Alcohol and Drug Use Among High School Students Before and During COVID-19

Key findings

• In 2021, about one in three U.S. high school students (30%) had drunk alcohol, used marijuana or misused prescription opioids in the past 30 days.
• Substance use had been declining for a decade before the COVID-19 pandemic, and most measures fell further from 2019 to 2021. Lifetime inhalant use was the exception: it rose.
• Among students using any of those three substances, 35.1% used two or more — most often alcohol and marijuana together.
• Use differed by sex, race and ethnicity, and sexual identity. Female students, and students identifying as lesbian, gay or bisexual, reported more use of most substances.

Why it was studied

Adolescence is a critical time of physical, cognitive, social and emotional development, and often when risky behaviors begin: most adolescents use some substance before finishing high school. Substance use in adolescence is linked with mental health problems, teen pregnancy, sexually transmitted diseases, delinquency, violence and poor school performance, and starting young raises the risk of use — and of substance use disorders — in adulthood.

• Overdose deaths among adolescents have risen dramatically. The Drug Enforcement Administration has warned of easily available counterfeit pills, made to look like commonly misused prescription medicines, that contain highly lethal substances such as illicit fentanyl.
• High-alcohol products have come onto the market, and alcohol-related deaths among adolescents have risen.
• In 2021, CDC's Adolescent Behaviors and Experiences Survey found students facing poor mental health, persistent sadness or hopelessness, and physical and emotional abuse during the pandemic — all risk factors for substance use — while remote schooling, isolation and canceled events may have added risk. One third of students in that survey who had ever used alcohol or drugs used them more during the pandemic.
• Earlier pandemic studies disagreed: one national survey found declines, another found more frequent use, and a third found no change.

The numbers

Ever used, 2021: alcohol 47.4%, marijuana 27.8%, prescription opioid misuse 12.2%, inhalants 8.1% (up from 6.4% in 2019), synthetic marijuana 6.5%, ecstasy 2.9%, cocaine 2.5%, methamphetamine 1.8%, injection drug use 1.4%, heroin 1.3%. From 2019 to 2021, lifetime use of alcohol, marijuana and cocaine and lifetime prescription opioid misuse fell.

The long view: every measure with trend data fell over the years measured — mostly 2009–2021. Past-month alcohol use went from 41.8% in 2009 to 22.7% in 2021, and lifetime alcohol use from 68.4% to 47.4%.

By sex

In 2021, female students reported more past-month use than males of alcohol (26.8% vs 18.8%), marijuana (17.8% vs 13.6%), binge drinking (12.2% vs 9.0%) and prescription opioid misuse (8.0% vs 4.0%), and more lifetime use of alcohol, marijuana, prescription opioids and inhalants (9.4% vs 6.8%). Male students reported more lifetime heroin use (1.6% vs 0.8%) and injection drug use (1.7% vs 0.9%).

From 2019 to 2021, past-month alcohol use and lifetime alcohol and marijuana use fell for both. Among males, binge drinking fell 3.7 percentage points — a 30% relative drop — and prescription opioid misuse 2.1 points, also 30%; lifetime ecstasy, cocaine and prescription opioid misuse fell too. Among females, lifetime inhalant use rose 2.5 points — a 40% relative increase.

By race and ethnicity

• Black students reported more past-month marijuana use (20.5%) than Hispanic (16.7%) and White (14.8%) students, but less past-month alcohol use (13.2%, against 25.9% of White and 22.9% of Hispanic students).
• White students reported less prescription opioid misuse (4.6%) than Black (8.6%) and Hispanic (8.3%) students.
• From 2019 to 2021, lifetime alcohol use fell in all three groups. Past-month and lifetime marijuana use fell among White and Hispanic students but not Black students. White students binge-drank less but reported more lifetime inhalant use; Hispanic students reported less lifetime ecstasy, cocaine and synthetic marijuana use; Black students reported less lifetime cocaine, methamphetamine and heroin use.

Students of other races and multiracial students were too few to analyze for most measures.

By sexual identity

Students identifying as lesbian, gay or bisexual reported more of every kind of substance use than heterosexual students — past-month marijuana use of 25.6% against 14.0%, for example, and lifetime prescription opioid misuse of 21.5% against 9.4%. Students identifying as questioning or other reported more past-month marijuana use and prescription opioid misuse than heterosexual students, but less past-month alcohol use, marijuana use and binge drinking than lesbian, gay or bisexual students. Only 2021 figures are given, because the survey's question on sexual identity changed.

Using more than one

Co-occurring substance use among high school students who reported any past-month use, 2021. Figure from the CDC report.

Among students who had used alcohol or marijuana or misused prescription opioids in the past month, 30.2% had used alcohol and marijuana, 7.9% alcohol and prescription opioids, 6.7% marijuana and prescription opioids, and 4.8% all three. That matters: combining substances raises the risk of health problems and overdose, and can strengthen their effects when they're used at the same time. A national survey found that about 40% of adolescents and adults who both drank and misused prescription pain relievers had misused them while drinking or within a couple of hours of it.

What might explain the trends

• Less access: during the pandemic, less contact with peers and more parental supervision may have cut use. Inhalants, found in most homes, stayed within reach — which may explain their rise. As social life resumes, use could return to prepandemic levels.
• Unequal trends may reflect worsening health inequities — access to prevention and treatment, racism and historical trauma, economic hardship — and the pandemic's uneven toll, such as parents and caregivers working on the front line, or families that suffered severe COVID-19 illness and death. Higher use among lesbian, gay and bisexual students, as in 2019, may reflect more violence, victimization, discrimination, adversity and isolation.
• Overdose risk: prescription opioid misuse didn't change, but adolescent overdose deaths have risen alongside counterfeit pills containing illicitly made fentanyl. Teens urgently need to be warned about lethal drugs disguised as common prescription pills, and to have more access to naloxone and fentanyl test strips.

What works

• Connection: feeling connected to family, positive peers, school and community helps protect against adverse childhood experiences, poor mental health and risk behaviors, including substance use.
• Families: programs that build parents' communication, monitoring and modeling of positive problem-solving and coping.
• Schools: a positive school climate and connectedness, with effective health education — CDC's What Works in Schools approach, for one — plus access to a counselor or psychologist, school policies on tobacco, alcohol and marijuana, and evidence-based prevention programs. Community–school partnerships such as PROSPER and Communities That Care have had protective effects into adulthood.
• Policy: fewer places selling alcohol, higher alcohol taxes, stronger enforcement of laws against selling alcohol and marijuana to minors, and enforcement of measures such as prescription drug monitoring programs.
• Tailoring prevention to different groups, alongside broader strategies that prevent adverse childhood experiences.

About the survey

The Youth Risk Behavior Survey has been run every two years since 1991, in a nationally representative sample of public and private school students in grades 9–12 in the 50 states and the District of Columbia; 17,232 students responded in 2021. Its limits here: the opioid questions give only opioid examples, so misuse may be overestimated if students counted non-opioid pain medicines; much data was missing for some measures; and the 2021 change to the sexual identity question rules out comparison with earlier years.

Sources

Based on Brooke E. Hoots, Jingjing Li, Marci Feldman Hertz, Marissa B. Esser, Adriana Rico, Evelyn Y. Zavala and Christopher M. Jones, "Alcohol and Other Substance Use Before and During the COVID-19 Pandemic Among High School Students — Youth Risk Behavior Survey, United States, 2021," MMWR Supplements, Centers for Disease Control and Prevention, as corrected by a later erratum; a work of the United States government in the public domain. Its social media graphic, built on a stock photograph, is not reproduced.