Post on 22-May-2020
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Wilson M. Compton, M.D., M.P.E. Deputy Director
National Institute on Drug Abuse
Prevention for an Era of Shifting Drug Use:
Opioids, Marijuana, E-‐Cigarettes
Healthy Heart Diseased Heart
Decreased Heart Metabolism in Heart Disease Patient
Addiction is a Disease of the Brain as other diseases it affects the tissue function
Control Cocaine Abuser
Decreased Brain Metabolism in Drug Abuse Patient
Sources: From the laboratories of Drs. N. Volkow and H. Schelbert
High
Low
Many Factors Lead to Drug Abuse and Addic�on
Addic�on
DRUG
Brain Mechanisms
Biology/Genes
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Environment
• Prevention Approaches Should Enhance Protective Factors & Reduce Risk Factors
Reduce these Elevate these
How Prevention Interventions Work
MODIFIABLE RISK and
PROTECTIVE FACTORS
Background Factors
Age Gender Race/ethnicity Poverty level Genotype
Early aggression Social skills deficits Academic problem
Misperceived drug use norms Association with deviant peers Neighborhood availability
Media glamorization Parental monitoring and
support
INTERVENTIONS
Parent skills training Social skills training
Self-‐regulation Impulse control
Tutoring Norms training Refusal skills
Community policing Health literacy
Nurse Home Visiting during pregnancy and first two years impacts substance use, mental health and academics
Arch Pediatr Adoles Med, 164(5) 412-‐418, 2010
Percent of Children Who Used Tobacco, Alcohol, or Marijuana (Last 30 Days)
Child Age 12
Percent of Children with Internalizing Problems (Borderline or Clinical)
Child Age 12
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Nurse Comparison0
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Nurse Comparison
PIAT Scores -‐ Reading & Math – Age 12 (Born to Low-‐Resource Mothers)
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Nurse Comparison
Percent of Mothers with Role Impairment due to Alcohol or Drug Use – Child Age 12
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Nurse Comparison
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PROSPER (Community/University Partnership) Reduces Illicit Substance Use
Sum of six lifetime illicit use measures (methamphetamines, Ecstasy, inhalants, Vicodin, prescription drug misuse overall, other illicit drug use); Intervention vs. Control difference in slope is statistically significant, as are differences at multiple time
points, including 11th and 12th grades.
Reduced Increase in Use Through 6½ Years Past Baseline
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2.00
2.50
Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12
Control
Interven�on
Source: Spoth, Redmond, Shin, Greenberg, Feinberg, et al. (2013). PROSPER community-‐university partnerships delivery system outcomes through 6½ years past baseline.
Higher Risk = Lifetime initiation of alcohol, cigarette or marijuana use at baseline; Lower Risk = No initiation at baseline.
Intervention effects are significantly stronger for the Higher-‐Risk subgroup, as compared to the Lower-‐Risk Subgroup.
Greater Impact of PROSPER on High Risk Youth Through 6½ Years Past Baseline
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Grade 6 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12
Higher-‐Risk in Control
Lower-‐Risk in Control
Higher-‐Risk in Interven�on
Lower-‐Risk in Interven�on
PROSPER (Community/University Partnership) Reduces Illicit Substance Use
Source: Spoth, Redmond, Shin, Greenberg, Feinberg, et al. (2013). PROSPER community-‐university partnerships delivery system outcomes through 6½ years past baseline.
Interventions Can Influence the Behaviors of Nonparticipants Through Friendship Networks
Adolescents with 3+ friends participating in the Strengthening Family Program were less likely to use cigarettes or get drunk than those who had no friends in the program (3 yrs post intervention).
Effects primarily diffused through friendship networks by reducing unsupervised time with friends, changing friends’ attitudes about SU, and then changing nonparticipants attitudes about SU.
0%
5%
10%
15%
20%
25%
baseline post-‐test 1 yr FU 2 yr FU 3 yr FU
% Repor�n
g An
y Past M
onth
Drunkeness
0 SFP friends
1 SFP friend
2 SFP friends
3+ SFP friends
interven�on implemented
Kelly et al., J Adolesc Health 2015
0%
5%
10%
15%
20%
25%
baseline post-‐test 1 yr FU 2 yr FU 3 yr FU
% Repor�n
g An
y Past M
onth Cigare�
e Use
0 SFP friends
1 SFP friend
2 SFP friends
3+ SFP friends
interven�on implemented
Preven�ve Interven�ons Can Have Long-‐term Effects on Drug
Use and Abuse
Responding to Shifting Drug Use and Policy Environments
MARIJUANA: The shifting legal landscape suggests possible population impacts
E-‐CIGARETTES: Both potential promise for established tobacco users and concern for increasing adolescent use
OPIOIDS: Impacts on public health in the USA starting with over-‐exposure to prescription opioids
2013 OD Deaths: 16,235 Rx opioid
– (16,917 in – )
8,257 Heroin – (4,397 in 2011)bb
Slight Reductions in Rx Opioid-‐Related Deaths but Marked Increases in Heroin
Sources: National Vital Statistics System, CDC
– (16,007 in 2012 and 16,917 in 2011)
– (5,927 in 2012 and 4,397 in 2011)
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Overall Increases in Deaths in 45-‐54 Year Old, White, Non-‐Hispanics in USA (Compared to Others)
U.S. Whites France Germany U.S. Hispanics United Kingdom Canada Australia Sweden
Case and Deaton, PNAS, 2 November 2015
Major Causes: Drug
Overdose
Alcohol
Suicide
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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Rx Opioid Use
High Rates of Rx Opioid Abuse: 12-‐Month Prevalence of Rx Opioid Misuse, USA Ages 18-‐64,
2003-‐2014
%
Data sources: Han, Compton et al. JAMA October 13, 2015; SAMHSA’s National Survey on Drug Use and Health (NSDUH) data, 2003-‐2014, adults aged 18-‐64 in the United States.
Trend, p < .001
0
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0.4
0.6
0.8
1
1.2
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
100+ Days
Increasing Frequent Rx Opioid Misuse: 12-‐Month Prevalence of 100+ days Rx Opioid, USA Ages 18-‐64,
2003-‐2014
% Trend, p < .001
Data sources: Han, Compton et al. JAMA October 13, 2015; SAMHSA’s National Survey on Drug Use and Health (NSDUH) data, 2003-‐2014, adults aged 18-‐64 in the United States.
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0.4
0.6
0.8
1
1.2
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Opioid Ab/Dep
Increasing Rx Opioid Abuse/Depedence: 12-‐Month Prevalence of Rx Opioid Ab/Dep, USA Ages 18-‐64, 2003-‐2014
% Trend, p < .001
Data sources: Han, Compton et al. JAMA October 13, 2015; SAMHSA’s National Survey on Drug Use and Health (NSDUH) data, 2003-‐2014, adults aged 18-‐64 in the United States.
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2004
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Rx Opioid Use Without 100+ or Ab/Dep
Opioid Ab/Dep
100+ Days
Increasing Intensity of Opioid Misuse: 12-‐Month Prevalence of Rx Opioid Misuse without Frequent Use or Ab/Dep,
Rx Opioid Ab/Dep, 100+ days Rx Opioid in USA Ages 18-‐64, 2003-‐2014
%Trends, p < .001
Data sources: Han, Compton et al. JAMA October 13, 2015; SAMHSA’s National Survey on Drug Use and Health (NSDUH) data, 2003-‐2014, adults aged 18-‐64 in the United States.
Patrick SW, Davis MM, Lehman CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015 Aug;35(8):667. doi: 10.1038/jp.2015.63. PubMed PMID: 26219703.
Increasing Neonatal Abstinence Syndrome Incidence & Geography, U.S. 2009-‐2012
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Opioids Lead to Infectious Diseases: Outbreak of HIV Linked to
Oxymorphone Injection Drug Use
80% 3%
17% (23)
Injection Drug Use
No Injection Drug Use Not Interviewed to Determine Status
All reported injecting tablets of oxymorphone As drug of choice
84.4% 114 co-‐infected with Hepatitis C
Reported average of 9 syringe-‐sharing partners, sex partners, or other social contacts at risk for HIV infection contacts
373
4
108
162 HIV Infections in Indiana Community of 4200
61.7%
4.6%
247 located
47% 53%
109 121 HIV-‐ HIV+
112
230 tested
128 not located
57.8% 42.2%
74 54
syringe-‐sharing or sex partners
social contacts regarded as at high risk for HIV
Similarities of Illicit & Prescription Opioids
Prescription Opioids Before Heroin: Shifting Pattern of Heroin v. Rx Opioid First
Percentage of Heroin-‐Addicted Treatment Admissions that Used Heroin or Prescription Opioid as First Opioid
Source: Cicero et al. JAMA Psychiatry. 2014;71(7):821-‐826
1960s: more than 80% started with heroin. 2000s: 75% started with prescription opioids. 2010-‐2013: Increasing initiation with heroin
Marked Increases in Heroin: Past Year Heroin Use, Persons Aged 12+, 2003-‐2014
314 398 379
560
373 455
582 621 620
669
914+
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100
200
300
400
500
600
700
800
900
1,000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
681
+ p < .05
Numbers in Thousands
Source: SAMHSA, 2014 National Survey on Drug Use
Overlap of Benzodiazepines and Opioids Opioid Analgesic ED Visits and OD Deaths Involving Benzodiazepines &
Benzodiazepine ED Visits and OD Deaths Involving Opioids
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Deaths Involving Benzodiazepines
ED Visits Involving Benzodiazepines
Deaths Involving Opioid Analgesics
ED Visits Opioid Analgesics
2004 2005 2006 2007 2008 2009 2010 2011
Perc
ent
Opioid Analgesics Benzodiazepines
Source: CM Jones, J Mcaninch analysis of CDC/NVSS and SAMHSA/DAWN Public Use Files, FDA, 2014, (In Press)
AAPC = 8.4% (95% CI 7.1%-‐9.7%) AAPC = 3.0% (95% CI 1.3%-‐4.8%)
AAPC = 1.5% (95% CI 0.8%-‐2.2%)
AAPC = 4.5% (95% CI2.4%-‐6.6%)
Secretary Burwell’s/HHS Opioid Priority Areas
Ø Opioid prescribing practices to reduce opioid use disorders and overdose
Ø The expanded use of naloxone, used to treat opioid overdoses
http://aspe.hhs.gov/sp/reports/2015/OpioidInitiative/es_OpioidInitiative.pdf
Ø Expanded use of medication-‐assisted-‐treatment (MAT) for opioid use disorders
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How Can NIH/NIDA Research Help?
PAIN: Less Abusable Analgesics and Alternative Therapeutics OVERDOSES: User Friendly Naloxone PREVENTION: Universal Prevention ADDICTION: New Medications and Immunotherapies IMPLEMENTATION SCIENCE: Greater Use of Evidence
Near Tripling of Opioid Prescriptions Dispensed by U.S. Retail Pharmacies, Years 1991-‐2013
IMS Health, Vector One®: National, Years 1991-‐2011, Data Extracted 2012 IMS Health, National Prescription Audit, Years 2012-‐2013, Data Extracted 2014
More than One Clinician (2.6%)
1Other category includes Wrote Fake Prescription," "Stole from Doctor’s Office/Clinic/Hospital/Pharmacy," and "Some Other Way."
Free from Friend/
Relative (53.0%)
Bought/Took from Friend/Relative
(14.6%)
Drug Dealer/ Stranger (4.3%)
Bought on Internet (0.1%)
Other1 (4.3%)
One Clinician (21.2%)
Source Where Respondent Age 12+ Obtained Analgesics:
Free from Friend/Relative
(5.1%) Bought/Took from
Friend/Relative (4.9%)
Drug Dealer/ Stranger (1.4%)
One Clinician (83.8%)
More than One Clinician
(3.3%)
Bought on Internet (0.3%)
Other1 (1.2%)
Source Where Friend/Relative Obtained
People Abusing Analgesics DIRECTLY & INDIRECTLY Obtain Them by Prescription: Most Recent Pill Source
Source: SAMHSA, 2012 and 2013 National Survey on Drug Use and Health
Opioid Prescribing Guidelines
Ø Intended for primary care providers Ø Will apply to patients >18 years old in chronic pain
outside of end-‐of-‐life care Ø Builds on joint CDC, NIDA, ONC, SAMHSA summary
on “Common Elements in Guidelines for Prescribing Opioids for Chronic Pain” and the NIH Pathways to Prevention for Opioids in Treating Chronic Pain
Ø Planned for publication in January 2016
Ø Current Landscape for Guidelines: § Small Number § Outdated § Not Conflict Free
Ø Solution….
Clinicians Need to Know… What Prescriptions Have Been Given to Their Patients By Other Practitioners
This information should be: 1. included in the patients’
electronic health care records 2. accessible through a
Prescription Drug Monitoring Program (PDMP) that provides immediate information
Decline in Drug Overdose Deaths After State Policy Changes in Florida, 2010–2012
PERIOD
Oxycodone
Alprazolam
Methadone
Heroin
Hydrocodone
Morphine De
ath
s p
er 1
00,0
00 p
op
ula
tion
4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0
Jan-Jun Jan-Jun Jan-Jun Jan-Jun Jan-Jun Jan-Jun Jan-Jun Jul-Dec Jul-Dec Jul-Dec Jul-Dec Jul-Dec Jul-Dec Jul-Dec
2006 2007 2008 2009 2010 2011 2012
A B C D E F G
Semi-Annual Drug Overdose Death Rates* for Selected Drugs, & Selected Prescription Drug Diversion & Misuse Actions Taken, Florida, 2006 – 2012+
*Per 100,000 population. Based on Florida Department of Health resident population estimates. + The source of overdose death data is the Florida Medical Examiners Commission.
Source: CDC, MMWR Vol 63, July 1, 2014.
A. 1/4/2010—Pain clinics must register B. 2/2010—Operation Pill Nation C. 10/1/2010—Pain clinic regulation D. 2/23/2011—Operation Pill Nation—raids E. 7/1/2011—Physician dispensing prohibited & statewide regional strike forces F. 9/1/2011—Mandatory PDMP reporting G. 7/1/2012—Wholesale regulations
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Hydrocodone Declines (22%) 2014 to 2015: Opioid Analgesic Prescriptions Dispensed from US Retail
Pharmacies for Select Opioids Q4-‐2009 to Q2-‐2015
30,088,966
23,384,486
0
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
30,000,000
35,000,000
Q4 2009
Q1 2010
Q2 2010
Q3 2010
Q4 2010
Q1 2011
Q2 2011
Q3 2011
Q4 2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
Q1 2013
Q2 2013
Q3 2013
Q4 2013
Q1 2014
Q2 2014
Q3 2014
Q4 2014
Q1 2015
Q2 2015
Num
ber o
f Prescrip
�ons Dispensed
hydrocodone oxycodone tramadol morphine fentanyl
Source: CM Jones. NIDA Webinar 9/1/2015. Based on IMS Health National Prescription Audit (extracted 8/24/2015) Retrieved from http://www.drugabuse.gov/news-‐events/meetings-‐events/2015/09/latest-‐prescription-‐trends-‐controlled-‐prescription-‐drugs.
** **
Universal Drug Abuse Prevention Reduces Prescription Drug Misuse
Notes: General=Misuse of narcotics or CNS depressants or stimulants. Source: R Spoth et al. American Journal of Public Health 2013
In this study, for 100 young adults in general population starting Rx abuse, only 35 young adults from an intervention community started.
** p<.01;
Overall, three studies now suggest the impact of universal prevention on prescription drug abuse.
15.5%
13.5%
5.4% 4.7%
0%
4%
8%
12%
16%
Age 25 General Age 25 Opioids
Control Family Program
Another Key Emerging Drug Issue in the USA: Status of Marijuana Laws in the USA
0
10
20
30
40
50
60
70
80
75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09 11 13
Percentage of U.S. 12th Grade Students Reporting Past Month Use of Alcohol,
Cigarettes
SOURCE: University of Michigan, 2014 Monitoring the Future Study.
Cigarettes Alcohol
Marijuana
and Marijuana
Increasing Potency of Marijuana (% Δ-‐9 THC)
SOURCE: University of Mississippi Marijuana Project
%
0
2
4
6
8
10
12
14
16
1995
19
96
1997
19
98
1999
20
00
2001
20
02
2003
20
04
2005
20
06
2007
20
08
2009
20
10
2011
20
12
2013
20
14
∆-9 THC
0
5
10
15
20
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Percent Who Reported
12th Graders Who Drove After Smoking Marijuana or Drinking Alcohol, 2001-2014
Source: University of Michigan, 2014 Monitoring the Future study, Unpublished special tabula�ons (December 2014).
During the LAST TWO WEEKS, have you driven a car, truck, or motorcycle a�er …
… drinking alcohol
… smoking marijuana
Since 2009, more high school seniors reported driving a�er smoking marijuana than driving a�er drinking alcohol.
See Also: Driving Under the Influence of Non-‐Alcohol Drugs – An Update. Gjerde H, Strand MC, Mørland J. Forensic Sci
Rev 27:89; 2015.
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0
20
40
60
80
100
95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14
8th Grade 10th Grade 12th Grade
SOURCE: University of Michigan, 2014 Monitoring the Future Study
Denotes significant difference between 2013 and 2014.
Perceived Riskiness of Smoking Marijuana has Declined
%
Perceiving Great Risk of Smoking Marijuana Occasionally
0
20
40
60
80
100
75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09 11 13
Past Year Use Perceived Risk
Perceived Risk is Correlated with Use of Marijuana
SOURCE: University of Michigan, 2014 Monitoring the Future Study
Denotes significant difference between 2013 and 2014.
%
12th Graders’ Use vs. Perceived Risk of Occasional MJ Use
Non-‐users used 1 Dx
used 2 Dx
used 3 Dx
-8
-6
-4
-2
0
2
Average Point D
ifference in IQ
score
(IQ at a
ge 38 – IQ at a
ge 13)
Persistent Marijuana Users Show Significant IQ Drop between Childhood and Midlife
Source: Meier MH et al., PNAS Early Edition 2012
Followed 1,037 individuals from birth to age 38. Tested marijuana use at 18, 21, 26, 32 and 38. Tested for IQ at ages 13 and 38
Silins, et al., Lancet Psychiatry 2014;1:286-‐293
HS Complete
Never
< Monthly
Monthly +
Weekly +
Daily
0
0.2
0.4
0.6
0.8
1
1.2
HS Complete
O.R.
0
5
10
15
20
Cannabis Depend
O.R.
0
2
4
6
8
10
Other Illicit Drug
O.R.
0 1 2 3 4 5 6 7 8
Suicide Attempt
O.R.
More Teenage Use of Cannabis Associated with Worse Outcomes in 20’s (3 Australia/New Zealand Studies)
Cannabis Associated with Schizophrenia
Giordano, Ohlsson, Sundquist, Sundquist, Kendler Psychological Medicine 2015
Baseline After 1 Yr After 5 Yrs After 7 Yrs
General Pop'n 10.44 9.19 5.95 4.24
Relative Pairs:
1st Cousin 9.40 8.37 5.85 4.05
Paternal 1/2 Sib 9.15 8.42 6.12 4.18
Maternal 1/2 Sib 6.00 5.85 3.42 2.58
Full Sibs 5.07 4.47 2.80 1.98
MZ Twins* 3.92 3.38 2.63 1.67
* Extrapolated
Risk (Odds Ratios) of hospital diagnosis of schizophrenia after prior registration for cannabis abuse in: (i) general population and (ii) co-
relatives, allowing time from exposure to disease to vary by 1-7 years
Adolescent Brain Cognitive Development National Longitudinal Study
NIDA, NIAAA, NCI, NICHD, NIMHD, ORWH, NIMH, NINDS, OBSSR
Ten year longitudinal study of 10,000 children from
age 10 to 20 years to assess effects of drugs on individual brain development trajectories
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Electronic Nicotine Delivery Systems—E-‐cigarettes: Promise and Peril
PROMISING for tobacco cessation? PERILOUS for new onset addiction?
More Youth Use E-‐Cigarettes Than Tobacco Cigs
Monitoring the Future Study 2014, University of Michigan
0
2
4
6
8
10
12
14
16
18
8th Grade 10th Grade 12th Grade
Tobacco Cigare�es
E-‐Cigare�es
Past Month Use of E-‐Cigs vs. Traditional Cigarettes in the 2014 Monitoring the Future Study of 8th, 10th and 12th Grade Students in USA
8.1%
16.2% 17.1%
4.0%
7.2%
13.6%
Large Numbers of Youth in USA Using E-‐Cigarettes Without Prior Use of Tobacco
Monitoring the Future Study 2014, University of Michigan
0
2
4
6
8
10
12
14
16
18
20
8th Grade 10th Grade 12th Grade
E-‐Cigs Only
E-‐Cigs and Any Life�me Tobacco
Past Month Use of E-‐Cigarettes Among Youth with/without Any Lifetime Use of Tobacco Cigarettes or Smokeless Tobacco in the 2014 Monitoring
the Future Study of 8th, 10th and 12th Grade Students in USA
36%
30%
21%
Risk for Onset and Outcomes from E-‐Cigs
2012-‐2013 U.S. study of 12-‐17 year olds (n=13,561), first tobacco product was flavored among users:
Cigarettes 50%
Smokeless 69%
E-‐Cigarettes 81% Ambrose, et al. JAMA, 26 October 2015
In a one year prospective study of 14 year old students, E-‐Cigarette use predicted onset of:
Any combustible 2.75 AOR
Combustible cigs 1.73 AOR Leventhal, et al. JAMA 2015;314(7):700-‐707.
Nicotine Effects Particularly Impacts Adolescent Brain
Schochet AE, et al. Neuroscience 135 (2005) 285–297
Adolescent Adult
Nicotine up-‐regulates arc (involved in synaptic plasticity) in adolescents but not adults (rodent models)
Levine A. et al., Sci Transl Med. 2011
Nicotine enhances response to cocaine in adolescents but not adults (rodent models)
Many Factors Lead to Drug Abuse and Addic�on
Addic�on
DRUG
Brain Mechanisms
Biology/Genes
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Summary Universal Risk-‐based Prevention is an essential standard, BUT
The shifting landscape of drug use suggests the potential value of drug-‐specific approaches as well.
Current and emerging drug abuse issues require our creative and vigorous responses
www.drugabuse.gov