Teens, Drugs, and Overdose: Contrasting Pre-Pandemic and Current Trends

Teenage drug and alcohol use is on the decline and, for the first time in recent years, drug overdose deaths among teens have slightly decreased. Adolescent overdose fatalities first spiked with the onset of the pandemic, nearly doubling from 282 deaths in 2019 to 546 deaths in 2020. These deaths decreased from 721 in 2022 to 708 in 2023, a small reduction that marked a plateau and possibly the start of a decline in adolescent overdose deaths. While it is too early to determine what the direction of overdose deaths may be, factors that may have contributed to the small decline include a decrease in pandemic-related stressors along with policies aimed at reducing overdose deaths. Through the Biden-Harris Administration, naloxone was made available over the counter, access to substance use treatment and education was expanded, including in schools, and the Kids Online Health and Safety Task Force was launched, which aims to prevent teens from purchasing drugs via social media. With the 2024 Presidential election approaching and both candidates’ plans to address the youth drug crisis differing widely, future policy efforts will depend on election outcomes.

This issue brief analyzes CDC WONDER data – including provisional data from 2023 – and data from national surveys of adolescent youth to highlight trends in substance use and overdose deaths. It explores how and where teenagers receive substance use information and treatment and how school settings can be leveraged to enhance prevention measures. Lastly, it examines federal and state prevention efforts and social media’s role in the drug crisis.

How have substance use and related deaths among adolescents changed in recent years?

Adolescent drug fatalities more than doubled in recent years – primarily due to opioids – but slightly decreased by the end of 2023. There were 708 adolescents drug fatalities in 2023, compared to 721 in 2022 (Figure 1). Additionally, a recent KFF analysis found that opioid-related deaths among adolescents decreased in the second half of 2023. Although these findings represent the first decrease in drug overdose fatalities in recent years, they remain more than twice as high as the number of adolescent overdose fatalities prior to the pandemic (708 deaths in 2023 vs. 282 deaths in 2019, Figure 1).

Fentanyl overdose deaths increased by 2% from 2022 to 2023, marking the smallest annual increase in fentanyl deaths among adolescents since the pandemic began. The synthetic opioid, fentanyl, has largely driven the increase in adolescent drug fatalities since the pandemic began. In the first year of the pandemic, adolescent overdose deaths involving fentanyl increased by 177% (from 128 deaths in 2019 to 354 in 2020, Figure 1). While these deaths remain higher than pre-pandemic levels, the increase slowed to 2% from 2022 to 2023 (527 and 539 deaths, respectively).

The share of all drug overdose deaths that involved fentanyl increased faster among adolescents than adults in recent years (Figure 2). Fentanyl deaths as a share of all adolescent drug overdose deaths increased significantly from 32% in 2018 to 65% in 2020. This increase marked the first time the share of drug fatalities involving fentanyl was higher among adolescents than adults (65% vs 62% in 2020). This gap has continued to slowly widen – in 2023, 76% and 69% of adolescent and adult drug fatalities involved fentanyl, respectively. While the share of fentanyl deaths increased more among adolescents than adults over time, the number and rates of these deaths remains much lower among adolescents compared to adults (539 vs. 72,000 deaths; and 2.1 vs. 27.6 deaths per 100,000 in 2023).

Adolescents may obtain drugs through social media, and these drugs are often contaminated with fentanyl. In 2023, seven out of every ten counterfeit opioid pills were found by the Drug Enforcement Administration to contain a potentially deadly dose of the drug. Fentanyl is exceedingly lethal and is often used to lace drugs because it is cheap and highly potent. With the onset of the pandemic, fentanyl spread quickly into drug supplies and is often trafficked by U.S. citizens (although misinformation incorrectly links the spread of fentanyl to undocumented immigrants). Adolescent fentanyl overdoses are thought to be mostly accidental, as teens search for prescription opioids or other drugs, either for recreational or self-medication purposes, but instead encounter fentanyl-contaminated pills. Adolescents may acquire drugs through social media platforms, which are frequently scrutinized for lacking regulation around illegal drug sales. The National Crime Prevention Council estimates that eight in ten teen and young adult fentanyl overdose deaths are associated with social media contact.

Despite the increase in drug overdose deaths among adolescents in recent years, their use of drugs and alcohol has slightly declined (Figure 3). In 2023, 10% of high school students reported ever using select illicit drugs, including cocaine, heroin, inhalants, methamphetamines, ecstasy, or hallucinogens, a slight decrease from 2017 (13%). Declines were also reported in opioid misuse (14% vs. 12%) and current alcohol use (30% vs. 22%) among high school students during the same period. Marijuana use has fluctuated, but ultimately decreased slightly since 2017 (20% vs. 17% in 2023). However, adolescent marijuana use may be linked to the onset of psychotic disorders, including depression and suicidality. Among high school students, the use of e-cigarettes declined from 14% in 2022 to 10% in 2023, although e-cigarettes remain the most often used tobacco product among this population in recent years. Factors that may have contributed to the overall decline in substance use among adolescents include public education initiatives and earlier intervention.

As adolescent substance use and related deaths showed slight signs of improvement in 2023, so did adolescent mental health. The share of high school students reporting feelings of sadness and hopelessness – which can be indicative of depressive disorder – increased from 30% in 2013 to 42% in 2021, before slightly declining to 40% in 2023. The co-occurrence of poor mental health and substance use is common, with one in five youth who had a major depressive episode in the last year also having a substance use disorder. In a recent, CDC convenience sample survey of teens (ages 13 to 18) who used substances in the last 30 days, many teenagers reported using substances to cope with negative emotions. Although it is too early to know whether adolescent substance use and poor mental health will continue to decline, efforts to identify and harness the driving factors behind this change may help continue the downward trend.

How and where do adolescents receive substance use messaging and treatment?

More than 6 in 10 adolescents report receiving information on drug and alcohol use disorder and prevention in school (Figure 4). This information is disseminated in multiple forms, including special substance use education classes, substance use-related films, lectures, and discussions outside of class, or substance use curricula integrated into health or physical education classes. A similar share of adolescents (63%) viewed messaging on substance use prevention outside of schools, while approximately half spoke with their parents on substance use harms (51%), and a small share participated in prevention programs outside of school settings (7%).

In 2023, only 2 out of 10 adolescents with a substance use disorder received treatment in the past year. In 2023, 8.5% of adolescents (or 2.2 million) had a substance use disorder in the past year.¹ Among these adolescents, 19.3% (or 423,000) received substance use disorder treatment in the past year.

Adolescents face a number of barriers to substance use treatment, including limited access to residential treatment facilities and buprenorphine. Among the total adolescent population, treatment for any substance use issue was more commonly received in an outpatient setting (3.3%) (i.e. at a medical clinic, doctor’s office, or therapist’s office), followed by an inpatient setting (1.4%) (i.e. at a hospital or residential treatment center) in 2023. Many residential addiction treatment facilities do not accept adolescent patients, and among facilities that do, beds may not be immediately available. The number of treatment facilities by state varies greatly, as do costs. Additionally, few facilities provide buprenorphine, a medication that can reduce withdrawal symptoms and cravings, to adolescents with opioid use disorder or discontinue it prior to discharge. Buprenorphine, a standard treatment for opioid use disorder is not approved for use by those under the age of 16, though it is recommended by the Society for Adolescent Health and Medicine. Still, some pediatricians feel uncomfortable prescribing it to adolescent patients.

Which efforts have been implemented in response to the adolescent drug crisis?

Recent federal efforts, including proposed bipartisan legislation, aim to strengthen youth substance use prevention programs in schools. The bipartisan Keeping Drugs Out of Schools Act was recently introduced, requesting federal authorization of 7 million dollars per year over 5 years for elementary, middle, and high schools to improve their drug prevention programs. The Biden-Harris administration also continues to respond to the youth drug crisis, most recently by allocating $94 million to community efforts to prevent youth overdoses via the Drug Free Communities Support Program, an initiative that often involves partnering with school districts to reduce youth substance use. Further, the Biden-Harris administration’s Safer Communities Act facilitated expansions of behavioral health services in schools through Medicaid resources.

Many states have policies allowing schools to stock naloxone (the opioid overdose reversal drug), an effort that is supported by the Biden-Harris administration, American Medical Association, and National Association of School Nurses. Most states have passed laws explicitly allowing schools to stock, naloxone, but only a few states, including Rhode Island and Washington, require it. Additionally, as of 2023, just over half of the nation’s largest school districts reported they mandate stocking naloxone. Several school districts, including, most recently, Virginia’s Loudon County School Board, have proposed or passed policies allowing students to carry and administer naloxone at school, after meeting certain requirements such as completing overdose-recognition training and obtaining written permission from their guardians. Some states, such as Washington and Oregon, have also passed legislation that integrates fentanyl education into school curricula. Among schools that do not stock naloxone, some worry that doing so will impact their image and label the school as having a drug problem, while others believe that there are more effective uses for limited school funds, as schools are fairly low frequency overdose locations.

Outside of schools, federal and state lawmakers are attempting to address adolescent substance use through online safety legislation. At the federal level, accompanied by the Surgeon General’s advisory on social media and youth mental health, the Biden-Harris Administration announced the Kids Online Health and Safety Task Force, which aims to enhance the health and safety of children on the internet. Similarly, the Kids Online Safety Act, a bill designed to increase regulation and accountability for social media companies, has been passed by the Senate, and President Biden stated he will sign it if it passes the House. Additionally, senators have introduced bipartisan legislation that aims to protect the privacy and wellbeing of children online. Multiple states have introduced legislation focused on media literacy, age verification, and the online distribution of controlled substances. Social media platforms are facing pressure from parents and lawmakers alike to increase regulation and to prevent online drug sales. These tech companies are protected by Section 230 of the Communications Decency Act, which states that they are not liable for material posted on their platforms by third parties. In July of 2024, the Supreme Court turned away a case that would have warranted a thorough review of Section 230, thereby preserving the immunity of these social platforms. With mounting pressure, some social media companies are creating safety features to protect young users, including Meta’s recently announced Teen Accounts feature.