievers between 2002 and 2003, from 29.6 million to 31.2 million. Specific pain relievers with statistically significant increases in lifetime use were Vicodin®, Lortab®, or Lorcet® (from 13.1 million to 15.7 million); Percocet®, Percodan®, or Tylox® (from 9.7 million to 10.8 million); Hydrocodone (from 4.5 million to 5.7 million); OxyContin® (from 1.9 million to 2.8 million); methadone (from 0.9 million to 1.2 million); and Tramadol (from 52,000 to 186,000) (Figure 2.4).
Figure 2.4 Numbers (in Millions) of Lifetime Nonmedical Users of Selected Pain Relievers among Persons Aged 12 or Older: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Age
Rates of drug use showed substantial variation by age. For example, 3.8 percent of youths aged 12 or 13 reported current illicit drug use in 2003 (Figure 2.5). As in other years, illicit drug use in 2003 tended to increase with age among young persons, peaking among 18 to 20 year olds (23.3 percent) and declining steadily after that point with increasing age.
Figure 2.5 Past Month Illicit Drug Use, by Age: 2003
Among youths, the types of drugs used differed by age in 2003, as was true in prior years. Among 12 or 13 year olds, 1.8 percent used prescription-type drugs nonmedically, 1.4 percent used inhalants, and 1.0 percent used marijuana (Figure 2.6). Among 14 or 15 year olds, marijuana was the dominant drug used (7.2 percent), followed by prescription-type drugs used nonmedically (4.1 percent) and inhalants (1.4 percent). Marijuana also was the most commonly used drug among 16 or 17 year olds (15.6 percent), followed by prescription-type drugs used nonmedically (6.1 percent), hallucinogens (1.9 percent), and cocaine (1.2 percent). Only 1.0 percent of youths aged 16 or 17 used inhalants.
Figure 2.6 Past Month Use of Selected Illicit Drugs among Youths, by Age: 2003
Among all youths aged 12 to 17 in 2003, 11.2 percent were current illicit drug users: 7.9 percent used marijuana, 4.0 percent used prescription-type drugs, 1.3 percent used inhalants, 1.0 percent used hallucinogens, and 0.6 percent used cocaine. Rates of use were highest for the young adult age group (18 to 25 years) at 20.3 percent, with 17.0 percent using marijuana, 6.0 percent using prescription-type drugs nonmedically, 2.2 percent using cocaine, and 1.7 percent using hallucinogens. Among adults aged 26 or older, 5.6 percent reported current illicit drug use: 4.0 percent used marijuana and 1.9 percent used prescription-type drugs. In this latter age group, less than 1 percent used cocaine (0.8 percent), hallucinogens (0.1 percent), and inhalants (0.1 percent).
The rate of current illicit drug use among youths aged 12 to 17 did not change significantly between 2002 (11.6 percent) and 2003 (11.2 percent), and there were no changes for any specific drug. The rate of current marijuana use among youths was 8.2 percent in 2002 and 7.9 percent in 2003. However, there were decreases in rates of past year use of LSD (1.3 to 0.6 percent), Ecstasy (2.2 to 1.3 percent), and methamphetamine (0.9 to 0.7 percent). In addition, there was a decline in past month marijuana use among youths aged 12 or 13, from 1.4 percent in 2002 to 1.0 percent in 2003. Past month inhalant use among youths aged 16 or 17 increased from 0.6 percent in 2002 to 1.0 percent in 2003.
Among young adults, past month Ecstasy use declined from 1.1 percent in 2002 to 0.7 percent in 2003 (Figure 2.7). However, there was an increase in past month nonmedical use of pain relievers, from 4.1 percent in 2002 to 4.7 percent in 2003. Past year use of hallucinogens declined in this age group from 8.4 percent in 2002 to 6.7 percent in 2003, with declines in the use of Ecstasy (5.8 to 3.7 percent) and LSD (1.8 to 1.1 percent). Rates of illicit drug use for adults aged 26 or older were unchanged between 2002 and 2003.
Figure 2.7 Past Month Use of Ecstasy and Nonmedical Use of Pain Relievers among Young Adults Aged 18 to 25: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Gender
As in prior years, men were more likely in 2003 to report current illicit drug use than women (10.0 vs. 6.5 percent). However, rates of nonmedical use of any prescription-type psychotherapeutic were similar for males (2.7 percent) and females (2.6 percent).
Among youths aged 12 to 17, the rate of current illicit drug use was similar for boys (11.4 percent) and girls (11.1 percent). While boys aged 12 to 17 had a higher rate of marijuana use than girls (8.6 vs. 7.2 percent), rates of nonmedical use of any prescription-type psychotherapeutics were 4.2 percent for girls and 3.7 percent for boys (not a statistically significant difference).
Pregnant Women
Among pregnant women aged 15 to 44 years, 4.3 percent reported using illicit drugs in the month prior to their interview during 2002 and 2003. This rate was significantly lower than the rate among women aged 15 to 44 who were not pregnant (10.4 percent). (These estimates are based on combined 2002 and 2003 NSDUH data.)
Race/Ethnicity
Rates of current illicit drug use varied significantly among the major racial/ethnic groups in 2003. The rate was highest among American Indians or Alaska Natives (12.1 percent), persons reporting two or more races (12.0 percent), and Native Hawaiians or Other Pacific Islanders (11.1 percent) (Figure 2.8). Rates were 8.3 percent for whites, 8.0 percent for Hispanics, and 8.7 percent for blacks. Asians had the lowest rate at 3.8 percent.
Figure 2.8 Past Month Illicit Drug Use among Persons Aged 12 or Older, by Race/Ethnicity: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Among youths aged 12 to 17, the rate of current illicit drug use among American Indians or Alaska Natives (19.3 percent) was higher than the rate among all youths (11.2 percent), and the rate among Asian youths (6.5 percent) was significantly lower compared with the overall rate for all youths (Figure 2.9)
Figure 2.9 Past Month Illicit Drug Use among Youths Aged 12 to 17, by Race/Ethnicity: 2002 and 2003
Note 1: Due to low precision, estimates for Native Hawaiians or Other Pacific Islanders are not shown.
Note 2: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
There were no statistically significant changes between 2002 and 2003 in the rates of current illicit drug use for any racial/ethnic subgroup. This was the case both for all persons aged 12 or older and for youths aged 12 to 17.
Although estimates of current hallucinogen use for all racial/ethnic groups combined showed a decrease between 2002 and 2003, this decrease was not evident among Hispanics. Among Hispanics aged 12 or older, the rate of past month hallucinogen use was 0.3 percent in 2002 and 0.5 percent in 2003. Although this was not a statistically significant increase, the rate of use among Hispanics aged 18 to 25 did increase significantly, from 0.7 percent in 2002 to 1.3 percent in 2003.
Education
Illicit drug use rates in 2003 were correlated with educational status. Among adults aged 18 or older, the rate of current illicit drug use was lower among college graduates (5.2 percent) compared with those who did not graduate from high school (9.0 percent), high school graduates (8.3 percent), or those with some college (9.2 percent). However, adults who had completed 4 years of college were more likely to have tried illicit drugs in their lifetime when compared with adults who had not completed high school (51.1 vs. 38.0 percent).
College Students
In the college-aged population (persons aged 18 to 22 years old), the rate of current illicit drug use was nearly the same among full-time undergraduate college students (21.4 percent) as for other persons aged 18 to 22 years, including part-time students, students in other grades, and nonstudents (22.5 percent). The rate of current illicit drug use among college students and other 18 to 22 year olds did not change between 2002 and 2003.
Employment
Current employment status was highly correlated with rates of illicit drug use in 2003. An estimated 18.2 percent of unemployed adults aged 18 or older were current illicit drug users compared with 7.9 percent of those employed full time and 10.7 percent of those employed part time.
Although the rate of drug use was higher among unemployed persons compared with those from other employment groups, most drug users were employed. Of the 16.7 million illicit drug users aged 18 or older in 2003, 12.4 million (74.3 percent) were employed either full or part time.
Geographic Area
Among persons aged 12 or older, the rate of current illicit drug use in 2003 was 9.3 percent in the West, 8.7 percent in the Northeast, 7.9 percent in the Midwest, and 7.4 percent in the South.
The rate of illicit drug use in metropolitan areas was higher than the rate in nonmetropolitan areas. Rates were 8.3 percent in large metropolitan counties, 8.6 percent in small metropolitan counties, and 7.0 percent in nonmetropolitan counties as a group (Figure 2.10). Within nonmetropolitan areas, counties that were urbanized had a rate of 7.9 percent, while completely rural counties had a significantly lower rate (3.1 percent).
Figure 2.10 Past Month Illicit Drug Use among Persons Aged 12 or Older, by County Type: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
The rate of current illicit drug use in completely rural counties declined between 2002 and 2003, from 6.7 to 3.1 percent. This was largely due to a decrease from 4.1 to 0.8 percent in the nonmedical use of prescription-type psychotherapeutic drugs in rural areas.
Criminal Justice Populations
In 2003, among the estimated 1.4 million adults aged 18 or older on parole or other supervised release from prison during the past year, 24.3 percent were current illicit drug users compared with 7.7 percent among adults not on parole or supervised release.
Among the estimated 4.8 million adults on probation at some time in the past year, 28.0 percent reported current illicit drug use in 2003. This compares with a rate of 7.4 percent among adults not on probation in 2003.
Frequency of Use
In 2003, 12.2 percent of past year marijuana users used marijuana on 300 or more days in the past 12 months. This translates into 3.1 million persons using marijuana on a daily or almost daily basis over a 12month period. This was the same number as in 2002. However, the number of youths aged 12 to 17 using marijuana daily or almost daily declined from 358,000 in 2002 to 282,000 in 2003 (Figure 2.11). The number of youths using marijuana on 20 or more days in the past month declined from 603,000 in 2002 to 482,000 in 2003.
Figure 2.11 Numbers (in Thousands) of Daily or Almost Daily Marijuana Users in the Past Year and Past Month among Youths Aged 12 to 17: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Association with Cigarette and Alcohol Use
In 2003, the rate of current illicit drug use was approximately 8 times higher among youths aged 12 to 17 who smoked cigarettes (48.4 percent) than it was among youths who did not smoke cigarettes (6.1 percent).
Illicit drug use also was associated with the level of alcohol use. Among youths aged 12 to 17 who were heavy drinkers, 64.5 percent also were current illicit drug users, whereas among nondrinkers, the rate was only 5.1 percent.
Among youths who were both smokers and heavy drinkers, 72.4 percent used illicit drugs compared with only 3.7 percent among youths who did not drink or smoke.
Driving Under the Influence of Illicit Drugs
In 2003, an estimated 10.9 million persons reported driving under the influence of an illicit drug during the past year. This corresponds to 4.6 percent of the population aged 12 or older. The rate was 14.1 percent among young adults aged 18 to 25. Among adults aged 26 or older, the rate was 3.1 percent. These rates were all similar to the rates in 2002.
How Marijuana Is Obtained
NSDUH includes questions asking marijuana users how, from whom, and where they obtained the marijuana they used most recently. In 2003, most users (56.9 percent) got the drug for free or shared someone else's marijuana. Almost 40 percent of marijuana users bought it.
Most marijuana users obtained the drug from a friend; 77.8 percent of those who bought their marijuana and 81.3 percent of those who obtained the drug for free had obtained it from a friend.
More than half (54.3 percent) of users who bought their marijuana purchased it inside a home, apartment, or dorm. This also was the most common location for obtaining marijuana for free (62.7 percent).
Among youths who bought their marijuana, 30.9 percent bought it inside a home, apartment, or dorm. Among youths who obtained their marijuana for free, 48.8 percent obtained it inside a home, apartment, or dorm.
Almost 9 percent of youths aged 12 to 17 who bought their marijuana obtained it inside a school building, and 4.6 percent bought it outside on school property.
3. Alcohol Use
The National Survey on Drug Use and Health (NSDUH) includes questions about the recency and frequency of consumption of alcoholic beverages, such as beer, wine, whiskey, brandy, and mixed drinks. An extensive list of examples of the kinds of beverages covered is given to respondents prior to the question administration. A "drink" is defined as a can or bottle of beer, a glass of wine or a wine cooler, a shot of liquor, or a mixed drink with liquor in it. Times when the respondent only had a sip or two from a drink are not considered as consumption. For this report, estimates for the prevalence of alcohol use are reported primarily at three levels defined for both males and females and for all ages as follows:
Current use - At least one drink in the past 30 days (includes binge and heavy use).
Binge use - Five or more drinks on the same occasion at least once in the past 30 days (includes heavy use).
Heavy use - Five or more drinks on the same occasion on at least 5 different days in the past 30 days.
About half of Americans aged 12 or older reported being current drinkers of alcohol in the 2003 survey (50.1 percent). This translates to an estimated 119 million people, similar to the 2002 estimate of 120 million current drinkers.
More than one fifth (22.6 percent) of persons aged 12 or older participated in binge drinking at least once in the 30 days prior to the survey in 2003. This translates to about 54 million people, comparable with the number reported in 2002.
In 2003, heavy drinking was reported by 6.8 percent of the population aged 12 or older, or 16.1 million people. These figures are similar to those of 2002, when 6.7 percent (15.9 million people) reported heavy drinking.
Age
Among young people, the prevalence of current alcohol use in 2003 increased with age, from 2.9 percent at age 12 to about 70 percent of persons 21 or 22 years old (Figure 3.1). Among older age groups, the prevalence of alcohol use decreased with increasing age, from 61.7 percent among 26 to 29 year olds to 46.2 percent among 60 to 64 year olds and 34.4 percent among people aged 65 or older.
Figure 3.1 Current, Binge, and Heavy Alcohol Use, by Age: 2003
Rates of binge alcohol use were 0.9 percent at age 12, 2.2 percent at age 13, 7.1 percent at age 14, 11.7 percent at age 15, 18.0 percent at age 16, and 24.5 percent at age 17. The rate peaked at age 21 (47.8 percent) and then decreased beyond young adulthood.
The highest prevalence of both binge and heavy drinking in 2003 was for young adults aged 18 to 25, with the peak rate of both measures occurring at age 21. The rate of binge drinking was 41.6 percent for young adults aged 18 to 25 and 47.8 percent at age 21. Heavy alcohol use was reported by 15.1 percent of persons aged 18 to 25 and by 18.7 percent of persons aged 21.
While 57.7 percent of the population aged 45 to 49 in 2003 were current drinkers, 23.2 percent of persons within this age range were binge drinkers and 6.8 percent drank heavily. Rates of binge and heavy drinking were relatively low among people aged 65 or older, with rates of 7.2 and 1.8 percent, respectively.
Among youths aged 12 to 17, an estimated 17.7 percent used alcohol in the month prior to the survey interview. Of all youths, 10.6 percent were binge drinkers, and 2.6 percent were heavy drinkers. These percentages for binge drinking and heavy drinking were very similar to those obtained in 2002 (10.7 and 2.5 percent, respectively).
Underage Alcohol Use
About 10.9 million persons aged 12 to 20 reported drinking alcohol in the month prior to the survey interview in 2003 (29.0 percent of this age group). Nearly 7.2 million (19.2 percent) were binge drinkers, and 2.3 million (6.1 percent) were heavy drinkers. These figures were essentially the same as those obtained from the 2002 survey.
More males than females aged 12 to 20 reported binge drinking (21.7 vs. 16.5 percent) and heavy drinking (7.9 vs. 4.3 percent) in 2003.
Among persons aged 12 to 20, past month alcohol use rates ranged from 18.2 percent among Asians and blacks to 33.2 percent for whites. Binge drinking was reported by 22.8 percent of underage whites, 20.8 percent of underage American Indians or Alaska Natives, and 16.9 percent of underage Hispanics, but only by 9.6 percent of underage Asians and 9.1 percent of underage blacks.
Across geographic regions in 2003, underage current alcohol use rates were higher in the Northeast (32.0 percent) and Midwest (31.7 percent) than in the South and the West (26.7 percent and 27.6 percent, respectively) (Figure 3.2). This pattern was essentially the same in 2002.
Figure 3.2 Past Month Alcohol Use among Persons Aged 12 to 20, by Geographic Region: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
In 2003, underage current alcohol use rates were similar by population density. Rates were 27.6 percent in large metropolitan areas, 30.1 percent in small metropolitan areas, and 31.2 percent in nonmetropolitan areas. The rate in nonmetropolitan rural areas was 25.4 percent.
Gender
In general, males were more likely than females to report past month alcohol use. In 2003, 57.3 percent of males aged 12 or older were current drinkers compared with 43.2 percent of females. However, for the youngest age group (12 to 17), the rates were not significantly different (17.1 percent for males vs. 18.3 percent for females).
Among adults aged 18 or older, 62.4 percent of males reported current drinking in 2003, unchanged from 2002. However, 46.0 percent of adult females reported current alcohol use in 2003, which was nearly 2 percent lower than the 2002 estimate of 47.9 percent.
Pregnant Women
Among pregnant women aged 15 to 44, 9.8 percent used alcohol and 4.1 percent reported binge drinking in the month prior to the survey. These rates were significantly lower than the rates for nonpregnant women of that age (53.0 and 23.2 percent, respectively). Heavy alcohol use was relatively rare (0.7 percent) among pregnant women. These estimates were based on data averaged over 2002 and 2003.
Race/Ethnicity
Whites were more likely than any other racial/ethnic group to report current use of alcohol in 2003. An estimated 54.4 percent of whites reported past month use (Figure 3.3). The rates were 44.4 percent for persons reporting two or more races, 43.3 percent for Native Hawaiians or Other Pacific Islanders, 42.0 percent for American Indians or Alaska Natives, 41.5 percent for Hispanics, 39.8 percent for Asians, and 37.9 percent for blacks.
Figure 3.3 Current, Binge, and Heavy Alcohol Use among Persons Aged 12 or Older, by Race/Ethnicity: 2003
The rate of binge alcohol use was lowest among Asians (11.0 percent). Rates for other racial/ethnic groups were 19.0 percent for blacks, 23.6 percent for whites, 24.2 percent for Hispanics, 29.6 percent for American Indians/Alaska Natives, and 29.8 percent for Native Hawaiians or Other Pacific Islanders.
Among youths aged 12 to 17 in 2003, blacks and Asians were least likely to report past month alcohol use. Only 8.7 percent of Asian youths and 10.1 percent of black youths were current drinkers, while rates were above 15 percent for other racial/ethnic groups.
Education
The rate of past month alcohol use increased with increasing levels of education. Among adults aged 18 or older with less than a high school education, 36.7 percent were current drinkers in 2003, while 66.5 percent of college graduates were current drinkers. However, binge drinking and heavy drinking were least prevalent among college graduates.
College Students
Young adults aged 18 to 22 enrolled full time in college were more likely than their peers not enrolled full time (i.e., part-time college students and persons not enrolled in college) to use alcohol, binge drink, and drink heavily. Past month alcohol use was reported by 64.9 percent of full-time college students compared with 54.6 percent of persons aged 18 to 22 who were not currently enrolled full time. Binge and heavy use rates for college students were 43.5 and 17.6 percent, respectively, compared with 38.7 and 13.4 percent, respectively, for other persons aged 18 to 22.
Among persons aged 18 to 22, full-time college students were more likely to be heavy drinkers than others (17.6 vs. 13.4 percent) (Figure 3.4). However, at later ages (26 or older), those who had graduated from college were less likely to drink heavily than those who had not graduated (4.4 vs. 6.5 percent).
Figure 3.4 Heavy Alcohol Use, by College Attendance and Age: 2003
There were no significant changes in rates of past month, binge, or heavy alcohol use between 2002 and 2003 among full-time college students aged 18 to 22.
Employment
Rates of current alcohol use were 61.2 percent for full-time employed adults aged 18 or older in 2003 compared with 57.0 percent of their unemployed peers (Figure 3.5). However, the patterns were different for binge and heavy alcohol use; rates were higher for unemployed persons (35.0 and 13.3 percent, respectively, for binge and heavy use) than for full-time employed persons (28.9 and 8.6 percent, respectively).
Figure 3.5 Current, Binge, and Heavy Alcohol Use among Adults Aged 18 or Older, by Employment Status: 2003
Most binge and heavy alcohol users were employed. Among the 51.1 million adult binge drinkers in 2003, 40.6 million (79.5 percent) were employed either full or part time. Similarly, 12.4 million (79.9 percent) of the 15.5 million adult heavy drinkers were employed.
Geographic Area
The rate of past month alcohol use for people aged 12 or older in 2003 was lower in the South (45.3 percent) than in the Northeast (54.3 percent), Midwest (52.7 percent), or West (51.2 percent).
Among people aged 12 or older, the rate of alcohol use in large metropolitan areas was 53.3 percent compared with 48.9 percent in small metropolitan areas and 42.1 percent in nonmetropolitan areas. There was less variation across county types in rates of binge and heavy drinking. The rate of heavy alcohol use was 6.5 percent in large metropolitan areas, 7.2 percent in small metropolitan areas, and 7.1 percent in nonmetropolitan areas.
Among youths aged 12 to 17, the rate of past month binge alcohol use was slightly higher in nonmetropolitan areas (12.8 percent) than in large or small metropolitan areas (9.6 and 11.2 percent, respectively). In rural nonmetropolitan areas, 11.3 percent of youths reported binge drinking.
Association with Illicit Drug and Tobacco Use
The level of alcohol use was strongly associated with illicit drug use in 2003. Among the 16.1 million heavy drinkers aged 12 or older, 32.5 percent were current illicit drug users. Persons who did not use alcohol in the past month were least likely to use illicit drugs (3.3 percent).
Drinking levels also were associated with tobacco use. Among heavy alcohol users, 61.7 percent smoked cigarettes in the past month, while only 20.7 percent of non-binge current drinkers and 17.4 percent of nondrinkers were current smokers. Smokeless tobacco and cigar use also were more prevalent among heavy drinkers than among non-binge drinkers and nondrinkers.
Driving Under the Influence of Alcohol
An estimated 13.6 percent of persons aged 12 or older drove under the influence of alcohol at least once in the 12 months prior to the interview in 2003 (a decrease from 14.2 percent in 2002). These percentages represent 32.3 million persons in 2003 and 33.5 million persons in 2002.
Driving under the influence varied by age group in 2003. About 9.7 percent of 16 or 17 year olds, 20.1 percent of 18 to 20 year olds, and 28.7 percent of 21 to 25 year olds reported driving under the influence of alcohol (Figure 3.6). Beyond age 25, these rates declined with increasing age.
Figure 3.6 Driving Under the Influence of Alcohol in the Past Year, by Age: 2003
Males were nearly twice as likely as females (18.2 vs. 9.3 percent, respectively) to drive under the influence of alcohol.
4. Tobacco Use
The National Survey on Drug Use and Health (NSDUH) includes a series of questions about the use of tobacco products, including cigarettes, chewing tobacco, snuff, cigars, and pipe tobacco. For analytic purposes, data for chewing tobacco and snuff are combined as "smokeless tobacco." Cigarette use is defined as smoking "part or all of a cigarette." Questions to determine nicotine dependence among current cigarette smokers also are included in the NSDUH. Nicotine dependence is based on criteria from the Nicotine Dependence Syndrome Scale (NDSS) or the Fagerstrom Test of Nicotine Dependence (FTND) (see Appendix B, Section B.4.2, of this report).
An estimated 70.8 million Americans reported current (past month) use of a tobacco product in 2003. This is 29.8 percent of the population aged 12 or older, similar to the rate in 2002 (30.4 percent) (Figure 4.1).
Figure 4.1 Past Month Tobacco Use among Persons Aged 12 or Older: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Among that same population, 60.4 million (25.4 percent of the total population aged 12 or older) smoked cigarettes in the past month, 12.8 million (5.4 percent) smoked cigars, 7.7 million (3.3 percent) used smokeless tobacco, and 1.6 million (0.7 percent) smoked tobacco in pipes. These rates remained unchanged from 2002.
Age
Young adults aged 18 to 25 reported the highest rate of current use of any tobacco products (44.8 percent). Past month rates of use for this age group were 40.2 percent for cigarettes, 11.4 percent for cigars, 4.7 percent for smokeless tobacco, and 0.9 percent for pipes. These rates were unchanged from 2002 (45.3 percent for any tobacco product, 40.8 percent for cigarettes, 11.0 percent for cigars, 4.8 percent for smokeless tobacco, and 1.1 percent for pipes).
An estimated 3.6 million youths aged 12 to 17 (14.4 percent) reported past month use of a tobacco product in 2003 (Figure 4.2). There were no statistically significant changes in past month rates of the different tobacco products among this age group between 2002 and 2003. However, there were significant declines in past year (from 20.3 to 19.0 percent) and lifetime (from 33.3 to 31.0 percent) cigarette use between 2002 and 2003. In addition, the rate of past month cigarette use decreased among 13 year olds (from 4.7 percent in 2002 to 3.3 percent in 2003) (Figure 4.3).
Figure 4.2 Past Month Tobacco Use among Youths Aged 12 to 17: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
In 2003, current cigarette smoking rates increased steadily with age up to age 20, from 1.7 percent at age 12 to 26.4 percent at age 17. The rate peaked at age 20 (44.1 percent). After age 22, rates generally declined with age: 30.9 percent for 30 to 34 year olds; 31.1 percent for 40 to 44 year olds; 25.0 percent for 50 to 54 year olds; 16.5 percent for 60 to 64 year olds; and 10.0 percent for persons aged 65 or older.
Smokeless tobacco use was most prevalent among young adults aged 18 to 25. Past month use was reported by 4.7 percent of young adults in 2003, which was similar to the 2002 rate (4.8 percent). Rates also did not change between 2002 and 2003 for youths aged 12 to 17 (2.0 percent in both years) or among persons aged 26 or older (3.2 percent in both years).
Current cigar use among the three age groups also was unchanged between 2002 and 2003. The rate was 4.5 percent in both years among youths aged 12 to 17; 11.4 percent in 2003 and 11.0 percent in 2002 among young adults aged 18 to 25; and 4.5 percent in 2003 and 4.6 percent in 2002 among adults aged 26 or older.
Gender
Males were more likely than females to report past month use of a tobacco product. In 2003, 35.9 percent of males aged 12 or older were current users of any tobacco product, a significantly higher proportion than among females (24.0 percent).
A higher proportion of males than females aged 12 or older smoked cigarettes in 2003 (28.1 vs. 23.0 percent). Among youths aged 12 to 17, however, girls (12.5 percent) were as likely as boys (11.9 percent) to smoke (Figure 4.4). There was no change in cigarette use among boys aged 12 to 17 between 2002 and 2003. However, among girls, cigarette use decreased from 13.6 percent in 2002 to 12.5 percent in 2003.
Figure 4.4 Past Month Cigarette Use, by Age Group and Gender: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Males were much more likely than their female counterparts to report current use of smokeless tobacco (6.2 percent of males aged 12 or older vs. 0.5 percent of females). This pattern remained consistent across age groups (12 to 17, 18 to 25, and 26 or older).
Pregnant Women
Based on combined data from 2002 and 2003, an estimated 18.0 percent of pregnant women aged 15 to 44 smoked cigarettes in the past month. Among nonpregnant women of the same age group, 30.7 percent smoked cigarettes in the past month.
Race/Ethnicity
American Indians or Alaska Natives were more likely than any other racial/ethnic group to report the use of tobacco products in 2003. Among persons aged 12 or older, 41.8 percent of American Indians or Alaska Natives reported using at least one tobacco product in the past month. The lowest current tobacco use rate among racial/ethnic groups in 2003 was observed for Asians (13.8 percent), which was a decrease from the 2002 rate (18.6 percent).
Among youths in different racial/ethnic groups, the highest rate of past month cigarette use in 2003 was among American Indians or Alaska Natives (23.2 percent), while the lowest was among Asians (3.7 percent) (Figure 4.5).
Figure 4.5 Past Month Cigarette Use among Youths Aged 12 to 17, by Race/Ethnicity: 2003
Note: Due to low precision, estimates for Native Hawaiians or Other Pacific Islanders are not shown.
Education
As in 2002, the prevalence of cigarette smoking decreased with increasing levels of education. Among adults aged 18 or older in 2003, college graduates were the least likely to report smoking cigarettes (14.0 percent) compared with 35.3 percent of adults who lacked a high school diploma.
College Students
Young adults aged 18 to 22 enrolled full time in college in 2003 were less likely to report current cigarette use than their peers not enrolled full time (i.e., part-time college students and persons not enrolled in college). Past month cigarette use was reported by 31.4 percent of full-time college students compared with 45.3 percent of their peers who were not enrolled full time.
Employment
Among unemployed adults aged 18 or older, rates of current cigarette smoking declined from 49.8 percent in 2002 to 42.7 percent in 2003. Current smoking rates among full-time and part-time workers in 2003 were 29.5 and 25.2 percent, respectively.
Geographic Area
Cigarette use rates among persons aged 12 or older in 2003 varied by region of the country. Past month cigarette use ranged from a low of 19.3 percent for persons living in the Pacific Division to 29.5 percent of persons living in the East South Central part of the country. This same pattern was noted in 2002.
Rates of current cigarette use among persons aged 12 or older were higher in less densely populated areas. In large metropolitan areas, 23.7 percent smoked in the past month compared with 26.9 percent in small metropolitan areas and 28.3 percent in nonmetropolitan areas (Figure 4.6). The highest rate of smoking occurred in urbanized nonmetropolitan areas (29.6 percent). However, this rate was not statistically different from rates in less urbanized nonmetropolitan areas (27.1 percent) and completely rural nonmetropolitan areas (28.0 percent).
Figure 4.6 Past Month Cigarette Use among Persons Aged 12 or Older, by County Type: 2003
Rates of current cigarette use declined between 2002 and 2003 in large metropolitan areas overall, from 25.1 to 23.7 percent. The decline was evident among adults aged 18 or older (from 26.7 to 25.3 percent) and for youths aged 12 to 17 (from 11.5 to 10.2 percent).
Frequency of Cigarette Use
Of the 60.4 million past month cigarette smokers, 62.9 percent (38.0 million) reported smoking every day in the past 30 days. Among youths aged 12 to 17 who smoked in the past month, 29.7 percent (900,000) were daily smokers.
Past month cigarette smokers in 2003 smoked an average of 13 cigarettes per day on the days they smoked. The average number of cigarettes smoked per day increased with age from 2 per day among 12 year olds to 6 per day among 17 year olds; 12 per day among 30 to 34 year olds; and 15 per day among 40 to 44 year olds, peaking at 19 per day among smokers aged 55 to 59. Smokers aged 60 to 64 averaged 14 per day, and smokers aged 65 or older averaged 15 per day.
Association with Illicit Drug and Alcohol Use
Current cigarette smokers were more likely to use other tobacco products, alcohol, and illicit drugs than were current nonsmokers. Comparing current smokers and nonsmokers, rates of binge alcohol use were 43.4 versus 15.5 percent, rates of heavy alcohol use were 16.5 versus 3.5 percent, and rates of current (past month) illicit drug use were 19.8 versus 4.2 percent. Rates of use of smokeless tobacco and cigars also were higher among current smokers compared with current nonsmokers (4.9 vs. 2.7 percent for smokeless tobacco; 12.2 vs. 3.1 percent for cigars).
Usual Brand of Cigarettes Smoked
Among past month cigarette smokers aged 12 or older, the most commonly smoked brands were Marlboro (41.3 percent), Newport (10.8 percent), and Camel (7.0 percent). These brands also were the most commonly reported in 2002.
Notable racial/ethnic differences existed with regard to brand of cigarettes smoked most often in the past month. In 2003, 43.8 percent of white smokers and 58.5 percent of Hispanic smokers reported smoking Marlboro cigarettes. Among black smokers, 7.2 percent smoked Marlboro cigarettes, while 46.0 percent smoked Newport cigarettes.
The same three brands accounted for most of the youth cigarette smoking in 2003. Among current smokers 12 to 17 years of age, 49.2 percent reported Marlboro, 23.4 percent reported Newport, and 9.7 percent reported Camel. No other individual cigarette brand was reported by more than 3.0 percent of youths. These three brands were also most commonly reported by youths in 2002.
Youth Access to Cigarettes
Youths who had smoked in the past 30 days were asked to report all the different sources from which they had obtained cigarettes in the past 30 days. Among youth smokers aged 12 to 17 in 2003, 77.0 percent reported that they or someone else purchased the cigarettes. The most commonly reported way that youth smokers obtained cigarettes was having a friend or relative buy the cigarettes (63.3 percent).
More than half of youth smokers aged 12 to 17 (53.3 percent) reported that they personally bought cigarettes at least once in the past month. More than one fourth of youth smokers (29.0 percent) reported buying cigarettes at a store where a clerk hands out the cigarettes, and 28.3 percent reported buying cigarettes in a small store, convenience store, or gas station. These percentages were all slightly lower than the corresponding estimates for 2002, but none of these differences was statistically significant. However, a significantly lower percentage of youth smokers in 2003 bought cigarettes in a drugstore (7.6 percent) compared with youth smokers in 2002 (9.8 percent).
Among youth smokers aged 12 or 13, 32.3 percent reported that they personally bought cigarettes in the past month. However, only 7.3 percent of smokers aged 12 or 13 reported buying cigarettes at a store where a clerk hands out the cigarettes. Approximately one fourth (24.1 percent) of smokers aged 12 or 13 reported buying cigarettes from a friend, relative, or someone at school.
Nicotine Dependence
An estimated 35.7 million Americans aged 12 or older in 2003 were classified as nicotine dependent in the past month because of their cigarette use (15.0 percent of the total population). These estimates are similar to the estimates for 2002.
Among the 60.4 million past month cigarette smokers aged 12 or older in 2003, 59.0 percent were nicotine dependent. The proportion of current cigarette smokers who were dependent increased with age. Among youths aged 12 to 17 who were current smokers, 38.4 percent were dependent. The dependence rate was 46.9 percent among smokers aged 18 to 25, 51.5 percent among smokers aged 26 to 34, 67.0 percent among smokers aged 35 to 49, and 70.1 percent among smokers aged 50 or older (Figure 4.7).
Figure 4.7 Past Month Cigarette Use and Nicotine Dependence, by Age: 2003
Of the 35.7 million nicotine-dependent smokers in 2003, 1.2 million were youths aged 12 to 17 (4.7 percent of youths), 6.0 million were young adults aged 18 to 25 (18.9 percent of young adults), and 28.5 million were aged 26 or older (15.8 percent of older adults).
Nicotine dependence among adult smokers was more likely among those who first used cigarettes at a young age than among those who first used at later ages. In 2003, current smokers aged 18 or older who had first smoked at age 14 or younger had a nicotine dependence rate of 66.9 percent compared with a dependence rate of 51.1 percent among current smokers who had smoked their first cigarette at age 18 or older.
5. Trends in Initiation of Substance Use
Estimates of substance use incidence, or initiation, describe the number of new users of illicit drugs, alcohol, or tobacco during a given year. Where prevalence estimates describe the extent of use of substances over some period of time, incidence data describe emerging patterns of use, particularly among young people. The incidence estimates are based on data from the combined 2002 and 2003 National Survey on Drug Use and Health (NSDUH). As the 2002 NSDUH constitutes a new baseline year for the survey, these data should not be compared with previously published data from the National Household Survey on Drug Abuse (NHSDA).
Incidence estimates are based on questions about age at first use, year and month of first use for recent initiates, the respondent's date of birth, and the interview date. Using this information along with editing and imputation when necessary, the date of first use is determined for each substance used by each respondent. By applying sample weights to incidents of first use, estimates of the number of new users of each substance are developed for each year. Responses to questions on country of birth and years lived in the United States are used to restrict estimates to initiation occurring only within the United States. This adjustment was not included in estimates shown in prior reports.
The estimates discussed in this chapter include the number of new users at any age (including those younger than age 12), by age group and gender, and the average age of new users. Estimates for the years from 1965 to 2002 are covered. Although they are not discussed in this chapter, estimates of age-specific incidence rates also are available. These rates are defined as the number of new users per 1,000 potential new users. More precisely, the rates are actually the number of new users per 1,000 person-years of exposure. This measure is widely used in describing the incidence of disease. The method used for computing these rates is described in Section B.4.4 in Appendix B.
The incidence estimates reported in this chapter are based on retrospective reporting; therefore, they may be subject to several sources of bias. These include bias due to differential mortality of users and nonusers of each substance, memory errors (recall decay and telescoping), and underreporting due to desire for social acceptability or fear of disclosure. A recent evaluation of the NSDUH retrospective estimates of incidence and lifetime prevalence (no longer produced) suggests that bias is significant and differs by substance and length of recall (Gfroerer et al., 2004). For very recent time periods, bias in estimates of marijuana, cocaine, alcohol, and cigarettes appears to be small, but for all other substances there is significant downward bias. Bias for all substances increases the further back in time the estimates are made, suggesting a relationship with the length of recall. Nevertheless, these estimates, when used cautiously, are useful in describing the number and characteristics of recent initiates, as well as identifying broad historical periods of increasing or decreasing initiation. They should not be used to compare levels of initiation between two separate time periods many years apart, such as the 1990s versus the 1960s. The description of the initiation data given in this chapter is made with these limitations in mind. See Section B.4.4 in Appendix B for further discussion.
Because the incidence estimates are based on retrospective reports of age at first use, the most recent year available for these estimates is 2002, based on the 2003 NSDUH. For two of the measures, first alcohol use and first cigarette use, initiation before age 12 is common. A 2year lag in reporting for "all ages" estimates is applied for these measures because the NSDUH sample does not cover youths under age 12. The 2year lag ensures that initiation at ages 10 and 11 is captured in the estimation.
Marijuana
There were an estimated 2.6 million new marijuana users in 2002. This means that each day an average of 7,000 Americans tried marijuana for the first time. About two thirds (69 percent) of these new marijuana users were under age 18, and about half (53 percent) were female.
The annual number of marijuana initiates generally increased from 1965 until about 1973. From 1973 to 1978, the annual number of marijuana initiates remained level at over 3 million per year. After that, the number of initiates declined, reaching a low point in 1990, then rose again until 1995. From 1995 to 2002, there was no consistent trend, with estimates varying between 2.4 million and 2.9 million per year (Figure 5.1).
Figure 5.1 Annual Numbers of New Users of Marijuana: 19652002
The proportion of marijuana initiates under age 18 (69 percent in 2002) has generally increased since the 1960s, when less than half of initiates were under age 18. The average age of marijuana initiates was around 19 in the late 1960s and 17.2 in 2002.
Cocaine
In 2002, approximately 1.1 million persons used cocaine for the first time. Incidence of cocaine use generally rose throughout the 1970s to a peak in 1980 (1.6 million new users) and subsequently declined until the early 1990s. Cocaine initiation steadily increased after 1993, averaging over a million new users per year during 2000 to 2002.
First use of cocaine usually occurs at age 18 or later, a pattern consistent since the 1960s. Approximately 70 percent of cocaine initiates in 2002 were age 18 or older. During the early 1980s, when cocaine initiation reached a peak, approximately 80 percent of initiates were age 18 or older.
The average age of cocaine initiates was around 22 years in the early 1980s, rose to about 23 in the late 1980s, then declined to about 21 by the late 1990s. The average age of initiates in 2002 was 20.3 years.
Heroin
From 1995 through 2002, the annual number of new heroin users ranged from 121,000 to 164,000. During this period, most new users were age 18 or older (on average 75 percent), and most were male (on average 63 percent).
Hallucinogens
The incidence of hallucinogen use has exhibited two notable periods of increase. Between 1965 and 1969, there was a tenfold increase in the estimated annual number of initiates. This increase was driven primarily by the use of LSD. The second period of increase in first-time hallucinogen use occurred from around 1992 until 2000, fueled mainly by increases in use of Ecstasy (i.e., MDMA) (Figure 5.2). Decreases in initiation of both LSD and Ecstasy were evident between 2001 and 2002, coinciding with an overall drop in hallucinogen incidence from 1.6 million to 1.1 million.
Figure 5.2 Annual Numbers of New Users of Ecstasy, LSD, and PCP: 19652002
Initiation of Ecstasy use increased from 1993 until 2001, when it peaked at 1.8 million new users. In 2002, the number declined to 1.1 million. Two thirds (66 percent) of new Ecstasy users in 2002 were 18 or older, and 50 percent were male.
LSD incidence dropped from 872,000 new users in 2000 to 631,000 in 2001 and then to 272,000 in 2002.
Inhalants
The number of new inhalant users was about 1 million in 2002. As in prior years, these new users were predominately under age 18 (78 percent), and about half (53 percent) were male.
Psychotherapeutics
This category includes nonmedical use of any prescription-type pain reliever, tranquilizer, stimulant, or sedative; it also includes methamphetamine. Over-the-counter substances are not included.
The numbers of new users of psychotherapeutics in 2002 were 2.5 million for pain relievers, 1.2 million for tranquilizers, 761,000 for stimulants, and 225,000 for sedatives.
Pain reliever incidence increased from 1990 to 2000, when there were 2.5 million (Figure 5.3). In 2001 and 2002, there was no change in the annual number of initiates. More than half (55 percent) of the new users in 2002 were females, and more than half (56 percent) were aged 18 or older.
Figure 5.3 Annual Numbers of New Nonmedical Users of Pain Relievers: 19652002
The number of new users of stimulants generally increased during the 1990s, but there has been little change since 2000. Incidence of methamphetamine use generally rose between 1992 and 1998. Since then, there have been no statistically significant changes. There were an estimated 323,000 methamphetamine initiates in 2002.
Initiation of tranquilizer use increased generally during the 1990s, reaching a peak at 1.4 million initiates in 2000, and remained relatively stable at 1.3 million in 2001 and 1.2 million in 2002.
The number of sedative initiates rose steadily during the late 1960s and early 1970s, and then declined during the early 1980s, remaining below 250,000 per year since 1984.
Alcohol
In 2001, the most recent year for which alcohol incidence estimates were made, an estimated 5.3 million Americans used alcohol for the first time. This translates to an average of more than 14,000 new drinkers each day. Most of these new alcohol users were under the legal drinking age of 21. An estimated 4.7 million (88 percent of initiates) were under 21, including 3.8 million (73 percent) under age 18.
Tobacco
The number of Americans who smoke cigarettes for the first time each year has remained above 2.5 million in nearly every year since 1965. In 2001, the most recent year for which cigarette incidence estimates are made, an estimated 2.7 million Americans used cigarettes for the first time. This translates to an average of more than 7,000 new smokers each day. About three quarters (76 percent) of these initiates were under age 18, and about half (51 percent) were males.
Following a period of increase from 1990 to 1997, cigarette initiation decreased from 3.3 million in 1997 to 2.7 million in 2001 (Figure 5.4). The number of new daily smokers decreased from 2.0 million in 1997 to 1.4 million in 2002. Among youths under age 18, the number of new daily smokers decreased from 1.1 million per year between 1997 and 2000 to 734,000 in 2002. This corresponds to a decrease from about 3,000 to about 2,000 new youth daily smokers each day.
Figure 5.4 Annual Numbers of New Users of Tobacco: 19652002
Initiation of cigar smoking more than doubled between 1990 and 1998, reaching a peak of 3.7 million new users in 1998. Between 2000 and 2002, cigar initiates declined from 3.6 million to 3.0 million. Since 1990, youths under 18 have constituted an increasingly greater proportion of the number of new cigar smokers, from 23 percent in 1990 to 46 percent in 2002. During that period, the proportion of cigar initiates that was female also increased, from 24 to 45 percent.
6. Youth Prevention-Related Measures
This chapter presents results from the 2003 National Survey on Drug Use and Health (NSDUH) for various measures related to the prevention of substance use among youths aged 12 to 17. These measures include perceptions of risk from substance use (cigarettes, alcohol, and illicit drugs), availability of substances, perceived parental disapproval of substance use, attitudes about school, involvement in delinquent behavior, participation in religious and other activities, and exposure to substance abuse prevention messages and programs.
NSDUH includes an extensive set of questions about risk and protective factors directed at youths aged 12 to 17. Risk factors include those individual characteristics or social environments associated with an increased likelihood of substance use, while protective factors are related to a decreased likelihood of substance use. These factors derive from circumstances, influences, and perceptions at many levels, such as the individual, peer, family, school, and community levels (Hawkins, Catalano, & Miller, 1992).
Perceptions of Risk
Youths were asked how much they thought people risk harming themselves physically and in other ways when they use various substances. Response choices in the survey were "great risk," "moderate risk," "slight risk," or "no risk." Youths perceiving great risk are generally less likely to use substances than youths who do not perceive great risk. For example, in 2003 among youths indicating that "smoking one or more packs of cigarettes per day" was a great risk, 9.5 percent had smoked cigarettes in the past month (Figure 6.1). However, among those indicating moderate, slight, or no risk, 17.2 percent had smoked cigarettes in the past month. Similarly, among youths who considered "smoking marijuana once a month" a great risk, 1.8 percent indicated that they had used marijuana in the past month. However, among youths who indicated moderate, slight, or no risk, the prevalence rate was 11.2 percent.
Figure 6.1 Past Month Use of Cigarettes and Marijuana among Youths Aged 12 to 17, by Perceptions of Risk: 2003
In 2002, 32.4 percent of youths indicated that smoking marijuana once a month was a great risk, and in 2003 that figure increased to 34.9 percent (Figure 6.2). Despite the increase in perceptions of great risk of once a month marijuana use among youths 12 to 17, there was no change from 2002 to 2003 in past month or past year marijuana use among youths. However, lifetime use of marijuana decreased, from 20.6 percent in 2002 to 19.6 percent in 2003 (Figure 6.3). Between 2002 and 2003, there also was a decrease in the number of youths using marijuana daily or almost daily (see Chapter 2, Figure 2.11).
Figure 6.2 Perceived Great Risk of Use of Selected Illicit Drugs among Youths Aged 12 to 17: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
There were no statistically significant changes between 2002 and 2003 in the percentages of youths aged 12 to 17 perceiving a great risk in using cigarettes, alcohol, cocaine, heroin, and LSD (Figures 6.2 and 6.4).
Figure 6.4 Perceived Great Risk of Cigarette and Alcohol Use among Youths Aged 12 to 17: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
There was a significant increase in the percentage of youths aged 14 or 15 who perceived a great risk in smoking one or more packs of cigarettes per day, from 62.6 percent in 2002 to 64.7 percent in 2003. During the same period, lifetime use of cigarettes among 14 or 15 year olds declined from 33.9 to 31.4 percent.
Availability
In 2003, approximately one in six youths (16.1 percent) reported that he or she had been approached by someone selling drugs in the past month. Those who had been approached reported a much higher rate of past month use of an illicit drug (35.0 percent) than those who had not been approached (6.7 percent). Between 2002 and 2003, there was no significant change in the percentage of youths who were approached by someone selling drugs (16.7 percent in 2002).
In 2003, slightly more than half of youths aged 12 to 17 indicated that it would be fairly or very easy to obtain marijuana if they wanted some (53.6 percent). However, the ease of obtaining marijuana varied greatly by age among youths aged 12 to 17. Only 25.2 percent of 12 or 13 year olds indicated that it would be fairly or very easy to obtain marijuana, but 77.2 percent of those 16 or 17 years of age indicated that it would be fairly or very easy to obtain this substance (Figure 6.5).
Figure 6.5 Perceived Availability of Marijuana and LSD among Youths Aged 12 to 17, by Age: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
The percentage of youths aged 12 to 17 reporting that it would be easy to obtain marijuana declined slightly between 2002 and 2003, from 55.0 to 53.6 percent. Among youths, this decrease was found for males, whites, blacks, Hispanics, and youths who lived in large metropolitan areas.
The percentage of youths reporting that LSD would be easy to obtain decreased between 2002 and 2003, from 19.4 to 17.6 percent.
Parental Disapproval of Substance Use
In 2003, youths who perceived that their parents would "strongly disapprove" of their use of substances were much less likely to use those substances than youths who perceived that their parents would only "somewhat disapprove" or "neither approve nor disapprove." For example, among youths who perceived that their parents would strongly disapprove of smoking one or more packs of cigarettes a day (89.8 percent of youths), 8.5 percent had used cigarettes in the past month compared with 45.2 percent of youths who perceived that their parents would not strongly disapprove.
Among youths in 2003 who perceived that their parents would strongly disapprove of their trying marijuana or hashish once or twice, 5.4 percent used marijuana in the past month, while among youths whose parents would not strongly disapprove, 28.7 percent used marijuana in the past month.
The majority of youths in 2003 indicated that their parents would strongly disapprove if they used marijuana once or twice (89.4 percent) or if they used marijuana once a month or more (92.2 percent). Most youths also indicated that their parents would strongly disapprove if they were to smoke one or more packs of cigarettes per day (89.8 percent) or have one or two alcohol drinks nearly every day (88.5 percent). These rates of perceived parental disapproval were all similar to the rates in 2002.
Attitudes about School
Youths were asked if they liked going to school, if assigned schoolwork was meaningful and important, if their courses at school during the past year were interesting, if the things learned in school during the past year would be important later in life, and if teachers in the past year let them know that they were doing a good job with schoolwork. Youths who had positive attitudes about school were less likely to use substances than other students. For example, in 2003, 79.1 percent of youths reported that they "liked a lot" or "kind of liked" going to school. Among those youths, 9.1 percent had used an illicit drug in the past month; however, among youths who either "didn't like very much" or "hated" going to school, 19.9 percent had used an illicit drug in the past month.
For each of the school characteristics listed above, at least 75 percent of youths aged 12 to 17 indicated positive attitudes. Youths' ratings of these school factors in 2003 were similar to the ratings from 2002 with the exception of whether youths thought teachers always or sometimes let students know that they were doing a good job with schoolwork. In this instance, the percentage increased from 75.7 percent in 2002 to 77.6 percent in 2003.
Delinquent Behavior
In 2003, youths were asked if they had engaged in the following delinquent behaviors during the past year: gotten into a serious fight at school or work, participated in a group-on-group fight, attacked someone with the intent to seriously hurt him or her, carried a handgun, sold illegal drugs, or stolen or tried to steal something worth $50 or more. Youths who had engaged in these behaviors were more likely to have used illicit drugs in the past month than other youths. For example, compared with youths who had not engaged in these behaviors, youths in 2003 were more likely to have used an illicit drug in the past month if they had gotten into a serious fight at school or work (19.6 vs. 8.6 percent), carried a handgun (32.5 vs. 10.4 percent), sold illegal drugs (67.0 vs. 9.1 percent), or stolen or tried to steal something worth $50 or more (39.1 vs. 9.9 percent) (Figure 6.6).
Figure 6.6 Past Month Illicit Drug Use among Youths Aged 12 to 17, by Participation in Delinquent Behaviors: 2003
Both the percentage of youths reporting that they had gotten into a serious fight at school or work and the percentage participating in a group-against-group fight in the past year increased between 2002 and 2003 from 20.6 to 23.8 percent and from 15.9 to 18.1 percent, respectively. The percentage selling illegal drugs in the past year decreased from 4.4 percent in 2002 to 3.6 percent in 2003. In 2003, 3.6 percent of youths indicated they had carried a handgun in the past year, 4.5 percent had stolen (or tried to steal) something worth more than $50, and 8.3 percent had attacked someone with the intent to seriously harm him or her; these percentages were similar to those in 2002.
Participation in Religious and Other Activities
Among youths aged 12 to 17 in 2003 who attended religious services 25 times or more in the past year (32.8 percent of youths), 7.0 percent had used an illicit drug in the past month. Among youths attending less often or not at all, 13.4 percent reported past month illicit drug use. Among youths who agreed or strongly agreed that religious beliefs are a very important part of their life (76.7 percent of all youths), 8.8 percent had used an illicit drug in the past month. In contrast, among youths who disagreed or strongly disagreed with the statement, 19.2 percent had used an illicit drug in the past month.
Among youths aged 12 to 17 in 2003 who participated in two or more youth activities, such as band, sports, student government, or dance lessons (86.7 percent of youths), 10.4 percent had used an illicit drug in the past month. Among youths indicating one or no youth activities in the past year, 17.9 percent had used an illicit drug in the past month.
Exposure to Prevention Messages and Programs
In 2003, a majority of youths aged 12 to 17 (83.6 percent) reported having seen or heard alcohol or drug prevention messages outside of school in the past year. Youths who had seen or heard these messages indicated a slightly lower prevalence of past month use of an illicit drug (10.8 percent) compared with youths who had not seen or heard these types of messages (13.7 percent). The percentage of youths hearing these messages remained unchanged from 2002 to 2003.
In 2003, 78.1 percent of youths aged 12 to 17 who were enrolled in school during the past 12 months reported having seen or heard drug or alcohol prevention messages in school. This was similar to the percentage reporting exposure to such messages in 2002. Of youths indicating they had seen or heard these messages, the rate of past month illicit drug use was 10.4 percent compared with 14.8 percent for youths who had not been exposed to prevention messages in school.
In 2003, over half of all youths aged 12 to 17 (58.9 percent) indicated that they had talked with at least one parent in the past year about the dangers of tobacco, alcohol, or drug use. The estimate for 2002 was similar (58.1 percent). Youths who had talked with a parent about the dangers of substance use were less likely to have used an illicit drug in the past month (10.0 percent) compared with youths who had not had such conversations (13.0 percent).
Youths were asked if they had participated in various special programs dealing with substance use and other related problems in the past year. The specific types of programs, and the percentages of youths participating in them are problem-solving, communication skills, or self-esteem groups (25.0 percent); violence prevention programs (17.2 percent); alcohol, tobacco, or drug prevention programs outside of school (13.9 percent); pregnancy or sexually transmitted disease (STD) prevention programs (14.9 percent); and programs for dealing with alcohol or drug use (6.0 percent). Youth participation in all of these programs except violence prevention programs and programs dealing with alcohol or drug use increased between 2002 and 2003.
7. Substance Dependence, Abuse, and Treatment
The National Survey on Drug Use and Health (NSDUH) includes a series of questions to assess dependence on and abuse of substances, including alcohol and illicit drugs, which include nonmedical use of prescription-type drugs. These questions are designed to measure dependence and abuse based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (American Psychiatric Association [APA], 1994). The questions on dependence ask about health and emotional problems, attempts to cut down on use, tolerance, withdrawal, and other symptoms associated with substances used. The questions on abuse ask about problems at work, home, and school; problems with family or friends; physical danger; and trouble with the law due to substance use. Dependence reflects a more severe substance problem than abuse, and persons are classified with abuse of a particular substance only if they are not dependent on that substance.
This chapter provides estimates of the prevalence and patterns of substance dependence and abuse in the Nation from the 2003 NSDUH and compares these estimates against the results from the 2002 NSDUH. It also provides estimates of the prevalence and patterns of the receipt of treatment for problems related to substance use and discusses the need for and receipt of treatment at specialty facilities for problems associated with substance use.
7.1 Substance Dependence and Abuse
An estimated 21.6 million persons aged 12 or older in 2003 were classified with substance dependence or abuse (9.1 percent of the total population). Of these, 3.1 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.8 million were dependent on or abused illicit drugs but not alcohol, and 14.8 million were dependent on or abused alcohol but not illicit drugs (Figure 7.1).
Figure 7.1 Past Year Substance Dependence or Abuse among Persons Aged 12 or Older: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Between 2002 and 2003, there was no change in the number of persons with substance dependence or abuse (22.0 million in 2002 and 21.6 million in 2003) (Figure 7.1).
Of the 6.8 million persons classified with dependence on or abuse of illicit drugs, 4.2 million were dependent on or abused marijuana. This represents 1.8 percent of the total population aged 12 or older and 61.4 percent of all those classified with illicit drug dependence or abuse.
In 2003, 57.4 percent of past year heroin users (0.2 million) were classified with dependence on or abuse of heroin (Figure 7.2). Among past year users of cocaine, 25.6 percent (1.5 million) were classified with dependence on or abuse of cocaine. Among past year users of marijuana, 16.6 percent (4.2 million) were classified with dependence on or abuse of marijuana, while 12.2 percent of past year users of pain relievers (1.4 million) were classified with dependence on or abuse of pain relievers.
Figure 7.2 Dependence or Abuse of Specific Substances among Past Year Users of Substances: 2003
There were 17.8 million persons aged 12 or older classified with dependence on or abuse of alcohol in 2003 (7.5 percent). Among past year users of alcohol, 11.5 percent were classified with alcohol dependence or abuse.
There were no changes between 2002 and 2003 in the estimated percentages of the population with dependence on or abuse of illicit drugs (3.0 percent in 2002 and 2.9 percent in 2003) and dependence on or abuse of alcohol (7.7 percent in 2002 and 7.5 percent in 2003). However, there was a decrease in the rate for dependence on or abuse of hallucinogens (0.2 to 0.1 percent).
Age at First Use
In 2003, adults who had first used substances at a younger age were more likely to be classified with dependence or abuse than adults who initiated use at a later age. For example, among adults aged 18 or older who first tried marijuana at age 14 or younger, 13.3 percent were classified with illicit drug dependence or abuse compared with only 2.2 percent of adults who had first used marijuana at age 18 or older. This pattern of higher rates of dependence or abuse among persons initiating their use of marijuana at younger ages was observed among all demographic subgroups analyzed.
A similar pattern was observed for age at first use of alcohol and dependence on or abuse of alcohol among adults. Among adults aged 18 or older who first tried alcohol at age 14 or younger, 16.7 percent were classified with alcohol dependence or abuse compared with only 3.7 percent of adults who had first used alcohol at age 18 or older. Adults aged 21 or older who had first used alcohol before reaching 21 also were more likely than adults who had their first drink at age 21 or older to be classified with alcohol dependence or abuse (9.2 vs. 2.6 percent).
Age
Rates of substance dependence or abuse in 2003 showed substantial variation by age. The rate for dependence or abuse was 1.2 percent at age 12, and rates generally increased for each successive year of age until the highest rate (23.6 percent) at age 21. After age 21, the rates declined with age. A similar pattern by age was observed in 2002.
In 2003, the rate of substance dependence or abuse was 8.9 percent for youths aged 12 to 17; 21.0 percent for persons aged 18 to 25; and 7.0 percent for persons aged 26 or older (Figure 7.3). Among persons with substance dependence or abuse, illicit drugs accounted for 58.1 percent of youths, 37.2 percent of persons aged 18 to 25, and 24.1 percent of persons aged 26 or older.
Figure 7.3 Past Year Illicit Drug or Alcohol Dependence or Abuse, by Age Group and Substance: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
From 2002 to 2003 among persons aged 12 to 17, there was a decrease in the rates of marijuana dependence or abuse (4.3 to 3.8 percent) and in the rates of marijuana dependence (2.5 to 2.0 percent).
Gender
In 2003, males were almost twice as likely to be classified with substance dependence or abuse as females (12.2 vs. 6.2 percent) (Figure 7.4). Among youths aged 12 to 17, however, the rate of substance dependence or abuse among females (9.1 percent) was similar to the rate among males (8.7 percent).
Figure 7.4 Past Year Illicit Drug or Alcohol Dependence or Abuse, by Age and Gender: 2003
Among persons aged 12 or older in 2003, the rate of substance dependence or abuse was highest among American Indians or Alaska Natives (17.2 percent). The next highest rates were among Native Hawaiians or Other Pacific Islanders (12.9 percent) and among persons reporting two or more races (11.3 percent). Asians had the lowest rate of dependence or abuse (6.3 percent). The rates among Hispanics (9.8 percent) and whites (9.2 percent) were higher than the rate among blacks (8.1 percent).
Between 2002 and 2003, there were no statistically significant changes in the rates of substance dependence or abuse for any racial/ethnic group.
Education/Employment
Rates of substance dependence or abuse varied with level of education. Among adults aged 18 or older in 2003, those who were college graduates had the lowest rate of dependence or abuse (6.7 percent), while those with some college, high school graduates, and those who were not high school graduates had higher rates (10.5, 9.1, and 10.6 percent, respectively).
Rates of substance dependence or abuse varied with current employment status. In 2003, an estimated 17.0 percent of unemployed adults aged 18 or older were classified with dependence or abuse, while 10.2 percent of full-time employed adults and 10.3 percent of part-time employed adults were classified as such.
Most adults with substance dependence or abuse in 2003 were employed either full or part time. Of the 19.4 million adults classified with dependence or abuse, 14.9 million (76.8 percent) were employed.
Criminal Justice Populations
In 2003, adults aged 18 or older who were on parole or a supervised release from jail during the past year were more likely to be classified with dependence on or abuse of a substance (32.6 percent) than those who were not on parole or supervised release during the past year (9.0 percent).
In 2003, probation status also was associated with substance dependence or abuse. The rate of substance dependence or abuse was 39.1 percent among adults who were on probation during the past year, while the rate was only 8.4 percent among adults who were not on probation during the past year.
Geographic Area
Rates of substance dependence or abuse for persons aged 12 or older did not vary greatly by region. The rates were 8.6 percent in the Northeast, 10.1 percent in the Midwest, 8.3 percent in the South, and 9.7 percent in the West.
In 2003, among persons aged 12 or older, the rate for substance dependence or abuse was 9.1 percent in large metropolitan counties, 9.5 percent in small metropolitan counties, and 8.5 percent in nonmetropolitan counties (Figure 7.5). The rate was lowest (5.7 percent) in completely rural counties.
Figure 7.5 Past Year Illicit Drug or Alcohol Dependence or Abuse among Persons Aged 12 or Older, by County Type: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
7.2 Past Year Treatment for a Substance Use Problem
Estimates described in this section refer to treatment received to reduce or stop drug or alcohol use, or for medical problems associated with the use of illicit drugs or alcohol. This includes treatment received in the past year at any location, such as in a hospital, at a rehabilitation facility (outpatient or inpatient), mental health center, emergency room, private doctor's office, self-help group, or prison or jail. The definition of treatment in this section is different from the definition of treatment described in Section 7.3 (specialty treatment) that excludes treatment at an emergency room, private doctor's office, self-help group, prison or jail, or at a hospital as an outpatient.
An estimated 3.3 million people aged 12 or older (1.4 percent of the population) received some kind of treatment for a problem related to the use of alcohol or illicit drugs in the 12 months prior to being interviewed in 2003. Of these, 1.3 million received treatment for both alcohol and illicit drugs, 0.5 million received treatment for illicit drugs but not alcohol, and 1.1 million received treatment for alcohol but not illicit drugs. (Estimates by substance do not add to the total because the total includes persons who reported receiving treatment but did not report for which substance the treatment was received.)
Between 2002 and 2003, there was no change in the number or percentage of the population receiving substance use treatment within the past year (3.5 million, 1.5 percent, in 2002; 3.3 million, 1.4 percent, in 2003).
Age, Gender, and Race/Ethnicity
Among persons aged 12 or older in 2003, males were more likely than females to receive treatment for an alcohol or illicit drug problem in the past year (2.0 vs. 0.9 percent, respectively). Among youths aged 12 to 17, males also were more likely to receive treatment than females (1.7 vs. 1.2 percent, respectively).
Among persons aged 12 or older in 2003, the rates of alcohol or illicit drug treatment during the 12 months prior to the interview were highest among American Indians or Alaska Natives (6.4 percent), persons reporting two or more races (2.6 percent), and Native Hawaiians or Other Pacific Islanders (2.1 percent). The rates among blacks and Hispanics were similar (1.7 and 1.8 percent, respectively). The rate among whites was 1.3 percent. The lowest rate of treatment was among Asians (0.4 percent).
Between 2002 and 2003, the rate of past year substance use treatment increased from 2.2 to 2.8 percent among young adults aged 18 to 25.
Location of Treatment and Substance Treated
In 2003, among the 3.3 million persons aged 12 or older who received treatment for alcohol or illicit drugs in the past year, more than half received treatment at a self-help group (1.9 million) (Figure 7.6). There were 1.2 million persons who received treatment at a rehabilitation facility as an outpatient, 752,000 at a rehabilitation facility as an inpatient, 729,000 at a mental health center as an outpatient, 587,000 at a hospital as an inpatient, 377,000 at a private doctor's office, 251,000 at an emergency room, and 206,000 at a prison or jail. (Note that the estimates of treatment by location include persons reporting more than one location.)
Figure 7.6 Locations Where Past Year Substance Treatment Was Received among Persons Aged 12 or Older: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Between 2002 and 2003, there were decreases in the number of persons who received treatment at a hospital as an inpatient (859,000 to 587,000), at a rehabilitation facility as an inpatient (1.1 million to 752,000), at a mental health center as an outpatient (1.0 million to 729,000), and at an emergency room (469,000 to 251,000) (Figure 7.6).
More than half (2.2 million) of the 3.3 million persons who received treatment for a substance problem in the past year received treatment for alcohol during their most recent treatment (Figure 7.7). An estimated 975,000 persons received treatment for marijuana, 557,000 persons received treatment for cocaine, 415,000 for pain relievers, and 281,000 for heroin. (Note that the estimates of treatment by substance include persons reporting more than one substance.)
Figure 7.7 Substances for Which Persons Aged 12 or Older Received Treatment in the Past Year: 2003
The estimated number of persons receiving treatment for cocaine decreased from 796,000 in 2002 to 557,000 in 2003.
7.3 Needing and Receiving Specialty Treatment
This section discusses the need for and receipt of treatment for a substance use problem at a "specialty" treatment facility. It includes estimates of the number of persons needing and receiving treatment, as well as those needing but not receiving treatment. These estimates are specified separately for alcohol, for illicit drugs, and for illicit drugs or alcohol. Specialty treatment is treatment received at drug or alcohol rehabilitation facilities (inpatient or outpatient), hospitals (inpatient only), or mental health centers. It excludes treatment at an emergency room, private doctor's office, self-help group, prison or jail, or hospital as an outpatient. An individual is defined as needing treatment for an alcohol or drug problem if he or she was dependent on or abused alcohol or drugs or received specialty treatment for alcohol or drugs in the past 12 months.
An individual needing treatment for an illicit drug problem is defined as receiving treatment for his or her drug problem only if he or she reported receiving specialty treatment for drugs in the past year. Thus, an individual who needed treatment for illicit drugs but only received specialty treatment for alcohol in the past year was not counted as receiving treatment for drugs. Similarly, an individual who needed treatment for an alcohol problem who only received specialty treatment for drugs was not counted as receiving alcohol treatment. Individuals who reported receiving specialty substance abuse treatment but were missing information on whether the treatment was specifically for alcohol or drugs were not counted in estimates of specialty drug treatment or in estimates of specialty alcohol treatment; however, they were counted in estimates for "drug or alcohol" treatment.
In 2003, the estimated number of persons aged 12 or older needing treatment for an alcohol or illicit drug problem was 22.2 million (9.3 percent of the total population). An estimated 1.9 million of these people (0.8 percent of the total population and 8.5 percent of the people who needed treatment) received treatment at a specialty facility. Thus, there were 20.3 million persons (8.5 percent of the total population) who needed but did not receive treatment at a specialty substance abuse facility in 2003 (Figure 7.8).
Figure 7.8 Past Year Need for and Receipt of Specialty Treatment for Any Illicit Drug or Alcohol Use among Persons Aged 12 or Older: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
The estimated number of persons needing but not receiving treatment for a substance use problem did not change between 2002 (20.5 million) and 2003 (20.3 million). The overall number needing treatment was slightly lower in 2003 (22.2 million) than in 2002 (22.8 million), but this difference was not statistically significant. However, a decline in the number receiving specialty treatment, from 2.3 million to 1.9 million, was statistically significant. This decline was driven by a decrease in treatment among adults aged 26 or older, from 1.7 million in 2002 to 1.2 million in 2003.
Of the 1.9 million people aged 12 or older who received specialty substance treatment, 595,000 persons received treatment for both alcohol and illicit drugs, 703,000 persons received treatment for alcohol only, and 508,000 persons received treatment for illicit drugs only. (Estimates by substance do not add to the total because the total includes persons who reported receiving specialty treatment but did not report for which substance the treatment was received).
In 2003, more than half of the 1.9 million persons aged 12 or older who received specialty substance treatment in the past year also received treatment at a self-help group (1.2 million persons). In addition, an estimated 237,000 received treatment at an emergency room, 235,000 received treatment at a doctor's office, and 168,000 received treatment at a prison or jail.
Of the 20.3 million people who needed but did not receive treatment in 2003, an estimated 1.0 million (5.1 percent) reported that they felt they needed treatment for their alcohol or drug problem (Figure 7.9). Of the 1.0 million persons who felt they needed treatment, 273,000 (26.3 percent) reported that they made an effort but were unable to get treatment and 764,000 (73.7 percent) reported making no effort to get treatment.
Figure 7.9 Past Year Perceived Need and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drugs or Alcohol: 2003
Among the 1.0 million people who needed but did not receive treatment and felt they needed treatment, the most often reported reasons for not receiving treatment were not ready to stop using (41.2 percent), cost or insurance barriers (33.2 percent), reasons related to stigma (19.6 percent), and did not feel the need for treatment (at the time) or could handle the problem without treatment (17.2 percent) (Figure 7.10).
Figure 7.10 Reasons for Not Receiving Treatment among Persons Aged 12 or Older Who Needed But Did Not Receive Treatment and Felt They Needed Treatment: 2003
Similar to 2002, in 2003 there were 2.3 million youths aged 12 to 17 (9.0 percent of this population) who needed treatment for an alcohol or illicit drug problem. Of this group, only 168,000 youths received treatment at a specialty facility (7.4 percent of youths who needed treatment), leaving an estimated 2.1 million youths who needed treatment for a substance abuse problem but did not receive it at a specialty facility.
Illicit Drug Treatment and Treatment Need
In 2003, the estimated number of persons aged 12 or older needing treatment for an illicit drug problem was 7.3 million (3.1 percent of the total population). An estimated 1.1 million of these people (0.5 percent of the total population and 15.0 percent of the people who needed treatment) received treatment at a specialty facility for an illicit drug problem. Thus, there were 6.2 million persons (2.6 percent of the total population) who needed but did not receive treatment at a specialty facility for an illicit drug problem in 2003.
The estimated number of persons needing but not receiving specialty treatment for an illicit drug problem in 2002 (6.3 million) was similar to the estimate for 2003 (6.2 million). The number of persons needing treatment for an illicit drug problem was slightly lower in 2003 (7.3 million) than in 2002 (7.7 million), but this difference was not significant. However, a decline in the number of persons receiving specialty treatment for an illicit drug problem, from 1.4 million to 1.1 million, was statistically significant (Figure 7.8). This decline was driven by a decrease in specialty treatment for an illicit drug problem among adults aged 26 or older, from 1.0 million in 2002 to 0.6 million in 2003.
Between 2002 and 2003, the number of persons receiving drug treatment for a cocaine problem during their most recent treatment at a specialty facility decreased from 471,000 in 2002 to 276,000 in 2003.
Among the 1.1 million persons who received specialty treatment for an illicit drug problem in the past year, 40.3 percent reported "own savings or earnings" as a source of payment for their most recent specialty treatment (Figure 7.11). An estimated 32.1 percent reported using private health insurance, 24.0 percent reported Medicaid, and 21.1 percent reported public assistance other than Medicaid as a source of payment. An estimated 16.4 percent reported using Medicare, and 19.0 percent reported relying on family members. (Note that the estimates of treatment by source of payment include persons reporting more than one source.)
Figure 7.11 Source of Payment for Most Recent Specialty Illicit Drug Treatment among Persons Aged 12 or Older Who Received Specialty Illicit Drug Treatment in the Past Year: 2003
Of the 6.2 million people who needed but did not receive specialty treatment for illicit drugs in 2003, an estimated 426,000 (6.8 percent) reported that they felt they needed treatment for their illicit drug problem. Information on effort to receive treatment is not presented because of low precision.
Among youths aged 12 to 17, an estimated 1.3 million (5.3 percent) needed treatment for an illicit drug abuse problem in 2003. Of this group, only 113,000 received treatment at a specialty facility (8.5 percent of youths aged 12 to 17 who needed treatment), leaving an estimated 1.2 million youths who needed treatment but did not receive it at a specialty facility.
Alcohol Treatment and Treatment Need
In 2003, the estimated number of persons aged 12 or older needing treatment for an alcohol problem was 18.2 million (7.7 percent of the total population). Of these, 1.3 million (0.5 percent of the total population and 7.1 percent of the people who needed treatment for an alcohol problem) received alcohol treatment at a specialty facility (Figure 7.8). Thus, there were 16.9 million people who needed treatment but did not receive treatment for an alcohol problem at a specialty facility.
The estimated number of persons needing but not receiving treatment for an alcohol problem was slightly lower in 2003 (16.9 million) than in 2002 (17.1 million). However, between 2002 and 2003, there was no statistically significant change in the estimated number of persons needing or receiving treatment for an alcohol problem.
Among the 1.3 million persons who received specialty treatment for an alcohol problem in the past year, 45.1 percent reported "own savings or earnings" as a source of payment for their most recent specialty treatment (Figure 7.12). An estimated 31.6 percent reported using private health insurance, 26.6 percent reported public assistance other than Medicaid, and 19.7 percent reported Medicaid. An estimated 14.4 percent reported using Medicare, and 18.4 percent reported relying on family members. (Note that the estimates of treatment by source of payment include persons reporting more than one source.)
Figure 7.12 Source of Payment for Most Recent Specialty Alcohol Treatment among Persons Aged 12 or Older Who Received Specialty Alcohol Treatment in the Past Year: 2003
Among the 16.9 million people who needed but did not receive treatment for an alcohol problem in 2003, an estimated 642,000 (3.8 percent) felt they needed treatment for their alcohol problem. Of the 642,000 persons, 173,000 (27 percent) made an effort but were unable to get treatment, and 469,000 (73 percent) did not make an effort to get treatment.
In 2003, there were 1.5 million youths aged 12 to 17 (6.0 percent) who needed treatment for an alcohol problem. Of this group, only 95,000 received treatment at a specialty facility (6.3 percent of youths aged 12 to 17 who needed treatment), leaving an estimated 1.4 million youths who needed but did not receive treatment.
8. Prevalence and Treatment of Mental Health Problems
This chapter presents national estimates of the prevalence and characteristics of persons aged 18 or older with serious mental illness (SMI) and of persons aged 12 or older who received treatment for mental health problems. In the National Survey on Drug Use and Health (NSDUH), different questions and definitions of treatment and counseling are used for adults aged 18 or older and youths aged 12 to 17. Both the youth and the adult questions specifically exclude treatment for problems with substance use, which is covered elsewhere in the interview. Because the survey covers the civilian, noninstitutionalized population, persons who reside in long-term psychiatric or other institutions at the time of interview are excluded from the sample and from the estimates presented in this chapter.
8.1 Serious Mental Illness
This section presents national estimates of the prevalence and characteristics of adults who had SMI in 2003. SMI is defined for this report as having at some time during the past year a diagnosable mental, behavioral, or emotional disorder that met the criteria specified in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association [APA], 1994) and that resulted in functional impairment substantially interfering with or limiting one or more major life activities. A scale consisting of six questions is used to measure SMI. These questions ask how frequently a respondent experienced symptoms of psychological distress during the 1 month in the past year when he or she was at his or her worst emotionally. Use of this scale to estimate SMI is supported by methodological research that determined the scale to be a good predictor of SMI, based on clinical assessments done on survey respondents (Kessler et al., 2003). The six questions and further discussion of this scale are given in Section B.4.5 of Appendix B.
Prevalence of Serious Mental Illness
In 2003, there were an estimated 19.6 million adults aged 18 or older with SMI. This represents 9.2 percent of all adults and is higher than the rate of 8.3 percent in 2002 (Figure 8.1).
Figure 8.1 Rates of Serious Mental Illness among Adults Aged 18 or Older, by Age:
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
Rates of SMI in 2003 were highest for adults aged 18 to 25 (13.9 percent) and lowest for those aged 50 or older (5.9 percent). Rates of SMI were somewhat higher in 2003 than in 2002 for all three adult age groups, but only the increase among those aged 26 to 49 was statistically significant (9.5 percent in 2002 vs. 10.4 percent in 2003) (Figure 8.1).
The percentage of adult females with SMI in 2003 was higher than the percentage of adult males with SMI (11.5 vs. 6.7 percent). As in 2002, rates were higher for women than men in all age groups.
Rates of SMI increased between 2002 and 2003 for both males and females. SMI increased among males from 6.0 to 6.7 percent and among females from 10.5 to 11.5 percent.
Among racial/ethnic groups in 2003, rates of SMI were highest among adults reporting two or more races (12.6 percent) and Native Hawaiians or Other Pacific Islanders (12.4 percent) and lowest among Asians (6.1 percent) (Figure 8.2). The rates of SMI increased between 2002 and 2003 among non-Hispanic whites (8.4 to 9.5 percent) and among Hispanics (6.9 to 9.0 percent). The rate for Native Hawaiians or Other Pacific Islanders was 5.4 percent in 2002 and 12.4 percent in 2003, but the change was not statistically significant due to small sample sizes.
Figure 8.2 Past Year Serious Mental Illness among Adults Aged 18 or Older, by Race/Ethnicity: 2003
As in 2002, college graduates in 2003 had the lowest rate of SMI (6.5 percent) compared with adults who had completed less education. The rate of SMI increased from 2002 to 2003 among adults who had not completed high school (9.6 to 11.3 percent).
Among persons aged 18 or older, the rate of SMI in 2003 was highest among unemployed persons (15.2 percent) and lowest among persons employed full time (8.2 percent). However, among persons aged 26 to 49, the highest rate of SMI was among adults not in the labor force (18.5 percent). This same pattern was observed in 2002. As in 2002, most of the 19.6 million adults with SMI in 2003 (63.5 percent) were employed either full time or part time.
Rates of SMI did not vary greatly by geographic region in 2003 or in 2002. Rates in 2003 were 9.6 percent in the South and West, 8.3 percent in the Northeast, and 8.9 percent in the Midwest. Rates of SMI increased between 2002 and 2003 in the South (from 8.4 to 9.6 percent) and in the West (from 7.8 to 9.6 percent).
Rates of SMI among adults in 2003 were similar in nonmetropolitan areas (9.9 percent), small metropolitan areas (9.6 percent), and large metropolitan areas (8.8 percent).
Serious Mental Illness and Substance Use
Adults in 2003 who used illicit drugs in the past year were more than twice as likely to have SMI as adults who did not use an illicit drug (18.1 and 7.8 percent, respectively). This pattern of higher rates of SMI among illicit drug users was observed within most demographic subgroups.
In 2003, adults with SMI were more than twice as likely as those without SMI to have used an illicit drug in the past year. Among persons with SMI, 27.3 percent used an illicit drug in the past year, while the rate was 12.5 percent among those without SMI (Figure 8.3). Similarly, among adults with SMI, the rate of past month cigarette use was 44.2 percent, while the rate was only 25.2 percent among adults without SMI.
Figure 8.3 Substance Use among Adults Aged 18 or Older, by Serious Mental Illness: 2003
SMI was not strongly correlated with alcohol use. The rate of past month alcohol use in 2003 among adults with SMI was almost the same as the rate among adults without SMI (53.2 vs. 53.9, respectively). However, SMI was correlated with binge alcohol use, defined as drinking five or more drinks on the same occasion on at least 1 day in the past 30 days. Among adults with SMI, 28.9 percent were binge drinkers compared with 23.5 percent of adults without SMI (Figure 8.3).
Co-Occurrence of Serious Mental Illness with Substance Dependence/Abuse
SMI was highly correlated with substance dependence or abuse. Among adults with SMI in 2003, 21.3 percent were dependent on or abused alcohol or illicit drugs, while the rate among adults without SMI was only 7.9 percent (Figure 8.4). Adults with SMI were more likely than those without SMI to be dependent on or abuse illicit drugs (8.6 vs. 2.0 percent) and alcohol (17.0 vs. 6.7 percent).
Figure 8.4 Past Year Substance Dependence or Abuse among Adults Aged 18 or Older, by Serious Mental Illness: 2003
In 2003, an estimated 4.2 million adults met the criteria for both SMI and substance dependence or abuse in the past year. Of these, an estimated 0.8 million with SMI also were dependent on or abused both alcohol and illicit drugs, 0.8 million with SMI also were dependent on or abused an illicit drug only, and 2.5 million with SMI were dependent on or abused alcohol only.
Among adults with substance dependence or abuse, 21.6 percent had SMI compared with an SMI rate of 8.0 percent among those who did not have substance dependence or abuse.
Serious Mental Illness among Adults on Probation or Parole
The rate of SMI in 2003 among adults who were on probation during the past year was more than twice the rate for those who were not on probation (19.2 vs. 9.0 percent).
The rate of SMI was higher for adults who were on parole or supervised release (15.7 percent) than among those who were not on parole or supervised release (9.2 percent).
8.2 Treatment and Unmet Need for Treatment among Adults
This section presents national estimates of the prevalence and characteristics of adults aged 18 or older who received treatment for mental health problems in 2003. Estimates are presented for the total adult population and separately for the adult population with SMI. Treatment is defined as the receipt of treatment or counseling for any problem with emotions, "nerves," or mental health in the 12 months prior to the interview in any inpatient or outpatient setting. It also includes the use of prescription medication for treatment of a mental or emotional condition. Treatment for only a substance abuse problem is not included. Unmet need is defined as a perceived need for treatment at any time in the 12 months prior to the interview that was not received.
In 2003, an estimated 28 million adults received treatment for mental health problems in the 12 months prior to the interview. This estimate represents 13.2 percent of the population 18 years old or older and is unchanged from 2002 (Figure 8.5).
Figure 8.5 Past Year Treatment for Mental Health Problems among Adults Aged 18 or Older, by Type of Treatment: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
The most prevalent type of treatment in the adult population in 2003 was prescription medication (10.9 percent), followed by outpatient treatment (7.2 percent). An estimated 1.8 million adults (0.8 percent) were hospitalized for mental health problems at some time within the past 12 months.
Rates of treatment for mental health problems among adults varied somewhat by age, with rates ranging from 8.6 percent among adults aged 65 or older to 17.5 percent for adults aged 45 to 49. The rate was 11.2 percent for persons aged 18 to 25.
In 2003, female adults were more likely than male adults to receive treatment (17.6 vs. 8.5 percent), but there was no gender difference in the rates of inpatient treatment (0.8 percent for males and 0.9 percent for females).
Among racial/ethnic groups, the rates of treatment for adults in 2003 were highest for those reporting two or more races (17.5 percent) and next highest for whites (15.3 percent). Other groups reported much lower rates of treatment (8.5 percent for blacks, 8.0 percent for Hispanics, and 4.9 percent for Asians). Among Asians, the overall treatment rate and the rate of outpatient treatment dropped from 2002 to 2003 (overall: 8.5 to 4.9 percent; outpatient: 6.7 to 3.1 percent).
The overall rate of treatment for mental health problems was lowest for adults with less than a high school education (10.5 percent) and highest for those with some college and college graduates (14.9 and 14.4 percent, respectively). There also were variations by type of treatment. Adults who had not completed high school were more likely than adults with some college or college graduates to have received inpatient treatment in 2003 (1.5 vs. 0.7 and 0.3 percent, respectively). This pattern was reversed for outpatient treatment (9.1 percent of college graduates, 8.1 percent of persons with some college, and 5.1 percent of persons who had not completed high school received outpatient treatment). Adults who had not completed high school were less likely (8.9 percent) than those with some college (13.0 percent) to have received prescription medication.
Among current employment status categories, adults who were employed full time had the lowest rates of treatment for mental health problems, at 11.9 percent, compared with 14.5 percent for adults employed part time, 13.0 percent for unemployed adults, and 15.3 percent for adults who were not in the labor force. Adults not in the labor force were more likely than full-time employed adults to have received inpatient mental health treatment (1.9 vs. 0.3 percent) and to have taken prescription medication (13.6 vs. 9.5 percent).
Adults in the West had the lowest rate of treatment for mental health problems in 2003 (11.9 percent) compared with rates of 13.7 percent for those in the Northeast, 14.3 percent for those in the Midwest, and 13.1 percent for those in the South. There was little variation in rates of treatment by type of county. By geographic area, between 2002 and 2003, there were increases in the receipt of prescription medication among adults in the Midwest (10.4 to 12.1 percent) and among those in completely rural areas (7.2 to 11.9 percent). The rate of outpatient treatment in the West decreased from 8.3 percent in 2002 to 6.6 percent in 2003.
In 2003, adults with an annual family income of less than $20,000 were more likely to have received treatment for mental health problems (15.4 percent) than were those with incomes of $20,000 to $49,999 (12.2 percent), those with incomes of $50,000 to $74,999 (13.3 percent), and those with incomes of $75,000 or more (13.0 percent).
Adults in families receiving government assistance were more likely to receive treatment for mental health problems in 2003 (19.3 percent) than adults in unassisted families (12.3 percent). Adults in assisted families also were more likely than those in unassisted families to receive inpatient treatment, outpatient treatment, or prescription medication.
More than half of adults who received treatment for mental health problems in 2003 (57.5 percent) reported that the treatment improved their ability to manage daily activities "a great deal" or "a lot." There was no change in this overall proportion between 2002 and 2003.
In 2003, 10.8 million adults, or 5.1 percent of the adult population, perceived an unmet need for treatment in the 12 months prior to their interview. Among the 28 million adults who received treatment for mental health problems, 19.0 percent (5.3 million) perceived some unmet need. Among the 184 million adults who did not receive treatment, 3.0 percent (5.5 million) perceived some unmet need. Unmet need among those who received treatment may be interpreted as delayed or insufficient treatment in the 12 months prior to the interview.
Among the 5.5 million adults who did not receive treatment but perceived an unmet need for treatment in the past year, the following were the five most commonly reported reasons for not receiving treatment: cost or insurance issues (45.1 percent), not feeling a need for treatment (at the time) or thinking the problem could be handled without treatment (40.6 percent), not knowing where to go for services (22.9 percent), perceived stigma associated with receiving treatment (22.8 percent), and did not have time (18.1 percent). Less commonly reported reasons were "treatment would not help" (10.3 percent), "fear of being committed or having to take medicine" (7.2 percent), and reasons relating to access barriers other than cost (3.7 percent) (Figure 8.6).
Figure 8.6 Reasons for Not Receiving Treatment in the Past Year among Persons Aged 18 or Older with an Unmet Need for Treatment Who Did Not Receive Treatment: 2003
Treatment and Unmet Need for Treatment among Adults with Serious Mental Illness
Among the 19.6 million adults with SMI in 2003, 9.3 million, or 47.3 percent, received treatment for a mental health problem in the 12 months prior to the interview. This estimate is similar to the estimate in 2002 (47.9 percent). However, the rate of inpatient treatment among adults with SMI increased between 2002 and 2003 (from 3.8 to 5.6 percent).
In 2003, the likelihood of receiving treatment among adults with SMI generally increased with age. More than half of adults aged 50 or older with SMI received treatment (54.0 percent), as did 49.4 percent of those aged 26 to 49 and 35.2 percent of those aged 18 to 25. In 2002, however, of adult age groups, adults aged 26 to 49 with SMI were most likely to receive treatment (54.4 percent) compared with 46.4 percent of those aged 50 or older and 34.2 percent of those aged 18 to 25. The rate of treatment among adults aged 26 to 49 with SMI declined from 2002 to 2003 (54.4 vs. 49.4 percent).
Females with SMI were more likely than males with SMI to have received treatment for mental health problems in the past year (52.1 vs. 38.5 percent). Similar rates were observed in 2002.
Slightly over half of adults with SMI who received treatment for mental health problems in the past year (51.2 percent) perceived that treatment helped them "a great deal" or "a lot" in managing daily activities. This proportion was unchanged between 2002 and 2003.
An estimated 30.1 percent of adults with SMI, or 5.9 million persons, perceived an unmet need for treatment in the 12 months prior to their interview, which was about the same as the percentage in 2002 (30.5 percent). The same pattern of perceived unmet need was seen in the SMI population as in the overall population; that is, the rate of perceived unmet need among persons with SMI was higher among those who did receive treatment (36.1 percent) than among those who did not receive any treatment (24.6 percent).
Cost or insurance issues were the most commonly reported reasons for not getting needed treatment among adults with SMI who did not receive treatment but perceived an unmet need for treatment in the past 12 months (51.4 percent). Other commonly reported reasons were the same as those reported by all adults with any unmet need: not feeling a need for treatment (at the time) or thinking the problem could be handled without treatment (32.7 percent), not knowing where to go for services (28.1 percent), stigma associated with receiving treatment (26.9 percent), and did not have time (16.0 percent). Less commonly reported reasons were "treatment would not help" (11.1 percent), "fear of being committed or having to take medicine" (10.5 percent), and reasons relating to access barriers other than cost (4.1 percent).
8.3 Treatment among Adults with Co-Occurring Serious Mental Illness and Substance Use Disorders
Among the 4.2 million adults with SMI and a substance use disorder in 2003, 47.3 percent (about 2.0 million) received treatment for mental health problems and 11.2 percent (0.5 million) received specialty substance use treatment (Figure 8.7).
Figure 8.7 Past Year Treatment among Adults Aged 18 or Older with Both Serious Mental Illness and a Substance Use Disorder: 2003
In 2003, about half (49.0 percent) of adults with both SMI and a substance use disorder received no treatment for either disorder. Only 7.5 percent (0.3 million) received both treatment for mental health problems and specialty substance use treatment. Another 39.8 percent received only treatment for mental health problems, and 3.7 percent received only specialty substance use treatment (Figure 8.7).
8.4 Treatment for Mental Health Problems among Youths
This section presents national estimates of the receipt of treatment or counseling for mental health problems among youths aged 12 to 17. Data on reasons for the last treatment visit and sources or locations of past year treatment also are discussed. Treatment for youths is defined as receiving treatment or counseling for problems with behaviors or emotions from specific mental health or other health professionals in school, home, outpatient, or inpatient settings within the 12 months prior to the interview. Treatment for only a substance abuse problem is not included.
In 2003, an estimated 5.1 million youths aged 12 to 17 received treatment or counseling for emotional or behavior problems in the year prior to the interview. This represents 20.6 percent of this population and is higher than the 2002 estimate of 4.8 million (19.3 percent) (Figure 8.8).
Figure 8.8 Past Year Treatment for Mental Health Problems among Youths Aged 12 to 17: 2002 and 2003
Note: Statistically significant differences (at 0.05 level) between 2002 and 2003 are denoted by " + ".
In 2003, there was little variation by age group in the overall rates of treatment among youths (20.5 percent of those aged 12 or 13, 21.6 percent of those aged 14 or 15, and 19.8 percent of those aged 16 or 17). There was an increase in the rate of treatment between 2002 and 2003 among youths aged 14 or 15 (19.9 to 21.6 percent) (Figure 8.8).
Among the 5.1 million youths receiving treatment in 2003, the most commonly reported sources were school counselors, school psychologists, or teachers (48.0 percent), as well as private therapists, psychologists, psychiatrists, social workers, or counselors (46.1 percent). An estimated 467,000 youths, or 9.1 percent of those receiving treatment, were hospitalized for treatment of mental health problems.
Females aged 12 to 17 were more likely than males aged 12 to 17 to have received treatment or counseling for mental health problems in 2003 (22.4 vs. 19.0 percent) (Figure 8.9).
Figure 8.9 Past Year Treatment for Mental Health Problems among Youths Aged 12 to 17, by Age and Gender: 2003
Among youths aged 12 or 13, boys were as likely as girls to have received treatment or counseling (20.3 vs. 20.8 percent) (Figure 8.9). However, girls aged 14 or 15 and those aged 16 or 17 had higher rates of treatment (23.7 and 22.5 percent, respectively) than boys in those age groups (19.6 and 17.0 percent, respectively).
The reason cited most often for the latest treatment session was "felt depressed" (50.2 percent of youths receiving treatment), followed by "breaking rules or acting out" (25.7 percent), "felt very afraid or tense" (21.4 percent), and "thought about killing self or tried to kill self" (18.9 percent) (Figure 8.10). These were the most commonly reported reasons in 2002 as well.
Figure 8.10 Past Year Treatment for Mental Health Problems among Youths Aged 12 to 17 Who Received Treatment, by Reason for Most Recent Treatment: 2003
Youths in families with incomes of less than $20,000 were more likely to have received treatment for mental health problems in 2003 (24.8 percent) than those in families with higher incomes. Treatment rates in other income groups were 20.7 percent of those with incomes of $20,000 to $49,999, 19.4 percent of those with incomes of $50,000 to $74,999, and 18.7 percent of those with incomes of $75,000 or more.
Youths aged 12 to 17 in families receiving government assistance were more likely than those in unassisted families to have received treatment in 2003 (26.7 vs. 19.3 percent).
Rates of treatment for mental health problems among youths aged 12 to 17 showed little variation by county type (21.2 percent for youths living in large metropolitan areas, 20.6 percent for those in small metropolitan areas, and 19.0 percent for those in nonmetropolitan areas).
The rate of treatment among youths aged 12 to 17 who used illicit drugs in the past year (28.1 percent) was higher than the rate among youths who did not use illicit drugs (18.6 percent).
9. Discussion
This report presents findings from the 2003 National Survey on Drug Use and Health (NSDUH). Conducted since 1971 and previously named the National Household Survey on Drug Abuse (NHSDA), the survey underwent several methodological improvements in 2002 that have affected prevalence estimates. As a result, the 2002 and 2003 estimates are not comparable with estimates from 2001 and earlier surveys. The primary focus of the report is on comparisons across subgroups of the U.S. population in 2003 and changes between 2002 and 2003 in the substance use and mental health measures addressed by the survey. Some of the key findings for 2003 are presented in the Highlights section of this report. This chapter provides additional discussion of the findings concerning one of the most important areas of concern, trends in substance use among youths and young adults.
An important step in the analysis and interpretation of NSDUH or any other survey data is to compare the results with results from other data sources. This can sometimes be difficult because the other surveys typically will have different purposes, definitions, and designs. Survey research has established that surveys of substance use and other sensitive topics often produce inconsistent results because of different methods used. Thus, it is important to understand that conflicting results often reflect differing methodologies, not incorrect results. Despite this limitation, comparisons can be very useful. Consistency across surveys can provide confirmation or support for conclusions, and inconsistent results can point to areas for further study. Further discussion of this issue is included in Appendix D, along with descriptions of methods and results from other substance use and mental health data sources.
Recent Trends in Youth and Young Adult Substance Use
This chapter presents some comparative analyses, focusing on the changes between 2002 and 2003 in substance use among youths and young adults. Unfortunately, there are few data sources that are available at this time to compare with NSDUH results. One established source is Monitoring the Future (MTF), a study sponsored by the National Institute on Drug Abuse (NIDA). The MTF surveys students in 8th, 10th, and 12th grades in classrooms during the spring of each year, and it also collects data by mail from a subsample of adults who had earlier participated in the study as 12th graders. Historically, NSDUH rates of substance use have been lower than those of MTF, but the two sources have usually shown the same trends in substance use prevalence among youths and young adults. The trend in marijuana incidence shown in Chapter 5 (see Figure 5.1) also is consistent with the trends in MTF data since 1975.
A comparison of NSDUH and MTF estimates for 2002 and 2003 is shown in Table 9.1 for selected substances and age groups. MTF data on 8th and 10th graders combined give the closest match on age to NSDUH youth estimates. The NSDUH results are generally consistent with MTF trends. Both surveys show decreases in the use of Ecstasy and LSD among youths and young adults. This recent downturn in hallucinogen use also is evident in estimates of incidence from NSDUH (see Figure 5.2). The significant declines in lifetime and past year youth marijuana use reported by MTF were evident in NSDUH results, but the change was not statistically significant for past year use. Both surveys show little change in alcohol use among both groups and declines in cigarette use among youths. An important finding from the 2003 MTF was the increase in past year inhalant use among 8th graders between 2002 and 2003, from 7.7 to 8.7 percent. A comparative analysis of NSDUH data (see Appendix D), restricted to youths enrolled in 8th grade during January-June each year (similar to the data collection period for MTF), does show a statistically significant increase in past year inhalant use, from 4.8 percent in 2002 to 7.6 percent in 2003. However, the combined 8th and 10th grade data from MTF and the NSDUH data for youths aged 12 to 17 both show that past year inhalant use was stable between 2002 and 2003.
Table 9.1 Comparison of NSDUH and MTF Prevalence Rates
NSDUH
MTF
NSDUH
MTF
Age 1217
8th and 10th Grades
Age 1825
Age 1928
2002
2003
2002
2003
2002
2003
2002
2003
Marijuana
Lifetime
20.6a
19.6
29.0a
27.0
53.8
53.9
56.8
57.2
Past Year
15.8
15.0
22.5a
20.5
29.8a
28.5
29.3
29.0
Past Month
8.2
7.9
13.1
12.3
17.3
17.0
16.9
17.3
Cocaine
Lifetime
2.7
2.6
4.9
4.4
15.4
15.0
13.5
14.7
Past Year
2.1
1.8
3.2
2.8
6.7
6.6
5.8
6.6
Past Month
0.6
0.6
1.4
1.1
2.0
2.2
2.2
2.4
Ecstasy
Lifetime
3.3a
2.4
5.5a
4.3
15.1
14.8
14.6
15.3
Past Year
2.2a
1.3
3.9a
2.6
5.8a
3.7
6.2a
4.5
Past Month
0.5
0.4
1.6a
0.9
1.1a
0.7
1.3
0.8
LSD
Lifetime
2.7a
1.6
3.8a
2.8
15.9a
14.0
15.1
14.6
Past Year
1.3a
0.6
2.1a
1.5
1.8a
1.1
1.8a
1.2
Past Month
0.2
0.2
0.7
0.6
0.1
0.2
0.3
0.2
Inhalants
Lifetime
10.5
10.7
14.4
14.3
15.7
14.9
12.4
12.2
Past Year
4.4
4.5
6.8
7.1
2.2
2.1
1.6
1.4
Past Month
1.2
1.3
3.1
3.2
0.5
0.4
0.5
0.3
Alcohol
Lifetime
43.4
42.9
57.0
55.8
86.7
87.1
90.2
89.3
Past Year
34.6
34.3
49.4
48.3
77.9
78.1
84.9a
83.3
Past Month
17.6
17.7
27.5
27.6
60.5
61.4
68.3
67.0
Cigarettes
Lifetime
33.3a
31.0
39.4a
35.7
71.2
70.2
--
--
Past Year
20.3a
19.0
--
--
49.0a
47.6
39.1
38.6
Past Month
13.0
12.2
14.2
13.5
40.8
40.2
29.2
28.4
-- Not available. a Difference between 2002 and 2003 estimates is statistically significant at the 0.05 level.
Note: MTF data for 8th and 10th graders are simple averages of estimates for those two grades. Data for 8th and 10th graders and for persons aged 19 to 28 are reported in Johnston, O'Malley, Bachman, and Shulenberg (2004a).
Sources:
SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002 and 2003.
The Monitoring the Future Study, University of Michigan, 2002 and 2003.
End Note
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