From 2009 to 2019, Youth Risk Behavior Survey data show lifetime illicit drug use among U.S. high school students declined from 20 to 15% (Centers for Disease Control and Prevention [CDC], n.d.). This shows great progress for U.S. youth aged approximately 14 to 18; however, illicit drug use continues to be a problem in some U.S. communities (Center for Behavioral Health Statistics and Quality [CBHSQ], 2020). Although not all illicit drugs are monitored in every state across all years, findings from the national Youth Risk Behavior Survey (YRBS) showed declines from 2009 to 2021 in lifetime use of inhalants, ecstasy, cocaine, methamphetamine, heroin, and prescription opioids among high school students (Hoots et al., 2023). Some state-level prevalence estimates can be monitored using maps of YRBS results, and reveals a group of states in the southeast (Alabama, Georgia, Louisiana, Mississippi, and South Carolina) with high prevalence of lifetime inhalant, ecstasy, cocaine, methamphetamine, and heroin use (CDC, 2022c).

Early initiation of any drug use is a strong predictor of the development of a substance use disorder (CDC, 2022b), and adolescents who use substances are more likely to face behavioral, cognitive, and mental health issues than their peers who do not use drugs (CDC, 2022b). Further, youth who use substances are at risk for delinquency, academic underachievement, violence, and sexually transmitted diseases (Office of the Surgeon General [OSG], 2016). Youth at high risk for substance use include high school students who identify as lesbian, gay, or bisexual (CDC, n.d.) or experience homelessness (Smith-Grant et al., 2022), and adolescents in foster care (Keller et al., 2010) or in the juvenile justice system (Field MB, 2023). Some of the highest high school dropout rates from 2013 to 2017 were found in states in the southeast (National Center for Education Statistics, n.d.), and youth who drop out of high school have higher rates of illicit drug use (Tice et al., 2013).

Other attributes of the southeastern U.S. may contribute to substance use among youth, including higher rates of poverty than the national average, lower rates of insurance coverage, including among youth (Artiga, 2016), high rates of opioid prescribing (CDC, 2021b), and overall worse health outcomes (Artiga, 2016). This is compounded by intersecting factors including racism, poor health behaviors, and lack of public health investment (Harris et al., 2016; Leider et al., 2020). Prevention scientists have outlined an opportunity for dismantling racism and discrimination (Murry et al., 2024). Thus, the objective of this study was to determine if decreasing illicit drug use among high school students occurring from 2009 to 2019 at the national level also occurred in five southeastern states. The current study focused on select illicit drugs (e.g., methamphetamines, cocaine, ecstasy, and inhalants) because regulated substances (e.g., marijuana, alcohol) often have state-level policies that would impact changes in prevalence differently in each state.

This study used data from the 2009 and 2019 U.S. Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System (YRBSS) (Underwood et al., 2020). This system consists of the national Youth Risk Behavior Survey (YRBS), which is conducted by CDC, and site surveys which are state, territorial, tribal, and school district YRBSs conducted by education and health agencies in those jurisdictions. The national survey and site surveys are school-based, anonymous surveys that use sampling strategies designed to provide data representative of high school students in grades 9–12 in that jurisdiction. Surveys are conducted every other year, typically in odd years (Centers for Disease Control and Prevention, 2023b; Underwood et al., 2020).

Lifetime use of methamphetamines, cocaine, ecstasy, or inhalants was lower in 2019 compared to 2009 among U.S. high school students overall (p < 0.01 for all illicit drugs; Table 1). Other than students in Alabama reporting increased methamphetamine use (5.3% in 2009 vs. 10.4% in 2019; p = 0.03) and students in Georgia reporting decreased ecstasy (6.5% in 2009 vs. 5.1% in 2019; p = 0.04) and inhalant (11.6% in 2009 vs. 7.5% in 2019; p < 0.01) use, illicit drug use patterns did not change significantly in each of the five states in the southeast from 2009 to 2019.

When all five states in the southeast were combined (hereafter referred to as “the southeast”), lifetime methamphetamine use remained stable from 2009 (4.8%) to 2019 (6.2%) after adjustment for age and sex (p = 0.11), even as it was lower in the U.S. overall in 2019 (2.1%) compared to 2009 (4.1%)(p < 0.01; Table 1). In the southeast, adjusted results for methamphetamine use were found to be sensitive to which states were included in the analysis (Table 2). A significant increase in methamphetamine use was found when Georgia was excluded (p = 0.03); however, exclusion of other states produced results consistent with the overall finding.

Lifetime use of cocaine, ecstasy, and inhalants also remained stable in the southeast in adjusted analyses while decreasing in the U.S. overall (Table 1; Fig. 1). Results for cocaine and ecstasy use were not sensitive to exclusion of any certain state in the southeast (Table 2). Overall results for inhalant use were close to the cut-off for statistical significance (p = 0.05) and conclusions were sensitive to which states were included in the analysis. A decrease in inhalant use was observed in the southeast when Alabama (p < 0.01) or Louisiana (p = 0.04) were excluded; however, exclusion of other states produced results consistent with the overall finding.

Demographic differences between students in the southeast and students in the U.S. were examined separately in 2009 and 2019 (data not shown). In both years, no differences by sex were found. The southeast had more students aged 16 or older compared to the U.S. in 2009 (68.9% vs. 63.7%, respectively) whereas in 2019, the percentages were similar (63.4% vs. 63.0%, respectively). Race/ethnicity differed between the southeast and the U.S. in both years. Students in the southeast were more likely to report Black race compared to students in the U.S. but were less likely to belong to other groups of color (Hispanic, American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander).

Stratifying by demographic groups, lifetime illicit drug use prevalence between students in the southeast and students in the U.S. were examined separately in 2009 and 2019. In Table 3, results among males and females are presented, followed by results in younger students (aged under 16 years) and older students (aged 16 or older). Finally, results among each racial/ethnic group for the southeast and U.S. are shown in Table 4.

Among both males and females, lifetime use of methamphetamines, cocaine, and ecstasy was similar between the southeast compared to the U.S. in 2009 but were each significantly higher in the southeast compared to the U.S. in 2019 (p < 0.01; Table 3). For inhalant use, male students in the southeast were more likely than male students in the U.S. to report use in both 2009 (13.0% vs. 10.6%, respectively; p = 0.02) and 2019 (11.2% vs. 5.7%, respectively; p < 0.01); female students in the southeast were more likely than female students in the U.S. to use inhalants in 2009 (9.7% vs. 12.9%, respectively; p < 0.01) but not in 2019 (8.5% vs. 6.9%, respectively; p = 0.08).

The difference between the southeast and the U.S. was evident among younger students (aged under 16 years) and older students (aged 16 or older, Table 3). Lifetime use of each of the four illicit drugs was similar in 2009 but in 2019 each illicit drug was more commonly used in the southeast compared to the U.S. For example, among older students, lifetime methamphetamine use was similar in 2009 (4.9% in the southeast and 4.4% in the U.S. overall; p = 0.33) but in 2019 use was higher in the southeast (6.3% vs. 2.3%; p < 0.01).

Among Black students, results were calculated in two different ways depending on whether analysis was restricted to non-Hispanic students reporting a single race, or no restrictions were applied (Table 4). For either classification, use of each of the four illicit drugs was similar among Black students in the southeast compared to the U.S. in 2009. In 2019, prevalence estimates were higher in the southeast compared to the U.S. for all four illicit drugs for unrestricted Black race (p < 0.05). Among non-Hispanic, single race Black students, differences in 2019 between the southeast and the U.S. for cocaine (6.6% vs. 4.0%; p = 0.03) and inhalants (10.8% vs. 7.2%; p = 0.01) were significant but methamphetamines (6.6% vs. 3.8%) and ecstasy (6.2% vs. 3.8%) were not different (p = 0.05).

Among non-Hispanic, single race White students, lifetime methamphetamine and ecstasy use were more common in the southeast compared to the U.S. overall in both 2009 and 2019. For cocaine and inhalants, use was similar in 2009 but higher in the southeast in 2019.

Among Hispanic students (of any race), methamphetamines, ecstasy, and inhalants were similar in the southeast and U.S. in 2009 and higher in the southeast in 2019. For cocaine, use was similar in the southeast and the U.S. at both time points. Among Native Hawaiian or other Pacific Islander students, only cocaine use was higher in the southeast than the U.S. in 2019 (18.8% vs. 7.3%; p < 0.05).

Previous reports have shown decreases in lifetime use of methamphetamines, cocaine, ecstasy, and inhalants from 2009 to 2019 among U.S. high school students (CDC, n.d.), but this study shows that the prevalence of these four illicit drugs did not change between 2009 and 2019 among students in the southeast (aggregate data from Alabama, Georgia, Louisiana, Mississippi, and South Carolina). In most cases, lifetime prevalence was similar in the southeast compared to the U.S. in 2009, but significantly higher in the southeast than the U.S. in 2019. The pattern was consistent for methamphetamines, cocaine, and ecstasy for males, females, younger students (aged under 16 years), and older students (aged 16 or older). The pattern was consistent for all illicit drugs among Black students (not restricted to non-Hispanic single race). The high prevalence of illicit drug use among Black students in the southeast compared to Black students in the U.S. overall, suggests that Black communities in the southeast would benefit from additional culturally relevant interventions to reduce disparities in youth illicit drug use, such as a family-centered approach that builds on the strengths of African-American families (Brody et al., 2012; University of Georgia, n.d.). Future studies can also take steps to ensure representation of racial and ethnic groups (Buckley et al., 2023) while examining if there are differences with experiences of racism or other adverse events in the southeast that could explain the higher prevalence of illicit drug use compared to other regions. Interventions used elsewhere may require rebuilding or retooling to improve health equity in the southeastern U.S. (Murry et al., 2024).

This study found a high prevalence of drug use among Native Hawaiian or other Pacific Islander students in the southeast in 2019. Other studies have found similarly high rates of illicit drug use among Pacific Islanders in the United States (Wu & Blazer, 2015). Pacific Islanders are among the fastest growing populations in the United States, and experienced the highest increase in drug overdose deaths from 2020 to 2021 (Spencer et al., 2022). More information is needed to understand why this population has a higher prevalence of drug use and what culturally relevant interventions may be effective.

Illicit drug use among youth by region are not frequently published. The Youth Risk Behavior Surveillance System supports uniform YRBS data collection among states²⁰ and provides the opportunity to study regional patterns. Continued efforts to harmonize and modernize national and state-level data collection for surveillance purposes will ensure that trends can be analyzed and directly compared across geographical regions.

Two other national surveillance systems that collect drug use data among youth include Monitoring the Future (Miech, 2020) and the National Survey on Drug Use and Health (NSDUH) (CBHSQ, 2020). Monitoring the Future data found that lifetime use of methamphetamines, cocaine, MDMA (ecstasy/molly), and inhalants decreased among students in 8th, 10th, and 12th grades from 2009 to 2019 (Miech, 2020). State level data from Monitoring the Future are not available. Similar to our findings, national NSDUH results show lifetime cocaine use decreased among adolescents aged 12–17 from 2009 to 2019; trends for other substances were not available (CBHSQ, 2020). For state-level estimates, NSDUH employs model-based small area estimation due to small sample sizes. Whereas our analysis found cocaine use remained stable, NSDUH estimates using this methodology showed past-year cocaine use decreased among adolescents aged 12–17 in Alabama, Georgia, Louisiana, Mississippi, and South Carolina (CBHSQ, 2020). However, direct state-level comparisons between YRBS and NSDUH are not possible because YRBS measures lifetime rather than past-year cocaine use. Also, YRBS state-level sample sizes are large enough to produce direct rather than model-based estimates. NSDUH state-level trends for lifetime cocaine use and for use of other substances were not available.

Outside the U.S., results from school surveys show mixed trends in substance use prior to the COVID-19 pandemic. Results from the European School Survey Project on Alcohol and Other Drugs show lifetime use of illicit drugs from 2007 to 2019 “slightly decreased or stabilized, except in Estonia, Montenegro, and Portugal” (ESPAD Group, 2020). The Ontario Student Drug Use and Health Survey showed most past year drug use measures showed a significant downward trend from 1999 to 2019 (Boak et al., 2020). Australian students aged 16–17 reported increased lifetime use of inhalants, cocaine, and ecstasy from 2011 to 2017 (Guerin & White, 2020).

This analysis did not include any information on drug use among high school students during the COVID-19 pandemic. The Adolescent Behaviors and Experiences Survey, administered by CDC during January – June 2021, found that nearly one-third of students who reported using marijuana, synthetic marijuana, cocaine, or other illegal drugs strongly agreed or agreed they used more drugs during the COVID-19 pandemic (Brener et al., 2022). Overall, research examining trends in substance use among adolescents during the pandemic have thus far yielded inconsistent results, and may be related to which substances (i.e., illicit drugs vs. prescription drugs) students were able to access during stay-at-home orders (Lundahl & Cannoy, 2021) or whether an adult was home while schools were closed.

This study could not examine changes in opioid use during 2009 to 2019 because questions about opioid use were not incorporated into the national and state YRBS until after 2009. Given the evolving overdose crisis (CDC, 2022a), this is a notable gap in this study. However, an increasing number of overdose deaths involve cocaine or psychostimulants such as methamphetamines or ecstasy (Spencer et al., 2022). In 2021, one in every five overdose deaths involved cocaine (Spencer et al., 2022). Although most racial and ethnic groups have seen increases in stimulant-involved overdoses, increases are among the highest in Black and Native American persons (CDC, 2021a). However, as the vast majority of overdose deaths involve opioids (Spencer et al., 2022), it would be useful if surveillance systems include questions on heroin use and prescription opioid misuse such as now found in the national YRBS.

Interventions aimed at curbing the opioid crisis may be a factor in declining rates in other substance use among high school students across the U.S. The Drug-Free Communities Program uses evidence-based frameworks to support local leaders in fostering safe environments for youth (CDC, 2024). Implementation of evidence-based programs at multiple levels of the social ecology may impact modifiable risk and protective factors as well as behaviors. Community factors (e.g., access to mental health and social services) may contribute to the higher prevalence of substance use in high school students in the southeast compared to the U.S. overall; regardless, the results of this study suggest that highly effective and culturally relevant interventions are needed for students in the southeast.

With a disproportionate number of historically underserved communities, the southeast may struggle to fully implement equitable public health interventions (Southern Poverty Law Center, 2021). For example, school interventions designed to develop social and emotional skills can help reduce substance use, but additional local efforts may be required to ensure programs are efficacious for students of color (Jones et al., 2021). Low resource interventions, such as standardized health education requirements for substance use prevention (Bruckner et al., 2014) or positive use of social media and peer-to-peer strategies, could be evaluated as approaches to reduce illicit drug use in particular communities (Evans et al., 2017; OSG, 2016). Availability of options for substance use disorder treatment for students of color, especially in rural areas, may also need to be addressed (Pullen & Oser, 2014).

This study is subject to three limitations. First, the YRBS is administered only to students who are enrolled in schools and attending in-person (Underwood et al., 2020). Drop-out students, including those engaged in the juvenile penal system, are at a higher risk of illicit drug use (Field MB, 2023; Tice et al., 2013), and are not eligible for the YRBS; thereby potentially leading to under-estimation of illicit drug use among high school age youth. Second, rural/urban status was unavailable in state-level YRBS data, therefore, analyses could not be conducted by this characteristic, although researchers have found that rural youth may have higher rates of substance use (Lambert et al., 2008) and rural/urban patterns of drug use vary by state (Hedegaard & Spencer, 2021). Lastly, these study findings (years 2009 and 2019) reflect pre-COVID-19 data; YRBS data comparing drug use during and after the pandemic have been published elsewhere (Hoots et al., 2023).

Interventions proven to impact youth at risk for substance use may not be reaching all populations. This study showed that between 2009 and 2019, there were reductions nationwide in lifetime use of methamphetamines, cocaine, ecstasy, and inhalants among high school students, but reductions occurring in the southeast were not statistically significant after adjustment for age and sex. To address the disparities in drug use between the southeast and the U.S. overall, a special focus on interventions that are tailored to communities in the southeast may be needed. Generally, awareness of the issues discovered in this study can prompt a closer look at the suitability and availability of drug use interventions in the region.