Written by: Crystal Maertens

In March of 2024, Thad Shunkwiler, LMFT, LPCC, ACS, and CCMHC presented at one of Champ Software’s Expert Webinars, examining drug use trends among adolescents and the impact of drug use on the physical and psychological well-being of the user, as well as prevention and intervention strategies public health professionals and others can employ to address this issue.  

Shunkwiler is a licensed behavioral health provider who works as an associate professor in the Department of Health Science, College of Allied Health and Nursing at Minnesota State University in Mankato. In addition to his faculty role, he is the founding Director of the Center for Rural Behavioral Health. 

Shunkwiler’s research includes prevention science and behavioral health workforce development. His research has led to various appointments from the Governor’s Office, Judicial Branch, and county government. Having been an invited speaker at numerous professional conferences, he is recognized as a national leader in training healthcare professionals on issues surrounding behavioral health and wellness. He has previously presented during Champ Software’s Expert Webinar series on the topics of vaping cessation strategies and the impact of THC on the developing brain.

This article covers a topic that is part of Champ Software’s Expert Webinar series, in which subject matter experts present on trending or urgent public health topics. Join our mailing list here to receive Expert Webinar invitations.

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The Trend Towards More Dangerous Drug Use

For this presentation, Shunkwiler gathered data from the Monitoring the Future (MTF) study, SAMHSA’s National Survey on Drug Use and Health (NSDUH), and the Minnesota Student Survey (MSS). 

Referencing the MTF study, Shunkwiler noted that drug use among adolescents showed a substantial decrease from 2020 to 2021 (likely due to the pandemic and lack of opportunity to procure illegal drugs). While 2022 saw a rebound of drug use among youth, 2023 has held steady to 2022’s numbers, with, “just over 10% of 8th graders using illegal drugs, almost 20% of 10th graders, and just over 31% of high school seniors reporting any illegal drug use in the past year,” Shunkwiler explained. However, although drug use has not seen a significant increase among youth between 2022 and 2023, there was a dramatic rise in overdose deaths among teens. 

Shunkwiler referenced Nora Volkow, MD, NIDA Director’s views^{1, 2} on the study results, “Though the data indicate that drug use is not becoming more common among young people than it has been in the past, the tragic increase in overdose deaths among this population suggest that drug use is becoming more dangerous than ever before.”

“The Big Five” Drugs You Should Know About

Shunkwiler told his audience that, due to time constraints for the webinar, he would focus on “The Big Five,” which he defined as the “drugs that parents, educators, and public health professionals alike really need to know about as it pertains to young people.”

Alcohol 

“We’re starting with what NIDA considers the biggest public health problem in this country, which is underage drinking,” said Shunkwiler, continuing, “178,000 people died last year and the year before that from excessive alcohol use in this country. We don’t think about alcohol and the fatalities related to alcohol in the same way that we do any other drugs. And a drug like Fentanyl is very dangerous- killed over 100,000 people last year in this country, but alcohol killed considerably more, people in this country.”  

While Shunkwiler did note that the alcohol deaths are most often related to chronic alcohol use versus Fentanyl which can cause death with one use, he said, “You can’t have a chronic problem, until you start.” Shunkwiler also pointed out that the use of alcohol in the USA is not only widely accepted but often glamorized. 

Shunkwiler went on to outline the many risks associated with alcohol use among young people:

• Adverse effects on the developing brain: “The brain isn’t fully developed until we’re about 25 years old, give or take, so anything we do to disrupt the neurology of that development has potentially lifelong effects.” He went on to say that studies are still ongoing to determine the full effects of alcohol on the developing brain but that there is a known negative impact on thinking, memory, and learning.
• Adverse effects on the liver: Elevated liver enzymes, indicating some degree of liver damage, have been found in some adolescents who drink alcohol.
• Adverse effects on growth and the endocrine system: Drinking alcohol during puberty may upset the critical hormonal balance necessary for the normal development of reproductive organs, muscles, and bones.
• Dependence: The earlier someone starts drinking, the more likely they are to develop dependence.

While alcohol is still one of “The Big Five,” alcohol use among youth has declined, “So that tells us that the efforts we’ve had around educating young people about drinking have worked to some degree over the past four or five years. However, we’ve seen these numbers kind of stabilize,” Shunkwiler said, concluding, “We have some work to do with alcohol.”

Nicotine 

Nicotine is a central nervous system stimulant, Shunkwiler explained, “So, it stimulates or increases neurological communication within the brain.” 

Health risks young people face when they use nicotine include:

• Adverse respiratory effects
• Increased heart rate: Because nicotine is a stimulant, it increases heart rate and blood pressure, which is dangerous to a young person’s health.
• Experimenting with other drugs: “… nicotine activates the reward circuitry in the brain and pushes, psychologically pushes kids to want to continue to activate that and increase the rewards. So, kids go from a stimulant, say, like nicotine, to a drug like alcohol, and then into maybe more potent stimulants like amphetamines,” Shunkwiler said. 
• Potentially deadly consequences of tobacco: Historically, Shunkwiler explained, tobacco is the number one way to administer nicotine to the body, “And tobacco kills half the people who smoke. Right? You show me someone who smokes their whole life and I’ll show you half those people die as a direct result of smoking cigarettes. You can’t say that about any other drug that I talk about today.” 

Shunkwiler did share some good news regarding youth nicotine use. Referencing the MTF study trends from 1970 to the present, regarding lifetime tobacco use, there has been a steady downward trajectory. Why? Shunkwiler said, “The reason for that isn’t because we’ve figured out cigarettes are bad for us. We knew that even before 1975, right? We learned, or at least we acknowledged, that cigarettes caused cancer in the 1960s. Really, where we saw the trajectory spiral down is when we socially created the mindset that cigarette smoking is gross and kids don’t want to be gross.”

Shunkwiler also shared a positive trend regarding vaping.  While in 2018 and 2019 there was an explosion of vaping, that fell off in 2020 due to the pandemic, he explained, and, despite concerns of a potential resurgence in vaping after the pandemic, “… we’ve kind of maintained some of that downward trajectory on vaping.”

Shunkwiler credits the decrease in vaping to an increase in risk perception. According to Shunkwiler, in 2019, 74% of Minnesota students surveyed by MSS saw no or only a slight risk of vaping. By 2022 (which was the most recent data available as of Shunkwiler’s presentation), only one-third of the students surveyed believed that vaping had no or only a slight risk. Shunkwiler praised education efforts in schools and through public health settings, to which he credited these results: “So this is a crystal clear picture of how those efforts have actually worked, at least here in Minnesota.” 

For a deeper dive on vaping and vaping cessation strategies, you can view Shunkwiler’s presentation on that topic at this link.

Caffeine (Especially Energy Drinks)

“You might be wondering, ‘Why on earth are we talking about caffeine in the same presentation as Fentanyl and alcohol,’ and the reason is, it’s the most widely used psychoactive substance in the world. This is the drug of choice for the majority of people, myself included,” Shunkwiler acknowledged.

Shunkwiler explained, “… our biggest concern with caffeine is when young people with underdeveloped brains are using it.”

While the FDA has outlined safe caffeine limits for adults, Shunkwiler cautioned, “They go on to say that there is no safe consumption for children under 12 and they only recently changed their guidance on teenagers because it was a futile effort to say that no teenager should consume caffeine as well. So, instead of just saying it’s none, they kind of met in the middle between adults and kids and said, ‘100 milligrams max for teens,’ but in their guidance, they specifically say, ‘No energy drinks.’”

What are the dangers of energy drinks for young people? 

• They contain significantly more caffeine than standard soda or coffee: They are designed to give the user a “jolt” of energy and can contain 200mg – 500mg of caffeine in a 24 oz can. 
• Increased heart rate and blood pressure: This can adversely affect youth health.
• Long term nervous system and/or neurological damage when consumed in large amounts over a period of time: Long term effects of energy drinks are only now becoming available as they’ve only been around for about 10 years. 
• Disruption in sleep patterns
• Link to obesity: Energy drinks are loaded with not only caffeine, but also sugar.
• Ease of access: Energy drinks can easily be obtained by young people at gas stations or convenience stores with no limit on purchase. 

Unlike other drug trends discussed during this presentation, the use of energy drinks is actually increasing. Shunkwiler referenced the MTF study trends on daily energy drink usage: for 12th graders, 16.8%; for 10th graders, 17.5%; for 8th graders, 13.1%. Shunkwiler emphasized, “So, not monthly or yearly or lifetime – this is every single day, the percentage of our young people who are reporting energy drink usage and these numbers are going in the wrong direction.”

Shunkwiler urged action, “And so, I think it’s important for us to talk with young people about their caffeine consumption and educate parents and young people alike that these things are not benign- that this is not like grandma and grandpa having six cups of coffee. These young people’s brains aren’t fully developed and there are neurological as well as health related issues tied to energy drinks.”

Opioids (Specifically Fentanyl)

Prescription opioid and illicit opioid (e.g. heroin) use among young people has dropped significantly. However, Fentanyl use is a big concern. 

Opioids are a family of drugs in which the psychoactive ingredient is morphine. Morphine is a natural molecule found in the poppy seed plant. However, synthetic opioids are person-made drugs that are intended to mimic morphine. 

“We have taken morphine, which is a pain reliever, and we have literally put it on steroids and have created synthetic opioids,” Shunkwiler explained, “and those are your drugs like oxycodone, your vicodin, your Dilaudid… and on the top of that scale, regarding potency, is Fentanyl. And Fentanyl is approximately 50 times as potent as morphine.”

Fentanyl dangers for youth include:

• Potency: As stated above, fentanyl is approximately 50 times more potent than morphine, making it easy to overdose unintentionally. 
• Accidental consumption: Oftentimes, people unknowingly consume Fentanyl, according to Shunkwiler. While Fentanyl is being introduced into street drugs such as counterfeit Oxycontin pills, it has also begun to be introduced into other, more unexpected drugs, such as stimulants like cocaine, methamphetamine, etc. 
• Unintentional death by overdose: Once Fentanyl hit the streets, there was a dramatic spike in overdose death rates among youth ages 15-19, with death rates doubling and quadrupling. 

Shunkwiler urged that it is imperative to educate young people about the risks of fentanyl and not only focus on drugs like methamphetamine or cocaine. “While it’s important for young people to understand the consequences of those drugs, the worst consequence of cocaine is that it’s laced with fentanyl. The worst consequence of amphetamines is that they’re laced with fentanyl. Fentanyl has such a high potency and toxicity that so many young people are losing their lives.” 

Marijuana

With the legalization and decriminalization of marijuana in many states, the ease of youth access to marijuana has become an increasing concern. Delta-9-tetrahydrocannabinol, otherwise known as THC, is the psychoactive element of marijuana that produces the intoxicating effect associated with marijuana or “weed” use or the consumption of edibles.  

“Whether or not it’s already in your state, the reality is that the momentum is on the side of decriminalizing and legalizing cannabis. And I’m not here to say whether it’s a good or a bad thing; I’m here to say it’s going to have an impact on young people using it. And we’re already seeing that,” said Shunkwiler. 

Shunkwiler also reported that past-year marijuana use among young adults reached 43% in 2023, which was a significant increase from 34% in 2018 and 29% in 2013.

Why is marijuana use increasing among young people? Shunkwiler credits the rise to a lowered perception of risk: “We are seeing alarming numbers of kids who don’t think smoking marijuana or using marijuana once or twice per week is harmful… Almost ⅔, so 62.99 or 63% of Minnesota 11th graders see no or only slight risk in weekly marijuana use.” The lowered perception of risk combined with increased ease of access will lead to exponential increases in youth use of marijuana, Shunkwiler predicts.

Health risks for youth who consume THC before the age of 25 include:

• Difficulty thinking and problem-solving
• Problems with memory and learning
• Difficulty maintaining attention
• Reduced coordination
• Links to a range of mental health problems, including depression and anxiety
• Higher likelihood of developing temporary psychosis, not knowing what is real, hallucinations, and paranoia
• Reduced school performance, including a higher likelihood of not finishing high school or going on to get a college degree

Shunkwiler cautioned, “And these things are chronic. These things don’t just happen while they’re using cannabis; because they’re altering the neurological development of their nervous system, these things have lifelong consequences.” He shared a statistic stating that adult marijuana users who started using when they were kids experienced an average IQ loss of 8 points by adulthood.

For a deeper dive into marijuana and prevention strategies, you can view Shunkwiler’s presentation on the effects of THC on the developing brain at this link.

Identifying Substance Abuse in Youth

Shunkwiler also discussed how to identify youth who are having a problem with alcohol or drugs.

While Shunkwiler pointed out that the only amount of drugs or alcohol that is safe for a young person to consume is zero, he also acknowledged, “They’re going to use. We just saw the data trends.” How can you identify when a young person has crossed the line from being a recreational or experimental user to having a problem?

The answer is complex, but Shunkwiler did share two red flags to watch for:

• A change in personality that goes beyond the normal puberty change (Shunkwiler admits this can be a difficult sign to observe)
• Possession of drug paraphernalia: Shunkwiler stresses that it would be rare for youth to have drug paraphernalia that was not their own

Intervention Resources

The best intervention is prevention. Shunkwiler explained, “You don’t need this huge, multifaceted, huge binder approach to drug prevention.” He shared some simple steps parents, public health professionals, and educators can take:

• Educate young people about the risks. While this includes educating young people about the physical and mental health risks of drug use, many young people feel invincible, and those risks may not be enough to deter them from using. Shunkwiler suggests it is also important to educate young people about the criminal consequences of drug use, including fines and loss of freedom. 
• Maintain an open dialogue around drugs. Ensure young people know a safe person they can turn to if they’re in a situation where drugs are being used, and ensure they have an exit plan. 
• Establish strong family values.
• Get parents involved. “The best predictor of young people using drugs is parental involvement. You show me a young person whose parents don’t care, who are not involved, and I will show you a young person who is much more likely to use drugs than a child who has parents who are involved,” Shunkwiler said. He urged public health professionals and educators to target parents with their prevention programs as well in order to help them understand how important their involvement is for their young people in choosing whether or not to use drugs. 

Last but not least, as Shunkwiler said, when you do find yourself working with a young person who does have a problem with drugs or alcohol or is showing signs of struggle, he stressed that the government makes it really easy to find help. While Shunkwiler doesn’t endorse any particular treatment program, he did say educators, parents, and public health professionals don’t need to reinvent the wheel. Shunkwiler noted two excellent resources: SAMSHA.gov and findtreatment.gov.

Conclusion

In conclusion, Shunkwiler shared, “My goal was simply to give you information to start this conversation.” View Shunkwiler’s full presentation at this link.

Citations

1. National Institute on Drug Abuse. “Most reported substance use among adolescents held steady in 2022 | National Institute on Drug Abuse.” National Institute on Drug Abuse, 15 December 2022, https://nida.nih.gov/news-events/news-releases/2022/12/most-reported-substance-use-among-adolescents-held-steady-in-2022. Accessed June 28, 2024.
2. National Institutes of Health. “Reported drug use among adolescents continued to hold below pre-pandemic levels in 2023.” National Institutes of Health (NIH), 13 December 2023, https://www.nih.gov/news-events/news-releases/reported-drug-use-among-adolescents-continued-hold-below-pre-pandemic-levels-2023. Accessed June 28, 2024.