CHAPTER 4
DRUG USE BY SELECTED POPULATION GROUPS

PREGNANT WOMEN AND UNBORN CHILDREN

Drug use during pregnancy places both mother and infant at risk for serious health problems. A child may become addicted to heroin in its mother's womb—provided the child is born at all (fetal death is a possibility). Cocaine use by the pregnant mother carries similar risks to the fetus and may kill the mother too. LSD use may lead to birth defects. PCP users may have smaller-than-normal babies who later turn out to have poor muscle control. Learning disabilities are associated with children born to pregnant women using cocaine, Ketamine, and Ecstasy. Smoking marijuana may prevent an embryo from attaching to the uterine wall and halt pregnancies. Pregnant women who smoke tobacco and drink alcohol further handicap their unborn child in its development.

The National Institute of Drug Abuse (NIDA) conducted its first national survey of drug use during pregnancy in 1992 by interviewing 2,613 women all over the United States ("NIDA Survey Provides First National Data on Drug Use During Pregnancy," NIDA Notes, January/February 1995, http://www.drugabuse.gov/NIDA_Notes/NNVol10N1/NIDASurvey.html). Data projected from this national sample suggested that 221,000 women in 1992 used illegal drugs while pregnant. Of these women, 119,000 had used marijuana and 45,000 had taken cocaine. Substantially larger numbers smoked at some point during their pregnancy (820,000); some 757,000 drank alcohol. Regarding racial/ethnic categories, the NIDA survey found as follows:

Overall, 11.3% of African-American women, 4.4% of white women, and 4.5% of Hispanic women used illicit drugs while pregnant. While African Americans had higher rates of drug use, in terms of actual number of users, most women who took drugs while they were pregnant were white. The survey found that an estimated 113,000 white women, 75,000 African-American women, and 28,000 Hispanic women used illicit drugs during pregnancy.

NIDA's survey was a one-time study not repeated since, but the Substance Abuse and Mental Health Services Administration (SAMHSA) has been collecting similar data annually in its National Survey on Drug Use and Health (formerly called the National Household Survey on Drug Abuse). The latest survey available, 2003 National Survey on Drug Use and Health (NSDUH), was published in September of 2004 (http://www.oas.samhsa.gov/nhsda/2k3nsduh/2k3ResultsW.pdf). Among other things, the survey determines the drug use of pregnant women within the last thirty days of the actual survey date; the data are thus somewhat narrower in definition than those used in the 1992 NIDA study. Data for 1994-2001 are presented in Figure 4.1. The graphic shows that 62,000 pregnant women (2.3% of all pregnant women) had taken some kind of illegal drug in the 1994-95 period (the data are two-year averages). Over time, SAMHSA's observations show a variable rate of drug use by pregnant women, but with a definite upward trend, so that in the 2002-03 time frame 105,000 pregnant women were using drugs, or 4.3% of all pregnant women. (See Table 4.1 and Table 4.2.)

Data for drug use during the 2002-03 period are shown in Table 4.3 for all women, subdivided into total, pregnant, and not pregnant categories by demographic characteristics. The data are for women ranging in age from fifteen to forty-four. Pregnant women in this group are much less likely to be using drugs than women who are not pregnant (4.3% versus 10.4% of those not pregnant). That gap is smallest in the fifteen-to-seventeen age group: 12.8% of those pregnant are involved with drugs versus 16.5% of those who are not pregnant: pregnancy, in this age group, may be the consequence of the same behavioral patterns that lead to drug use. In fact, for the 2000-01 period, according to SAMHSA's report from that year, a higher percentage of pregnant fifteen-to-seventeen-year-olds used drugs than of their nonpregnant peers.

Drug use among pregnant women is highest in the youngest group and decreases with age. Based on averages from SAMHSA's 2002 and 2003 surveys, 12.8% of pregnant women aged fifteen to seventeen had recently used some kind of illegal drug. In the 2002-03 period pregnant African-American women had the highest rates of illicit drug use at 8.0%, compared to 4.4% and 3.0% for whites and Hispanics, respectively. Survey numbers were too imprecise to permit estimates for other races.

Drug use among pregnant women is highest in the first trimester (7.7%) and drops thereafter. Still, an estimated 18,000 women were taking drugs in the third trimester of pregnancy (2.3%).

Marijuana was by far the drug most used by pregnant women on drugs. (See Table 4.1 and Table 4.2.) The next most-used category was psychotherapeutic drugs taken without medical supervision. Within that category, use of pain relievers lead in frequency. The National Institutes of Health has

shown that marijuana use can terminate pregnancies in some cases; marijuana use also leads to low birth weight in babies. In the 2002-03 period, eight thousand pregnant women used cocaine and, of those, one thousand smoked crack. SAMHSA reported one thousand pregnant heroin users, but reporting of heroin use is, according to SAMHSA, least reliable because the survey respondents often withhold such information. Six thousand pregnant women reported using hallucinogens (four thousand of those using Ecstasy) and one thousand said that they had used methamphetamine.

Babies of women who are using cocaine, heroin, hallucinogenics, and methamphetamines are most at risk for major health problems. The Center for the Evaluation of Risks to Human Reproduction, an element of the National Institutes of Health, reports that cocaine use can cause miscarriage or trigger premature labor ("Cocaine Use During Pregnancy" http://cerhr.niehs.nih.gov/genpub/topics/drugs-ccae.html). The

unborn baby may die or have a stroke or suffer irreversible brain damage. Low birth weight is the consequence of blocked flow of oxygen and nutrients to the fetus; babies may have smaller heads and brains. Birth defects are more likely. Mothers who use cocaine early in the pregnancy, for instance, are five times as likely to give birth to babies with malformed urinary tracts than mothers who do not use the drug.

DRUG USE BY YOUTHS

Drug use may begin before birth, but habituation tends to start in school. Appropriately enough, the nation's most comprehensive survey of drug use in youth is called Monitoring the Future (MTF). It is conducted annually by the Institute for Social Research at the University of Michigan under the sponsorship of the National Institute on Drug Abuse. The survey began in 1975 and initially focused on seniors in high school; it was then known as the National High School Senior Survey. Since 1991,

MTF has also surveyed the drug use behavior of eighth and tenth graders and of young adults aged nineteen to twenty-eight. MTF, in effect, surveys drug use in the age categories that use drugs most intensively. The latest MTF chronicles findings from 2004 (http://www.monitoringthefuture.org/pubs/monographs/overview2004.pdf). As shown earlier from data collected by SAMHSA, drug use is principally a youth phenomenon if legal drugs (alcohol and tobacco) are excluded.

Prevalence

A picture of drug use is presented in Figure 4.2 and Figure 4.3 from 1975 to 2003 for high school seniors and from 1991 to 2003 for eighth and tenth graders. The data in Figure 4.3 show the percentage of youths in these categories who used any illicit drug within the last twelve months of each year's survey date. According to the survey, the pattern mirrors that of the population as a whole. Drug use as measured here peaked for seniors in 1979, when more than half of all seniors (54.2%) used some kind of drug; usage then declined steadily to 1992, when 27.1% of seniors used drugs. Thereafter, usage increased again and reached a second peak for seniors in 1997 (42.4%). Thereafter use of any illicit drugs by seniors has been declining gradually as measured by MTF in 2003.

The White House's 2004 National Drug Control Strategy tracks a similar curve in drug usage by eighth, tenth, and twelfth graders combined, beginning in 1991. Figure 4.4 demonstrates that use of any illicit drug in the past month peaked in 1996 and steadily declined thereafter. MTF also collected data for eighth and tenth graders beginning in 1991. As demonstrated in Figure 4.2 and Figure 4.3, the youngest age group—eighth graders—appears to "lead" usage trends. This group signaled the new increase in drug usage a year before it began for tenth graders and seniors. Eighth graders reached their peak a year ahead of tenth graders in 1996; since that time eighth-grade use of any illicit drug has been decreasing every year.

Race and Gender

Data for high school seniors, for whom more than a quarter century of observations are available, show that drug use by African-American youths follows the same up-and-down patterns as use by whites and Hispanics, but African-American youths use drugs less than the other two major groups. According to MTF, over the 1977-2003 time frame, using two-year averages, white seniors used illicit drugs more than the other two groups except in 1992, when Hispanic senior drug use matched whites, and in 2000, when Hispanic seniors surpassed whites by 2%.

Male seniors consistently used drugs more than female seniors, but the overall pattern of use was similar during the 1975 to 2003 period. (See Figure 4.5.) The difference between females and males was smallest in 1981 (2.8%) and largest in 1978, when 58.6% of males but only 48.7% of females used some illegal drug in the year before, according to data in MTF.

Patterns of Drug Use

Of eighth, tenth, and twelfth graders tracked by the MTF program who had used drugs, more had used marijuana than any other illicit drug in 2003. (See Figure 4.6.) The survey tracks info for those in these grades using various substances from 1991 to 2003. (See Table 4.4.) In 2003, 7.5% of eighth graders had smoked marijuana in the thirty days before the survey; 17.0% of tenth graders had done so, and 21.2% of seniors. The next category of drugs used came at some distance. Among eighth graders, inhalants were sniffed by 4.1%. Among both tenth and twelfth graders, amphetamines were consumed by 4.3 and 5.0%, respectively. About 0.9% of eighth graders, 1.3% of tenth graders, and 2.1% of seniors reported using cocaine. Heroin use was lowest, at 0.3-0.4% of all three groups. Use of marijuana among eighth, tenth, and twelfth graders is demonstrated over the years in Figure 4.7, inhalants in Figure 4.8, cocaine in Figure 4.9, heroin in Figure 4.10, and Ecstasy in Figure 4.11.

The data displayed in Table 4.4 through 2002 are graphed in Figure 4.12 for each age group using the same scale so that both progression over time and the differences between the three age groups can be assessed at a glance. As noted earlier, 1992 was a low point in general drug use followed by a new upsurge. The graphic begins on the left by showing the last part of the dip down and then the rise, flattening, and downturn of drug use late in the 1991-2002 period. That pattern is observable in all three age groups, with the exception of eighth graders who began to increase drug consumption one year before the older classes.

Comparing the three groups to each other, several things stand out. First is the dramatic rise in marijuana consumption with age, involving about a tenth of the youngest group at its peak year of use, a fifth of the tenth graders, and nearly a quarter of the seniors. Second, in all three of the age groups, use of the other drugs involved no more than 6% of the students in each class in 2002. In the eighth grade inhalants were used by almost 5% of the students on average between 1991 and 2002. Among tenth graders, stimulants are the next most-used drugs, at over 5% since 1995. Among seniors, stimulants showed growth from 1991 to 2002. Also, among tenth graders and seniors, cocaine gained in usage over time, increasing between 2001 and 2002, the only drug category to do so in that year of declining usage of other drugs.

Disapproval

As part of its survey work, MTF also measures its respondents' views of others who take drugs, of respondents' perceptions of the risks involved in using drugs, and their opinion on the ease or difficulty of obtaining drugs.

Disapproval ratings—the percentage of those who disapprove of others who use drugs—are the inverse of use. (See Table 4.5.) In 2003, for example, 78.7% of seniors disapproved of those who smoked marijuana regularly. In that year, 21.2% of twelfth graders reported using marijuana or hashish within the last thirty days. (See Table 4.4.) These two percentages, added together, result in 99.9%. Those who do not use the drugs generally disapprove of those who do.

Perceptions of risk (to be discussed below) also appear to influence disapproval ratings; in 2003, among seniors, the lowest disapproval rating was associated with trying marijuana once or twice (53.4% disapproved) and the highest with taking heroin regularly (97.1%). Between 1990 and 2003, disapproval of marijuana use has dropped more than 10% for all categories of use; disapproval of heroin use has remained almost unchanged between 1990 and 2003.

High school students' disapproval ratings for two activities, marijuana smoking and using crack, are shown in Figure 4.13 and Figure 4.14, respectively. Eighth graders' disapproval ratings for marijuana smoking are decisively higher than those of tenth and twelfth graders. Interestingly, eighth graders' disapproval of using crack once or twice is not higher than that of students in later grades—probably reflecting eighth graders' ignorance of risks. But disapproval ratings for crack are uniformly higher than for marijuana.

Risk Perception

In 1991, 83.8% of eighth graders, 82.1% of tenth graders, and 78.6% of seniors said that "great risk" was associated with smoking marijuana regularly, according to MTF. Only 5.2 points separated the risk ratings of twelfth graders from those of eighth graders. Twelve years later, the "great risk" ratings of eighth, tenth, and twelfth graders were 74.2, 63.9, and 54.9%

respectively; in 2003, 19.3 points separated eighth graders from seniors. This downward trend in risk perception is shown, along with risk perceptions relating to using cocaine (for twelfth graders only), in Figure 4.15 and Figure 4.16. Cocaine is viewed by youths as more risky. More than 60% of all twelfth-grade students saw great risk in taking it, even if only occasionally.

Availability of Drugs

"How difficult do you think it would be for you to get each of the following types of drugs, if you wanted some?"

The MTF project puts this question to students in its annual survey. The question is followed by a list of substances, including alcohol and cigarettes. According to the 2003 MTF, the two substances students have consistently judged "easy" or "fairly easy" to get have been alcohol and cigarettes, in that order. In 2003 the least available drug reported by eighth graders was PCP, followed by the crystalline form of methamphetamine ("crystal meth" or "ice"); 13.7% reported that it was easy or fairly easy for them to get this PCP, and 14.1% to get ice. Heroin was least available to tenth graders (19.9% reporting it easy/fairly easy to get). Seniors put amyl and butyl nitrites into the "least available" category; these nitrites are inhalants with intoxicating effects. In 2003, 87.1% of twelfth graders thought that they could easily get marijuana. (See Figure 4.17.)

Trends in availability have been fairly flat during the 1992 to 2003 period as reported by MTF. There are some exceptions. Availability of marijuana shows a slight upward trend, most notably for tenth graders. Among eighth graders, between 45 and 55% of students have reported marijuana easy to get during this time; since 1995, more than 75% of tenth graders and more than 85% of seniors have reported easy access to marijuana.

Perceived availability of cocaine powder shows a slight downward trend by each age group tracked by MTF. Over the 1992-2003 period, one in four eighth graders reported it easy to get powdered cocaine, compared with about one in three tenth graders, and just under 45% of seniors. These, of course, are reported perceptions of availability rather than reports of purchases. Only 0.9% of eighth graders and 2.1% of seniors actually reported using cocaine in the most recent thirty days, and, according to MTF, only 3.6% of eighth graders and 7.7% of seniors had ever used cocaine.

DRUGS IN THE WORKPLACE

Drug use in the workplace is tracked by SAMHSA in its national survey that captures the employment status of its survey respondents (http://www.oas.samhsa.gov/NHSDA/A-11/TOC.htm). The SAMHSA survey is based on self-reporting. The results of drug tests performed on behalf of private and public employers are another lens through which drug use in the workplace can be viewed. Drug testing results are published periodically by Quest Diagnostics Incorporated ("The Drug Testing Index," http://www.questdiagnostics.com/). Quest Diagnostics is the nation's leading provider of drug testing services.

In recent years SAMHSA has collected data by those employed full time, part time, those unemployed, and an "other" category that includes the retired, disabled, homemakers, students, and others to whom the employment/unemployment categories do not apply. Data for the most recent year show (as data in past surveys also consistently show) that the youngest age group in the work-age population, those eighteen to twenty-five, use drugs at higher rates than do those twenty-six years old and older. In this category of users, as in all others, marijuana largely accounted for the majority of uses whereas only small proportions of the population used the more dangerous drugs.

Use rates are higher for part-time workers than full-time workers and highest for the unemployed for the eighteen-to-twenty-five group. In the older age group, the unemployed used drugs at the highest rates as well, but those in the older age group were less likely to have used drugs overall.

Table 4.6 and Table 4.7 provide data on drug use and employment status. In 2003 nearly two-thirds of full-time workers ages eighteen to twenty-five had used illicit drugs in their lifetime, and about one-third in that age group had used drugs in the past year. For full-time workers aged twenty-six and older, the figures were 55.7% and 12.2%. The percentages in each employment status category remained relatively stable between 2002 and 2003.

Demographic and Occupational Profile

Using data from the 2000 household survey, SAMHSA completed and published a special analysis showing data for full-time workers aged eighteen to forty-nine by gender, age groups, occupation, and employing sector. (See Table 4.8.)

In 2000 men working full time were 1.5 times more likely to be using drugs than women (past-thirty-days usage) and twice as likely to have been dependent upon or abusing drugs (past-year usage). When the eighteen-to-forty-nine age group is segmented into three groups, drug use is highest among those eighteen to twenty-five (14.9% current use), lower among those twenty-six to thirty-four (7.9%), and lowest among those thirty-five to forty-nine (5.5%)—once more demonstrating that drug use diminishes with age. Within occupational groupings, production, craft, and repair workers had the highest current usage (11.2%) and those practicing some professional specialty had the lowest (4.7%). Executive/administrative occupations were toward the low end (6.5%), and those in the service industry at the higher end (9.7%). By type of industry, people working in construction and mining had the highest rate of drug use, at 12.3%, followed by those in the wholesale and retail sector, at 10.8%. The two lowest rated groups were government employees (3.7% using drugs currently) and those providing professional services (5%).

Drug Testing of Employees

Another view of drug use in the workplace is presented by actual counts of people who tested positive for illicit drugs, known in the testing industry as "positivity rates." People are tested as a condition of employment, periodically, on return to duty, or at random—all such tests based on corporate or government agency policy. People are also tested for cause when behavioral deviations from the norm suggest their involvement with drugs; tests are also performed after accidents. According to the American Management Association's annual survey of workplace medical testing (http://www.amanet.org/research/pdfs/Medical_testing_04.pdf), 61.8% of companies surveyed engaged in employee drug testing in 2004; 54.5% of these companies test new employees, including qualified applicants who have been offered a job pending results of a physical. Under federal law, the U.S. Department of Transportation and the Nuclear Regulatory Commission require the testing of "safety-sensitive" workers; pilots, bus drivers, and truck drivers fall into this category as do people who work in nuclear power plants.

Positivity rates as measured by Quest Diagnostics' 2003 drug testing index have been dropping. (See Table 4.9 and Table 4.10.) In 1988, 13.6% of employees undergoing tests showed positive results. The rate had been nearly halved by 1994 to 7.5%; Quest Diagnostics' most recent compilation showed that the rate was down to 4.5% in 2003. The types of drugs used by those testing positively has changed from 1999 to 2003, with use of amphetamines, methadone, and opiates, for example, rising, and use of barbiturates, cocaine, and marijuana decreasing.

1988-2003 data from SAMHSA's national household survey show that in the period 1988 through 1993, full-time workers reporting on their own drug use were a consistently lower percentage of the workforce than as measured by drug testing results. Both SAMHSA and Quest Diagnostics, however, showed a dropping prevalence of drug use. After 1993, self-reported rates were consistently higher than those shown by drug testing results. The Quest Diagnostics index measures very current drug use, current enough so that the drugs are still detectable in blood or urine samples, whereas the SAMHSA data include drug use within the past thirty days.

Drug test outcomes for the workforce population tested, as reported by Quest Diagnostics, showed that in 2003 marijuana was the leading cause for a positive result in 55% of cases, followed by cocaine (13.8% of positives), amphetamines (9.0%, a fairly large jump from previous years) and opiates (6.3%). (See Table 4.10.) Heroin is in the opiate category. According to Quest Diagnostics, in 1997 the leading categories were the same, but opiates held the third rank and amphetamines came in fourth.

DRUGS IN THE MILITARY

The U.S. Department of Defense (DOD), through the Office of the Assistant Secretary of Defense for Health, conducts surveys of drug use in the military at three- to four-year intervals. The DOD surveys go back to 1980, with the latest available data being for 2002. Military personnel are concentrated in the younger age groups most prone to use drugs; the military may also be said to be one of the most disciplined voluntary bodies in the U.S. workforce. The military thus presents a unique window on drug use.

In 2002 drug use in the military was down sharply from 1980, a year in which military personnel used drugs at high rates. (See Table 4.11.) In 1980 nearly 28% of all service personnel had used drugs in the last thirty days and more than a third (36.7%) had used drugs in the past twelve months. The highest rate was observed in the U.S. Marine Corps: 37.7% had used drugs during the past month and 48% during the past year. The U.S. Air Force had the lowest rates, 14.5% in the past month and 23.4% in the last year. The high usage rate of drugs in the military in 1980 reflects the high prevalence of drugs in the population as a whole: past-month use in the eighteen-to-twenty-five age

group nationally was 38% in 1979 and past-year use by this same age group was 45.5%. (See Table 3.2 in Chapter 3.)

By 2002 past-month drug use across the military services had declined to 3.4% and past-year usage to 6.9%, though it should be noted that these figures are slightly higher than those found during the 1990s. In 2002 the U.S. Army had the highest rate at 4.8% for the past thirty days and 10.4% for the past year. Air Force personnel consistently used drugs least between 1980 and 2002. Declines in drug use were greatest in the 1980 to 1988 period (22.8% change for past-month use DOD-wide) and grew slightly after 1998.

When one compares the military population with civilians, both populations displayed a declining prevalence of drug use, but military personnel consistently displayed a substantially lower rate of use, less than half that of the civilian population in 1988, 1992, and 1995, and a little more than half since then, according to data from the DOD and SAMHSA.

In the military services, as in the general population and in the working-age population, marijuana was the drug that produced significant rates of prevalence for past-month use in 2002. (See Table 4.12.) According to the DOD survey, about half of DOD-wide current use prevalence was accounted for by marijuana smoking. Use of painkillers (analgesics) in a nonmedical manner ranked second in the military.

A profile of military drug use within the last twelve months is presented in Table 4.13 using a variety of categories. Men used drugs more than women (7.2% of men, 5.5% of women). Hispanic service people were most prone to have used drugs in the last year, 8.3%, with both African Americans and whites at 6.7%. The lower the educational level of the service person, the higher his or her drug use. Those abroad or afloat on ships used drugs more than those stationed in the contiguous forty-eight states of the nation. Drug use rates declined with age from 14.1% of those twenty or younger to 2.2% of those thirty-five or older. Single personnel used drugs more than those who were married, and among those married, those whose spouse was present used drugs less than those whose spouse was absent. Drug use was lowest among senior enlisted personnel (pay grades E7-E9) and warrant officers (such as technical specialists like helicopter pilots or demolitions experts, pay grades W1-W5 in Table 4.13.)

Current drug use in the military was significantly lower than in the full-time work force in 2002, but patterns of drug use in the services were similar to patterns in the general population: more of those in the youngest age groups used drugs than those in the oldest, and use was lowest among those with the highest skill qualifications. Males in the military were also more likely to use drugs than females, as in the general population.