We have recent signs of hope regarding the substance use epidemic currently plaguing the United States. Provisional data indicate that drug overdose deaths declined from 112,910 in the year ending October 2023 to 84,076 in the year ending October 2024 (−25.5%). In this issue of the Journal, McCabe and colleagues report analyses of serial cross-sectional annual surveys of 12th-graders from the Monitoring the Future Study collected from 2009 to 2022 showing that non-medical use of prescription opioids, benzodiazepines, and stimulants significantly declined over that time frame. Respondents also report that prescription forms of these controlled substances have become increasingly hard to obtain. However, while lifetime medical use of prescription opioids also decreased over time, lifetime medical use of prescription benzodiazepines and amphetamines did not.

McCabe et al. provide solid explanations for the decline in medical and non-medical use of prescription opioids. Over the past decade treatment guidelines and other sources have discouraged the use of opioids to treat chronic and sometimes even acute pain and have recommended provision of limited quantities when these medications are prescribed. Although psychiatrists have a very limited role in prescribing opioids, clinicians who do treat pain in adolescents are best advised to eschew opioids whenever possible, rely primarily on acetaminophen and non-steroidal anti-inflammatory medications for acute pain unless extremely severe, and use cognitive behavioral therapy for chronic pain management.

One question that remains is whether the much more circumscribed prescribing of opioids is solely responsible for the declines in use or whether attitudes toward use of opioids have also changed among successive cohorts of adolescents. On that point reasons for the welcome declines in nonmedical use of benzodiazepines and amphetamines remain more obscure, and additional research into this topic is needed. If we better understood the dynamics behind these positive trends, we might uncover interventions to enhance them further.

Psychiatrists do play large roles in prescribing benzodiazepines and stimulants. The approach to prescribing each of these two classes of medications is almost diametrically opposite. Regarding benzodiazepines, justification for prescribing them to adolescents at all is difficult to envision, except for alcohol withdrawal and perhaps in the context of extreme acute anxiety. We have evidence-based psychotherapies for anxiety disorders and insomnia that are generally more effective than medications, and if medications are to be used, there are safer alternatives to benzodiazepines which obviously can cause intoxication and can induce tolerance, and lead to withdrawal symptoms if used repeatedly and then stopped.

In contrast, stimulants are the treatment of choice for attention-deficit/hyperactivity disorder (ADHD), which is common and can be disabling among adolescents. All available evidence suggests that for individuals with ADHD, prescribing stimulants is not associated with increased likelihood of developing a stimulant or other substance use problem but does contribute to better overall functional status in social, academic, and work-related domains. Thus, accurate diagnosis of ADHD should be encouraged with prescription of stimulants when it is confirmed, and increasing stimulant prescriptions in this context would be a positive sign among 12th graders in light of evidence that many adolescents with ADHD do not receive treatment for their symptoms. Nevertheless, since McCabe et al. also show that the most common source for non-medical use derives from one’s own leftover supply of medication, clinicians need to monitor closely adolescents’ adherence to stimulant regimens and prescribe the least amount needed to maintain stability. Additionally, patients and families should be educated about resources on medicine take-back options at the time of prescribing.

Broadening the scope from the specifics of the McCabe et al. paper, prescription medications are hardly the only substances that are misused by adolescents, with illicit forms of opioids (particularly fentanyl and its analogs), benzodiazepines (especially alprazolam), and methamphetamines widely and inexpensively available. Happily, more good news on this front comes from the latest iteration of the Monitoring the Future Study which shows that in 2024 illicit drug use also declined among 12th graders, reaching the lowest level during the 50-year existence of the study, with 26.5% reporting past year use of any illicit drug (decline from 38.7% in 2020) and 6.5% any illicit drug other than cannabis (decline from 11.4% in 2020). Despite increasing legalization across states, past year use of cannabis also significantly declined in 12th graders as well in 2024 (25.8%; decline from 35.2% in 2020) as did past year rates of alcohol use (41.7%; decline from 55.3% in 2020) and nicotine vaping (21.0%; decline from 34.5% in 2020).

Despite some positive trends, we cannot come close to claiming victory. The number of non-fatal fentanyl exposures (most intentional) among individuals ages 13–19 reported to U.S. poison centers increased from 32 in 2015 to 514 in 2023. Also, data from the 2023 National Survey on Drug Use and Health indicate that over two million U.S. children between the ages of 12 and 17 had a current substance use disorder, with the vast majority being cannabis use disorder. Only a small fraction (3.3%) of these children believed they needed treatment, and most of those who recognized the need still did not seek treatment. We need more readily available and better treatments specifically targeted toward adolescents, particularly for cannabis use disorder.

Adolescence represents a critical juncture in the lifespan for the onset of. substance use and the development of substance use disorders. Most initial experimentation with substances occurs during adolescence, and in many cases (as noted below), if no intervention supervenes, a substance use disorder can develop potentially leading to a lifetime of disability which could have been prevented by timely intervention. The evidence we have indicates that delaying experimentation to later ages can reduce risk of engaging in hazardous use or developing a substance use disorder, and so to some extent external controls that have been applied to opioids in the past decade might decrease or delay initial exposures, thereby reducing the risk for development of substance use disorders. Additionally, a school-based intervention consisting of two cognitive behavioral-focused sessions directed specifically at 7th-graders with personality traits indicating risk for substance use was recently demonstrated in a cluster-randomized trial to delay onset of use and reduce rates of proceeding to a substance use disorder over a 5 year follow-up period (8.5% intervention versus 10.4% control). This intervention deserves further study and likely widespread real-world implementation.

Furthermore, capitalizing on the positive trends noted above, we should leverage digital platforms for public health messaging to counter misinformation, help deter adolescents’ use of cannabis and other substances, and encourage those who need treatment to seek it. Since adolescents spend considerable time on their smartphones, finding innovative ways to provide such messages via social media sites, intriguing video games, or text messaging appears promising.

So, to meet the moment, the findings from McCabe and colleagues encourage us to continue to place controls on and discourage use of prescription opioids and benzodiazepines among adolescents, while also appropriately prescribing stimulants to adolescents with ADHD along with careful monitoring. Beyond these measures, we should support effective school-based initiatives that prevent and delay substance use within targeted populations of adolescents; wisely deploy public health messaging through venues in which adolescents obtain their information; and design, test, and make readily available treatments for adolescent substance use disorders. Such a panoply of initiatives, while hardly trivial to enact, would likely improve the overall well-being of some of our youngest citizens and lead them toward more productive and gratifying adulthoods while benefiting us all. Psychiatry can play a major role in this endeavor.

Summary

Recent data indicate a hopeful trend in the United States' substance use landscape, with drug overdose deaths declining. Analysis of annual surveys from the Monitoring the Future Study (2009-2022) revealed a significant decrease in the non-medical use of prescription opioids, benzodiazepines, and stimulants among 12th-grade students. Respondents also reported increased difficulty in obtaining these prescription substances. Beyond prescription drugs, illicit drug use among 12th graders also reached its lowest level in 50 years in 2024, alongside declines in cannabis use, alcohol consumption, and nicotine vaping.

The observed decline in prescription opioid use is largely attributed to shifts in treatment guidelines over the past decade, which now discourage their use for chronic and even acute pain, advocating for limited quantities when prescribed. For adolescents, clinicians are advised to prioritize alternatives such as acetaminophen, non-steroidal anti-inflammatory medications, and cognitive behavioral therapy for pain management. While reasons for the decrease in non-medical benzodiazepine and amphetamine use are less clear, further research is warranted. Psychiatrists play a significant role in prescribing these latter two classes of medications. Benzodiazepines are generally discouraged for adolescents due to risks like intoxication, tolerance, and withdrawal, with evidence-based psychotherapies and safer alternatives often being more effective. In contrast, stimulants are the recommended treatment for Attention-Deficit/Hyperactivity Disorder (ADHD), a common and potentially disabling condition in adolescents. Stimulant prescription for ADHD is associated with improved functional outcomes and does not increase the likelihood of substance use problems. Therefore, accurate ADHD diagnosis and appropriate stimulant use should be encouraged, with careful monitoring to prevent diversion of leftover medication supplies.

Despite these positive trends, significant challenges persist. The number of non-fatal fentanyl exposures among individuals aged 13–19 increased substantially between 2015 and 2023. Additionally, a substantial number of adolescents between 12 and 17 years old have a current substance use disorder, with cannabis use disorder being the most prevalent. A concerningly low percentage of these individuals believe they need treatment, and many who recognize the need do not seek it. This highlights a critical need for more accessible and targeted treatments for adolescent substance use disorders, particularly for cannabis.

Adolescence represents a crucial period for the onset of substance use and the development of disorders. Evidence suggests that delaying initial experimentation can significantly reduce the risk of hazardous use or developing a substance use disorder. External controls, such as those applied to opioids, may help in this regard. Promising school-based interventions, like a cognitive behavioral-focused program for at-risk 7th graders, have demonstrated effectiveness in delaying substance use onset and reducing disorder rates. Leveraging digital platforms for public health messaging, through social media, video games, or text messages, also holds promise for countering misinformation, deterring substance use, and encouraging treatment seeking among adolescents.

Addressing adolescent substance use effectively requires a multi-faceted approach. This includes continued controls on prescription opioids and benzodiazepines, alongside appropriate and carefully monitored stimulant prescribing for ADHD. Furthermore, supporting effective school-based prevention initiatives, strategically deploying public health messages through relevant digital channels, and developing accessible treatments for adolescent substance use disorders are essential. Such comprehensive initiatives aim to improve the overall well-being of young individuals, fostering more productive and fulfilling adult lives, a goal in which the field of psychiatry can play a vital role.

Summary

Recent data indicate a hopeful shift in the substance use epidemic within the United States. Provisional figures show a significant decrease in drug overdose deaths, declining from 112,910 in the year ending October 2023 to 84,076 in the year ending October 2024, a reduction of 25.5%. Research presented by McCabe and colleagues, based on annual surveys of 12th-graders from 2009 to 2022, also reveals a notable decline in the non-medical use of prescription opioids, benzodiazepines, and stimulants. Respondents reported increased difficulty in obtaining these prescription substances. This decline in non-medical opioid use can be largely attributed to updated treatment guidelines over the past decade, which have discouraged the use of opioids for chronic pain and recommended limited quantities when prescribed. Clinicians treating pain in adolescents are increasingly advised to avoid opioids where possible, favoring non-opioid medications for acute pain and cognitive behavioral therapy for chronic pain management.

While the reasons for the decline in non-medical opioid use are relatively clear, the dynamics behind the decreased non-medical use of benzodiazepines and amphetamines are less understood, indicating a need for further research. Regarding benzodiazepines, their prescription to adolescents is rarely justified, with exceptions for severe cases like alcohol withdrawal or extreme acute anxiety. Evidence-based psychotherapies are generally more effective for anxiety and insomnia, and safer alternatives to benzodiazepines exist due to their potential for intoxication, tolerance development, and withdrawal symptoms. In contrast, stimulants remain the primary treatment for attention-deficit/hyperactivity disorder (ADHD), a common and potentially debilitating condition in adolescents. Available evidence suggests that stimulant prescriptions for individuals with ADHD do not increase the likelihood of developing a substance use problem; instead, they contribute to improved social, academic, and work-related functioning. Therefore, accurate ADHD diagnosis and appropriate stimulant prescription should be encouraged, though clinicians must carefully monitor adherence and prescribe the minimum effective dose to prevent diversion, also educating patients and families about safe medication disposal.

Beyond prescription medications, positive trends are also evident in the use of illicit substances. The latest Monitoring the Future Study indicates that illicit drug use among 12th graders reached its lowest level in 50 years in 2024, with declines in overall illicit drug use, illicit drug use excluding cannabis, cannabis use (despite increasing legalization), alcohol consumption, and nicotine vaping. Despite these encouraging developments, significant challenges persist. Non-fatal fentanyl exposures among adolescents aged 13–19 reported to U.S. poison centers substantially increased from 32 in 2015 to 514 in 2023. Additionally, 2023 data reveal that over two million U.S. children aged 12 to 17 had a current substance use disorder, predominantly cannabis use disorder. A very small fraction of these adolescents believed they needed treatment, and most of those who recognized the need did not seek help, highlighting a critical demand for more accessible and targeted treatments for adolescent substance use disorders, particularly for cannabis.

Adolescence represents a crucial period for the onset of substance use and the development of substance use disorders. Most initial experimentation occurs during these years, and timely intervention can prevent a lifetime of disability. Evidence suggests that delaying initial substance experimentation to later ages can reduce the risk of hazardous use or developing a substance use disorder. External controls, similar to those applied to opioids, may decrease or delay initial exposures. Furthermore, a school-based intervention involving two cognitive behavioral-focused sessions for 7th-graders with personality traits indicating substance use risk demonstrated positive outcomes in a cluster-randomized trial, delaying onset of use and reducing rates of progression to a substance use disorder over five years. Such interventions warrant further study and widespread implementation. Leveraging digital platforms is also crucial for public health messaging to counter misinformation, deter substance use among adolescents, and encourage treatment seeking, given the significant time adolescents spend on smartphones and social media.

To effectively address adolescent substance use, a multifaceted approach is recommended. This includes continued controls and discouragement of non-medical prescription opioid and benzodiazepine use, alongside appropriate and monitored stimulant prescribing for adolescents with ADHD. Further efforts should support effective school-based initiatives for prevention, strategically deploy public health messaging through digital channels where adolescents obtain information, and design, test, and ensure the ready availability of treatments for adolescent substance use disorders. Such comprehensive initiatives, though challenging to implement, have the potential to significantly enhance the well-being of young people, contributing to more productive and fulfilling adulthoods for them and benefiting society as a whole. Medical professionals, including psychiatrists, can play a significant role in this endeavor.

Summary

Recent data suggest positive changes in the substance use situation in the United States. Drug overdose deaths decreased from October 2023 to October 2024. A study of 12th-graders from 2009 to 2022 also found a significant decline in the non-medical use of prescription opioids, benzodiazepines, and stimulants. These students reported that it has become harder to get these prescription drugs. Beyond prescription medications, a broader study shows that illicit drug use, cannabis use, alcohol use, and nicotine vaping have also decreased among 12th graders, reaching their lowest levels in 50 years.

The decline in opioid use can be linked to updated medical guidelines that discourage prescribing opioids for chronic pain and recommend smaller quantities when they are necessary. While the reasons for the decline in non-medical use of benzodiazepines and amphetamines are less clear and need more research, specific guidance exists for prescribers. For example, prescribing benzodiazepines to adolescents is generally not advised, except in very specific situations like alcohol withdrawal or extreme anxiety, as safer and more effective alternatives exist. In contrast, stimulants are the preferred treatment for Attention-Deficit/Hyperactivity Disorder (ADHD), and their appropriate use can improve a person’s social, academic, and work-related functioning without increasing the risk of substance use problems. However, it is important for clinicians to monitor stimulant use closely and educate patients and families about safely disposing of leftover medication.

Despite these encouraging trends, significant challenges remain. The number of fentanyl exposures among teenagers has increased sharply. Furthermore, over two million adolescents between 12 and 17 years old currently have a substance use disorder, with most cases related to cannabis. A small percentage of these young people believe they need treatment, and even fewer seek it. There is a clear need for more readily available and effective treatments specifically designed for adolescents, especially for cannabis use disorder.

Adolescence is a critical time when many people first try substances, which can sometimes lead to developing a substance use disorder. Evidence suggests that delaying this initial experimentation can lower the risk of later problems. For instance, a school-based program for 7th-graders at risk for substance use was shown to delay the start of substance use and reduce the development of substance use disorders over five years. Such interventions deserve further study and broader use. Additionally, using digital platforms for public health messages can help correct false information, discourage substance use, and encourage those who need treatment to seek help, especially since adolescents spend a lot of time on their phones.

To continue addressing this issue, healthcare professionals should keep limiting and discouraging the non-medical use of prescription opioids and benzodiazepines among adolescents. They should also appropriately prescribe stimulants to adolescents with ADHD, along with careful monitoring. Beyond these actions, it is important to support effective school-based programs that prevent and delay substance use. Public health messages should be delivered through channels adolescents use most, and treatments for adolescent substance use disorders need to be developed, tested, and made easily accessible. These efforts, while challenging, would greatly improve the well-being of young people and help them achieve more productive and fulfilling adult lives.

Summary

Recent information shows hopeful signs in the fight against drug use in the United States. Fewer people are dying from drug overdoses. This number dropped from over 112,000 in October 2023 to about 84,000 in October 2024. Also, a study of 12th graders found that fewer teens are misusing powerful medicines like pain pills, calming pills, and stimulants. These medicines are also harder for teens to get. Doctors are now giving out fewer pain pills, which helps explain why their misuse is down. However, it is not fully clear why teens are using fewer calming pills and stimulants for non-medical reasons.

Doctors have different rules for giving out these medicines to teens. It is usually hard to find a good reason to give calming pills (benzodiazepines) to teens because they can be risky. There are safer ways to help with worry or sleep problems. On the other hand, stimulant medicines are often the best treatment for teens with ADHD. When stimulants are used correctly for ADHD, they do not seem to cause more drug problems. Instead, they can help teens do better in school and life. Doctors should watch how much medicine is given and tell families how to safely get rid of leftover pills.

Even more good news is that 12th graders are also using illegal drugs less often. This includes street forms of opioids, calming pills, and meth. Drug use among 12th graders is now at its lowest point in 50 years. Use of cannabis (marijuana), alcohol, and vaping products has also gone down for these teens.

Despite these good changes, problems still remain. More teens ages 13-19 are getting poisoned by fentanyl, which is a very strong drug. Also, a study shows that over two million teens (ages 12-17) in the U.S. have a problem with drug use, mostly cannabis. Very few of these teens believe they need help, and even fewer actually get treatment. It is important to know that most drug use starts during the teen years. Getting help early can stop a lifetime of problems. Programs in schools that teach teens about drug risks have shown good results in delaying drug use.

To keep these good trends going, certain steps are needed. Doctors should continue to be careful with prescribing pain pills and calming pills, while still giving stimulants when needed for ADHD. Public messages about health should be shared using phones and social media, where teens spend a lot of time. This can help prevent drug use and encourage teens to get help if they need it. It is also important to create and offer more ways to treat drug problems especially for teens. These actions can help young people live healthier and more successful lives.