Clinical Implications of Substance Abuse in Young Adults

Figure 1. AUDIT-C is a 3-item screening test that can be used in college students using a cut-off score of 7 in men and 5 in women; in the general population, scores of 4 or more in men and 3 or more in women are considered positive.

Figure 2. DAST-10 is a modified version of the DAST developed by Harvey A. Skinner: scores of 0 (no problems reported) suggest no action; 1-2 (low level problems) suggest monitoring and reassessment; 3-5 (moderate level problems) suggest further investigation; and 6-8 (substantial level problems) or 9-10 (severe level problems) suggest intensive assessment.

The transition from high school to college often sparks excitement and fear in the new high school graduate. There are many things to consider as he or she plans for this transition, and these considerations are influenced by the experiences of parents and older siblings and friends; advice from teachers and guidance counselors; and-last but not least-popular media, including movies, television, and music.

These sources play a major role in shaping the idea of what college might be like. Some nights will be spent in the library writing term papers, while others may be spent socializing at fraternity parties playing beer pong and drinking a mysterious “jungle juice.” Along with the sense of newfound freedom from the “hall pass,” high school truancy laws, and the umbrella of parental oversight comes increased access to alcohol, illicit substances, and pharmaceutical drugs.

As clinicians, we may find it difficult to address this developmental period. We understand how important it is for youth to develop an individualized sense of self outside the context of previous constraints, but we also want to limit risk to young persons and to the community, which makes it difficult to determine when and how to intervene.

Prevalence

Alcohol use among college students far exceeds that of any other psychoactive substance. The most recent data from the Monitoring the Future National Survey estimate that 63% of college students in 2014 consumed alcohol within the past 30 days and 35% had occasions of heavy drinking (5 or more drinks in a row) in the past 2 weeks.¹ In addition, 43% reported being drunk in the past 30 days; 13% reported having 10 or more drinks in a row in the past 2 weeks, and 5% reported having 15 or more in a row. With the exception of the latter 2 rates of extreme binge drinking, these estimates range between 6% and 9% higher in college students. While in high school, the college-bound students were less likely to consume alcohol; thus, these rates indicate a substantial increase in alcohol consumption in the transition between high school and college.

In contrast, the annual prevalence of illicit drug use was lower among college students compared with their noncollege peers: at 39% and 44%, respectively. In the college population, the highest annual prevalence was for marijuana use (34%), followed by medically unsupervised amphetamines (10%), medically unsupervised sedatives/tranquilizers (6.6%), and ecstasy/3,4-methylenedioxymethamphetamine (5%). Prescription opioid narcotics, cocaine, and hallucinogen misuse was slightly under 5%, while use of inhalants, gamma hydroxybutyrate, ketamine, and heroin was much rarer. It is worth noting that, like alcohol use, past-year amphetamine salts misuse was higher among college students compared with their noncollege peers. Annual prevalence of marijuana use was 5% greater in college men than in women, and amphetamine misuse was 2.5% greater in men.

While these rates may seem trivial, the consequences are clear. Excessive college drinking has a profound effect on the individual and the community, with yearly estimates of 1825 deaths; 599,000 injuries; 696,000 assaults; and 97,000 sexual [[{"type":"media","view_mode":"media_crop","fid":"45062","attributes":{"alt":"© DenisNata/shutterstock.com","class":"media-image media-image-right","id":"media_crop_9417137922043","media_crop_h":"337","media_crop_image_style":"-1","media_crop_instance":"5100","media_crop_rotate":"0","media_crop_scale_h":"406","media_crop_scale_w":"100","media_crop_w":"83","media_crop_x":"20","media_crop_y":"1","style":"float: right;","title":"© DenisNata/shutterstock.com","typeof":"foaf:Image"}}]]assaults or date rapes.² More than 80% of all apprehensions by campus police involve alcohol. And a quarter of students report academic problems related to alcohol consumption.³ It is abundantly clear that college substance abuse poses a significant community health risk. Furthermore, the increased risk to the individual may be long-lasting and have lifelong consequences.

Neurobiology of substance use and development

At the biological level, various regions of the brain continue to develop and mature at different intervals throughout young adulthood. These active processes make the individual more likely to engage in novelty-seeking behaviors while simultaneously making the brain more susceptible to neurotoxic processes that can result from substance use. For substance abusers, increased neuroplasticity during development comes with a cost.

Imaging studies have confirmed various neural structural and physiological changes associated with adolescent and young adult alcohol use.^4,5 These changes include reduced hippocampal volumes and accelerated gray matter reduction in the frontal and temporal cortices with attenuated white matter growth in the corpus callosum and pons. These effects translate into problems with executive function, learning and memory, impulse control, and affective regulation. In addition, neurobiological changes alter cognition and increase the risk of substance use disorders and other neuropsychiatric processes.

Impact on psychopathology

Drug use among college students puts them at increased risk for adverse health, behavioral, and social consequences. Among adults aged 18 or older with serious mental illness in 2014, the percentage of those who had past-year substance use disorder was highest among 18- to 25-year-olds (35%), followed by 26- to 49-year-olds (25%).^6[

^]  Evidence suggests that heavy drinking during adolescence and young adulthood is associated with poor neurocognitive functioning and is particularly associated with poor visuospatial skills and attention.⁷

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Students who regularly used marijuana and those who increased their use mid-college utilized health care services more often and had higher levels of depressive and anxiety-related symptoms up to 7 years after college.⁸ Substance use may also be an independent risk factor for suicide, and it is important to recognize this during risk assessments, especially in adolescents and young adults. In college students, the co-occurrence of substance use behaviors and mental health problems (eg, major depression, panic disorder, generalized anxiety disorder) was associated with higher odds of cigarette smoking. Among the 67% with co-occurring frequent binge drinking and mental health problems, only 38% received mental health services in the past year.⁹

The most recent data from the National College Health Assessment survey reported that 35% of undergraduates felt so depressed it was difficult to function in the past year, 58% felt overwhelming anxiety, and a staggering 10% seriously contemplated suicide.¹⁰ This contrasts with low reports of college students who received treatment for depression (13%), anxiety (15.8%), and substance abuse (1%). Given the established bidirectional relationship between substance abuse and depression and anxiety, as well as the clear increased risk of suicide with substance abuse, this information is alarming for families, college campuses, and mental health providers alike.

Among the 20.2 million adults aged 18 or older in 2014 who had a past substance use disorder, 2.3 million (11.3%) also had a serious mental illness.^6[

^] It is clear that substance abuse during the early college years is significant and that the potential consequences are not only imminent but may be lasting. However, this also presents an opportunity to make a change early because a large number of youths transitioning to adulthood on college campuses can be reached during this vulnerable period.

Primary prevention on college campuses

Colleges and universities are especially critical for early intervention, given that they are the gateway to adulthood for nearly half of the US population and that the college years are the period during which young adults initiate or increase drug use.¹

In terms of comorbidities, approximately 1% of adults in the general population met criteria for both mental illness and substance use disorder in the past year.⁶ Delivering interventions in settings where students who have problems with alcohol are most likely to be seen, such as in health or counseling centers, may be most effective. Research shows that several carefully conducted community initiatives aimed at reducing alcohol problems among college-age youths have been effective, leading to reductions in underage drinking, alcohol-related assaults, emergency department visits, and alcohol-related crashes.¹¹

One strategy to increase participation in these interventions is to make screening routine in university health centers and to use new technology to reach a larger percentage of students.¹² A review of computerized and web-based brief interventions for college students suggested that personalized feedback may be the key component in this strategy’s success, both in motivating students and in helping them learn the skills they need to successfully change their behavior.¹³

Anonymous mandatory surveys during new and returning student orientation could dually serve to increase college administrators’ awareness of the prevalence of substance use and allow the student to reflect on his or her substance use patterns. However, using universal screenings as a means of mandating treatment referrals may result in under-reporting and thus limit their utility to both administrators and students. New college students, in particular, are only beginning to appreciate that honest information does not always result in restriction or punishment. This allows an opportunity to establish a relationship that is more likely to result in a partnership with college administrators and potentially with clinicians in the future.

Another strategy to improve prevention and increase participation of students is to develop a system of referral and financial penalties for students who are disciplined for substance-related infractions, such as a mandated intervention at campus student health. These types of practices may prevent the escalation of alcohol or drug use in students who are just beginning to experiment with substances.

Screening considerations

The most critical skill for clinicians is to recognize problem drinking or substance use behaviors. Keep in mind that most college students have only recently been released from parental oversight; thus, the most effective approach is likely to be non-confrontational and nonjudgmental and to lack paternalism. The AUDIT (Alcohol Use Disorders Identification Test) is a commonly used 10-item alcohol screening tool.¹⁴ It has been shown to be effective in the college population, with a sensitivity of 91% when compared with a more comprehensive diagnostic interview. Findings indicate that the AUDIT-C, which consists of the first 3 items from the AUDIT, is effective at detecting at-risk drinking in the college population (Figure 1).¹⁵

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Screening college students for substance use other than alcohol may be more complicated for a number of reasons. Simply asking about drug use may result in a negative screening because the college student may consider only substances such as cocaine, heroin, or methamphetamine in this category (the prevalence of abuse of these substances in the college population is low). Asking specifically about marijuana use and the use of their friends’ prescription medications, especially stimulants, is likely to result in more clinically useful information. The Drug Abuse Screening Test (DAST) is a 28-item instrument that has been validated as a clinical screening tool for past-year substance use.¹⁶ The brief 10-item version, DAST-10, has been shown to be effective in college-age students (Figure 2).¹⁷

An additional complication of substance use screening is the ever-growing list of new illicit drugs and variations of old ones, which limits the use of a list of commonly abused drugs with yes or no checkboxes. Regardless of the tool that is used, maintaining a nonjudgmental stance, asking the right questions, and reminding college students that their parents and college deans cannot access their medical records are likely to result in a more clinically meaningful substance use history.

Treatment options

Pharmacotherapy. There have been no FDA approvals for medications for alcohol dependence in over 10 years, which leaves disulfiram, naltrexone, and acamprosate as the only FDA-approved options. Other medications including gabapentin, topiramate, and ondansetron have been shown to improve drinking outcomes, with the latter specifically showing a reduction in early-onset (before age 25) alcoholism.¹⁸

Agonist therapies, including methadone and buprenorphine, remain the mainstay of opioid dependence treatment. In the college student population, treatment with buprenorphine is likely a more acceptable alternative to methadone maintenance, which requires daily visits to a methadone clinic. Another option for opioid dependence is antagonist therapy with oral or monthly injections of naltrexone.

Unfortunately, current evidence for cannabis dependence, the most widely abused substance in this population, is limited to a handful of open-label studies; more research on pharmacotherapy is needed.

Nonpharmacological interventions. A study involving students mandated to substance abuse treatment showed a reduction in high-risk drinking with either a brief motivational intervention (MI) or an alcohol education session, but students who received a brief MI reported fewer alcohol-related problems.¹⁹ A follow-up study of high-risk college students who received a single brief MI continued to show a significant reduction in negative alcohol-related consequences at 4 years.²⁰ These positive results for a brief MI have also been shown to generalize to drug use in a college student health clinic.²¹

No published study has examined the utility of pharmacotherapy with a brief intervention for alcohol dependence specifically in youth transitioning to adulthood. A brief MI, such as the BASICS (Brief Alcohol Screening and Intervention for College Students) program, continues to be the most validated therapeutic option in this population. A recent review focused on different modalities for adolescent substance use, including 12-step–based therapy, cognitive behavioral therapy (CBT), motivation-based therapy, family-based intervention, and mixed or other approaches.²² A consistent pattern emerged that showed overall positive effects for all treatment modalities; however, family-based intervention, CBT, and motivational enhancement therapy had the best outcomes.

Although pharmacotherapy may play some role for college students with substance abuse problems, effective psychotherapies remain the mainstay of treatment. Furthermore, as is true for all age groups, the importance of treating comorbid mood and anxiety disorders cannot be overemphasized.

Conclusion

College substance use is clearly a prevalent and controversial issue. Many who engage in binge drinking, experiment with illicit drugs, and/or misuse pharmaceuticals will go through this rite of passage relatively unscathed. However, others will not. Identifying and treating problematic substance use behaviors in college students may prevent injury, sexual assault, academic difficulties, and legal complications during college, and may reduce the risk of future substance dependency or mental health complications.

Disclosures:

Dr Blevins and Dr Khanna are third-year psychiatry residents in the department of psychiatry and neurobehavioral sciences at the University of Virginia Medical School in Charlottesville, VA. The authors report no conflicts of interest concerning the subject matter of this article.

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