Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health

Key Substance Use and

Mental Health Indicators

in the United States:

Results from the 2020 National

Survey on Drug Use and Health

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health

Acknowledgments

is report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA),

U.S. Department of Health and Human Services (HHS), under Contract No. HHSS283201700002C with

RTI

International. Douglas Richesson and Jennifer M. Hoenig were the SAMHSA authors. Rong Cai served as the

government project oﬃcer and as the contracting oﬃcer representative.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied without permission

from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or

distributed for a fee without the speciﬁc, written authorization of the Oﬃce of Communications, SAMHSA, HHS.

Electronic Access and Printed Copies

is publication may be downloaded or ordered at https://store.samhsa.gov/. Or call SAMHSA at

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators

in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No.

PEP21-07-01-003, NSDUH Series H-56). Rockville, MD: Center for Behavioral Health Statistics and Quality,

Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/

Originating Ofﬁce

Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration,

5600 Fishers Lane, Room 15-E09D, Rockville, MD 20857. For questions about this report, please e-mail

[email protected]v.

Nondiscrimination Notice/Aviso de no discriminación

SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, or sex. SAMHSA cumple con las leyes federales de derechos civiles aplicables y no

discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Behavioral Health Statistics and Quality

Populations Survey Branch

Publication Number PEP21-07-01-003

October 2021

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | iii

Summary ��1

Introduction ��7

Survey Background ��7

Data Collection in the First Quarter of 2020 ��7

Changes to Data Collection Methods Because of the

COVID-19 Pandemic

��7

Data Presentation and Interpretation ��8

Presentation of National Estimates for 2020 ��8

Interpretation of Estimates for 2020��8

General Substance Use in the Past Month ��9

Tobacco Use or Nicotine Vaping in the Past Month ��10

Tobacco Product Use ��11

Cigarette Use ��11

Daily Cigarette Use ��11

Nicotine Vaping ��11

Underage Tobacco Use or Nicotine Vaping ��11

Alcohol Use in the Past Month ��12

Any Alcohol Use ��13

Binge Alcohol Use ��13

Heavy Alcohol Use ��13

Underage Alcohol Use ��13

Illicit Drug Use in the Past Year ��14

Any Illicit Drug Use ��14

Marijuana Use ��14

Cocaine Use ��15

Heroin Use ��15

Methamphetamine Use ��15

Hallucinogen Use ��16

Inhalant Use ��16

Misuse of Psychotherapeutic Drugs ��16

Stimulant Misuse ��17

Tranquilizer or Sedative Misuse ��17

Benzodiazepine Misuse ��18

Pain Reliever Misuse ��18

Misuse of Subtypes of Pain Relievers ��18

Main Reasons for the Last Misuse of Pain Relievers ��19

Source of the Last Pain Reliever That Was Misused ��19

Opioid Misuse ��20

Central Nervous System Stimulant Misuse ��20

Other Substance Use in the Past Year �� 21

GHB Use ��21

Nonprescription Cough and Cold Medicine Misuse ��21

Kratom Use ��22

Synthetic Marijuana Use ��22

Synthetic Stimulant Use ��22

Initiation of Substance Use ��23

Initiation of Cigarette Use ��23

Initiation of Alcohol Use ��23

Initiation of Marijuana Use ��23

Initiation of Cocaine Use ��24

Initiation of Heroin Use ��24

Initiation of Methamphetamine Use ��24

Initiation of Hallucinogen Use��24

Initiation of Inhalant Use ��25

Initiation of Prescription Stimulant Misuse ��25

Initiation of Prescription Tranquilizer or Sedative Misuse ��25

Initiation of Prescription Tranquilizer Misuse ��25

Initiation of Prescription Sedative Misuse ��25

Initiation of Prescription Pain Reliever Misuse ��25

Perceived Risk from Substance Use ��26

Substance Use Disorders in the Past Year ��27

Alcohol Use Disorder ��28

Illicit Drug Use Disorder��28

Marijuana Use Disorder ��29

Cocaine Use Disorder ��29

Heroin Use Disorder ��29

Methamphetamine Use Disorder ��30

Prescription Stimulant Use Disorder ��30

Prescription Tranquilizer Use Disorder or Sedative Use Disorder ��30

Prescription Pain Reliever Use Disorder ��30

Opioid Use Disorder ��30

Central Nervous System Stimulant Use Disorder ��30

Major Depressive Episode in the Past Year �� 31

MDE and MDE with Severe Impairment among Adolescents ��31

MDE and MDE with Severe Impairment among Adults ��31

Any Mental Illness among Adults in the Past Year ��32

Serious Mental Illness among Adults in the Past Year ��32

Co‑Occurring MDE and SUD among Adolescents ��33

Substance Use among Adolescents with MDE �� 33

Co‑Occurring Mental Health Issues and SUD among Adults ��34

Co-Occurring AMI and SUD ��34

Co-Occurring SMI and SUD ��34

Table of Contents

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Healthiv | October 2021

Substance Use among Adults, byMental Illness Status ��34

Suicidal Thoughts and Behaviors among Adults ��35

Serious Thoughts of Suicide among Adults ��35

Suicide Plans among Adults ��35

Suicide Attempts among Adults ��35

Suicidal Thoughts and Behaviors among Adults Because

of COVID-19

��35

Suicidal Thoughts and Behaviors among Adolescents �� 36

Substance Use Treatment in the Past Year ��37

Need for Substance Use Treatment ��37

Receipt of Substance Use Treatment ��38

Receipt of Any Substance Use Treatment ��38

Receipt of Any Substance Use Treatment among

People with a Past Year SUD

��38

Receipt of Substance Use Treatment at a Specialty Facility ��39

Receipt of Substance Use Treatment at a Specialty

Facility among People Who Needed Substance

Use Treatment

��39

Receipt of Virtual (Telehealth) Services for Substance

Use Treatment

��39

Perceived Need for Substance Use Treatment ��39

Reasons for Not Receiving Substance Use Treatment ��40

Medication-Assisted Treatment for Alcohol Use or Opioid Misuse ��40

Medication-Assisted Treatment for Alcohol Use ��40

Medication-Assisted Treatment for Opioid Misuse ��41

Mental Health Service Use in the Past Year ��41

Treatment for Depression among Adolescents ��41

Treatment for Depression among Adults ��42

Mental Health Service Use among Adolescents ��42

Receipt of Mental Health Services in Specialty and

Nonspecialty Settings among Adolescents

��43

Receipt of Virtual (Telehealth) Mental Health Services

among Adolescents

��43

Mental Health Service Use among Adults ��43

Receipt of Inpatient or Outpatient Mental Health

Services or Prescription Medication among Adults

��43

Receipt of Virtual (Telehealth) Mental Health Services

among Adults

��44

Mental Health Service Use among Adults with AMI ��44

Receipt of Inpatient or Outpatient Mental Health

Services or Prescription Medication among Adults with AMI

��44

Receipt of Virtual (Telehealth) Mental Health Services

among Adults with AMI

��44

Mental Health Service Use among Adults with SMI ��45

Receipt of Inpatient or Outpatient Mental Health

Services or Prescription Medication among Adults with SMI

��45

Receipt of Virtual (Telehealth) Mental Health Services

among Adults with SMI ��45

Perceived Unmet Need for Mental Health Services

among Adults with Mental Illness

��46

Perceived Unmet Need for Mental Health Services

among Adults with AMI

��46

Perceived Unmet Need for Mental Health Services

among Adults with SMI

��46

Reasons for Not Receiving Mental Health Services

among Adults with Mental Illness and a Perceived

Unmet Need

��47

Receipt of Services for Co‑Occurring Substance Use

Disorder and Mental Health Issues ��47

Receipt of Services among Adolescents with

Co-Occurring SUD and an MDE ��47

Receipt of Services among Adults with Co-Occurring SUD and AMI ��47

Receipt of Services among Adults with Co-Occurring SUD and SMI ��48

Perceived Recovery ��49

Substance Use, Mental Health Issues, and the COVID‑19

Pandemic ��49

Perceived Negative Effects on Mental Health Because of

the COVID-19 Pandemic ��50

Perceived Negative Effects on Mental Health Because

of the COVID-19 Pandemic among Adolescents

Aged 12 to 17

��50

Perceived Negative Effects on Mental Health Because

of the COVID-19 Pandemic among Adults Aged 18 or Older

��51

Perceived Effects on Substance Use Because of the

COVID-19 Pandemic

��51

Perceived Effects on Alcohol Use ��52

Perceived Effects on the Use of Drugs Other than Alcohol ��52

Perceived Effects on Access to Services Because of the

COVID-19 Pandemic

��53

Access to Substance Use Treatment ��53

Access to Mental Health Services ��54

Access to Medical Services ��54

Endnotes ��56

AppendixA: Special Tables of Estimates for Substance

Use and Mental Health Indicators in the United States �� A‑1

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 1

Summary

e National Survey on Drug Use and Health (NSDUH)

underwent some major methodological changes for 2020,

including a shift to web-based interviewing in Quarter 4 (i.e.,

October to December). In addition, 2020 marked the ﬁrst

year in which substance use disorders (SUDs) were evaluated

using criteria deﬁned in the Diagnostic and Statistical Manual

of Mental Disorders, 5th edition (DSM-5), as opposed to

criteria speciﬁed in the Diagnostic and Statistical Manual of

Mental Disorders, 4th edition (DSM-IV). Additional changes

were made to the questionnaire itself. erefore, care must be

taken when attempting to disentangle the eﬀects on estimates

due to real changes in the population (e.g., the coronavirus

disease 2019 [COVID-19] pandemic and other events) from

the eﬀects of these methodological changes.

Substance Use

• Among people aged 12 or older in 2020, 58.7 percent (or

162.5 million people) used tobacco, alcohol, or an illicit

drug in the past month (also deﬁned as “current use”),

including 50.0 percent (or 138.5 million people) who

drank alcohol, 18.7 percent (or 51.7 million people) who

used a tobacco product, and 13.5 percent (or 37.3 million

people) who used an illicit drug.

Tobacco Product Use or Nicotine Vaping

• Among people aged 12 or older in 2020, 20.7 percent (or

57.3 million people) used tobacco products or used an

e-cigarette or other vaping device to vape nicotine in the

past month.

• Among people in 2020 who used tobacco products or

vaped nicotine in the past month (i.e., nicotine product

users), the use of speciﬁc nicotine products varied by age

group. Nearly two thirds of adolescents aged 12 to 17 who

used nicotine products in the past month (63.1 percent)

vaped nicotine but did not use tobacco products. Among

adults aged 26 or older who used nicotine products in

the past month, however, 88.9 percent used only tobacco

products.

• Among people aged 12 or older in 2020 who used any

tobacco product in the past month (regardless of whether

they vaped nicotine), 65.3 percent smoked cigarettes but

did not use other tobacco products, 14.8 percent smoked

cigarettes and used some other type of tobacco product,

and 19.9 percent used only noncigarette tobacco products

(i.e., other tobacco products but not cigarettes).

• In 2020, 10.4 million people aged 12 or older (or

3.8 percent) used an e-cigarette or other vaping device to

vape nicotine in the past month. e percentage of people

who vaped nicotine was highest among young adults aged

18 to 25 (11.7 percent or 3.9 million people), followed

by adolescents aged 12 to 17 (5.1 percent or 1.3 million

people), then by adults aged 26 or older (2.4 percent or

5.2 million people).

• Among people aged 12 to 20 in 2020, 11.8 percent (or

4.4 million people) used tobacco products or used an

e-cigarette or other vaping device to vape nicotine in the

past month. Among people in this age group, 7.7 percent

(or 2.9 million people) vaped nicotine, 6.7 percent

(or 2.5 million people) used tobacco products, and

4.1 percent (or 1.5 million people) smoked cigarettes in

the past month.

Alcohol Use

• Among people aged 12 or older in 2020, 22.2 percent

(or 61.6 million people) were binge alcohol users in the

past month. e percentage was highest among young

adults aged 18 to 25 (31.4 percent or 10.5 million

people), followed by adults aged 26 or older (22.9 percent

or 50.0 million people), then by adolescents aged 12 to 17

(4.1 percent or 1.0 million people).

• Among the 138.5 million current alcohol users aged 12 or

older in 2020, 61.6 million people (or 44.4 percent) were

past month binge drinkers. Among past month binge

drinkers, 17.7 million people (28.8 percent of current

binge drinkers and 12.8 percent of current alcohol users)

were past month heavy drinkers.

• Among people aged 12 to 20 in 2020, 16.1 percent

(or 6.0 million people) were past month alcohol users.

Estimates of binge alcohol use and heavy alcohol

use in the past month among underage people were

9.2 percent (or 3.4 million people) and 1.8 percent (or

669,000 people), respectively.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health2 | October 2021

Illicit Drug Use

• Among people aged 12 or older in 2020, 21.4 percent (or

59.3 million people) used illicit drugs in the past year.

• In 2020, marijuana was the most commonly used illicit

drug, with 17.9 percent of people aged 12 or older

(or 49.6 million people) using it in the past year. e

percentage was highest among young adults aged 18 to

25 (34.5 percent or 11.6 million people), followed by

adults aged 26 or older (16.3 percent or 35.5 million

people), then by adolescents aged 12 to 17 (10.1 percent

or 2.5 million people).

• Among people aged 12 or older in 2020, 3.7 percent

(or 10.3 million people) misused central nervous

system (CNS) stimulants in the past year. Among the

10.3 million people who misused CNS stimulants in the

past year, about one third used only cocaine (32.4 percent

of CNS stimulant misusers or 3.3 million people),

about one third misused only prescription stimulants

(32.3 percent of CNS stimulant misusers or 3.3 million

people), and about 1 in 7 used only methamphetamine

(14.4 percent of CNS stimulant misusers or 1.5 million

people). An estimated 353,000 people used or misused

all three CNS stimulants in the past year (3.4 percent of

CNS stimulant misusers).

• Among people aged 12 or older in 2020, 3.4 percent

(or 9.5 million people) misused opioids (heroin or

prescription pain relievers) in the past year. Among the

9.5 million people who misused opioids in the past year,

9.3 million people misused prescription pain relievers

compared with 902,000 people who used heroin.

• Among people aged 12 or older in 2020, 3.3 percent (or

9.3 million people) misused prescription pain relievers in

the past year. e percentage was highest among young

adults aged 18 to 25 (4.1 percent or 1.4 million people),

followed by adults aged 26 or older (3.4 percent or

7.5 million people), then by adolescents aged 12 to 17

(1.6 percent or 396,000 people).

• In 2020, 2.6 percent of people aged 12 or older (or

7.1 million people) used hallucinogens in the past year.

e percentage among young adults aged 18 to 25

(7.3 percent or 2.4 million people) was higher than the

percentages among adolescents aged 12 to 17 (1.5 percent

or 370,000 people) or adults aged 26 or older (2.0 percent

or 4.3 million people).

Initiation of Substance Use

• Among people aged 12 or older in 2020, 1.3 million

people initiated cigarette smoking in the past year (i.e.,

never smoked cigarettes before the past 12 months). e

vast majority of people (approximately 90 percent of past

year initiates) tried cigarettes for the ﬁrst time by age 25.

Corresponding numbers of initiates of cigarette smoking

by age group were 385,000 adolescents aged 12 to 17,

752,000 young adults aged 18 to 25, and 127,000 adults

aged 26 or older.

• Among people aged 12 or older in 2020, 4.1 million

people initiated alcohol use in the past year, not counting

sips from another person’s drink. Consistent with the

pattern for initiation of cigarette smoking, relatively few

people started to use alcohol after age 25. Corresponding

numbers for initiation of alcohol use by age group were

1.8 million adolescents aged 12 to 17, 2.1 million young

adults aged 18 to 25, and 176,000 adults aged 26 or

older.

• Among people aged 12 or older in 2020, 2.8 million

people initiated marijuana use in the past year, including

1.0 million adolescents aged 12 to 17, 1.1 million young

adults aged 18 to 25, and 664,000 adults aged 26 or

older. Consistent with the pattern for cigarette smoking

and alcohol use, most people started using marijuana

before age 26.

• Among people aged 12 or older in 2020, 1.2 million

people initiated prescription pain reliever misuse in

the past year. Unlike initiates of cigarette, alcohol, and

marijuana use, nearly two thirds of past year initiates

tried prescription pain relievers for the ﬁrst time after age

25 (i.e., 774,000 adults aged 26 or older who initiated

prescription pain reliever misuse).

Perceived Risk from Substance Use

• Among people aged 12 or older in 2020, 70.7 percent of

people perceived great risk of harm from smoking one or

more packs of cigarettes a day, and 68.7 percent perceived

great risk from having four or ﬁve alcoholic drinks nearly

every day. Percentages of people who perceived great risk

from cocaine or heroin use once or twice a week were

84.7 and 93.2 percent, respectively. In contrast, about one

fourth of people (27.4 percent) perceived great risk from

smoking marijuana once or twice a week.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 3

• Adults aged 26 or older were more likely than adolescents

aged 12 to 17 or young adults aged 18 to 25 to perceive

great risk of harm from smoking one or more packs of

cigarettes per day or to perceive great risk of harm from

daily binge drinking.

• Young adults aged 18 to 25 in 2020 were less likely than

adolescents aged 12 to 17 or adults aged 26 or older

to perceive great risk of harm from smoking marijuana

weekly.

Substance Use Disorders in the Past Year

• As stated previously, the 2020 survey marked the ﬁrst year

in which SUDs were assessed using the criteria deﬁned

in DSM-5 instead of criteria speciﬁed in DSM-IV. is

change from DSM-IV to DSM-5 criteria for assessing

SUDs led to breaks in the comparability of 2020 SUD

estimates with estimates from prior years.

• In 2020, 40.3 million people aged 12 or older (or

14.5 percent) had an SUD in the past year, including

28.3 million who had alcohol use disorder, 18.4 million

who had an illicit drug use disorder, and 6.5 million

people who had both alcohol use disorder and an illicit

drug use disorder.

• In 2020, the percentage of people aged 12 or older with

an alcohol use disorder was highest among young adults

aged 18 to 25 (15.6 percent or 5.2 million people),

followed by adults aged 26 or older (10.3 percent or

22.4 million people), then by adolescents aged 12 to 17

(2.8 percent or 712,000 people). Young adults also were

more likely than adolescents or adults aged 26 or older to

have had at least one illicit drug use disorder in the past

year.

Major Depressive Episode

• Among adolescents aged 12 to 17 in 2020, 17.0 percent

(or 4.1 million people) had a past year major depressive

episode (MDE), and 12.0 percent (or 2.9 million people)

had a past year MDE with severe impairment.

• Among adults aged 18 or older in 2020, 8.4 percent

(or 21.0 million people) had a past year MDE, and

6.0 percent (or 14.8 million people) had a past year MDE

with severe impairment. Percentages for past year MDE

and MDE with severe impairment were highest among

young adults aged 18 to 25, followed by adults aged 26 to

49, then by adults aged 50 or older. Among young adults,

17.0 percent (or 5.6 million people) had a past year

MDE, and 12.1 percent (or 4.0 million people) had a

past year MDE with severe impairment.

Mental Illness among Adults

• Among adults aged 18 or older in 2020, 21.0 percent (or

52.9 million people) had any mental illness (AMI) and

5.6 percent (or 14.2 million people) had serious mental

illness (SMI) in the past year.

• Percentages of adults in 2020 with AMI or SMI in the

past year were highest among young adults aged 18 to

25, followed by adults aged 26 to 49, then by adults

aged 50 or older. Among young adults, 30.6 percent

(or 10.2 million people) had AMI, and 9.7 percent (or

3.3 million people) had SMI in the past year.

Co‑Occurring Mental Health Issues and Substance Use

Disorder

• Among adolescents aged 12 to 17 in 2020, 20.9 percent

(or 5.1 million people) had either an SUD or an MDE in

the past year, 14.4 percent (or 3.5 million people) had an

MDE but not an SUD, 3.7 percent (or 900,000 people)

had an SUD but not an MDE, and 2.7 percent (or

644,000 people) had both an MDE and an SUD in the

past year.

• Among adults aged 18 or older in 2020, 29.3 percent (or

73.8 million people) had either AMI or an SUD in the

past year, 14.2 percent (or 35.9 million people) had AMI

but not an SUD, 8.3 percent (or 20.9 million people) had

an SUD but not AMI, and 6.7 percent (or 17.0 million

people) had both AMI and an SUD.

• Among adults aged 18 or older in 2020, 18.4 percent (or

46.5 million people) had either SMI or an SUD in the

past year, 3.4 percent (or 8.5 million people) had SMI but

not an SUD, 12.8 percent (or 32.3 million people) had

an SUD but not SMI, and 2.2 percent (or 5.7 million

people) had both SMI and an SUD.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health4 | October 2021

Substance Use among People with Mental Health

Issues

• Among adolescents aged 12 to 17 in 2020, those with a

past year MDE were more likely than adolescents without

a past year MDE to be past year illicit drug users (28.6 vs.

10.7 percent) or past year marijuana users (22.0 vs.

7.9 percent). Adolescents with a past year MDE also were

more likely than those without a past year MDE to be

past month binge alcohol users (6.2 vs. 3.8 percent). In

addition, adolescents with a past year MDE were more

likely than those without a past year MDE to use tobacco

products or vape nicotine in the past month (12.9 vs.

5.1 percent).

• Among adults aged 18 or older in 2020, those with SMI

or AMI in the past year were more likely than those

with no mental illness in the past year to be past year

users of illicit drugs (47.8 percent for adults with SMI

and 39.8 percent for adults with AMI vs. 17.0 percent

for adults with no mental illness), past year users of

marijuana (39.2 and 32.8 percent vs. 14.6 percent), or

past year misusers of opioids (i.e., heroin users or misusers

of prescription pain relievers) (11.6 and 8.1 percent vs.

2.3 percent).

• Adults aged 18 or older in 2020 with SMI or AMI in the

past year were more likely than adults with no mental

illness in the past year to be past month binge alcohol

users (30.9 and 28.5 percent vs. 22.8 percent) and to

use tobacco products or vape nicotine in the past month

(37.4 and 30.9 percent vs. 19.6 percent).

Suicidal Thoughts and Behavior

• Among adults aged 18 or older in 2020, 4.9 percent (or

12.2 million people) had serious thoughts of suicide,

1.3 percent (or 3.2 million people) made a suicide plan,

and 0.5 percent (or 1.2 million people) attempted suicide

in the past year.

• Among young adults aged 18 to 25 in 2020, 11.3 percent

(or 3.8 million people) had serious thoughts of suicide,

4.0 percent (or 1.3 million people) made a suicide plan,

and 1.9 percent (or 627,000 people) attempted suicide in

the past year.

• Among adolescents aged 12 to 17 in 2020, 12.0 percent

(or 3.0 million people) had serious thoughts of suicide,

5.3 percent (or 1.3 million people) made a suicide plan,

and 2.5 percent (or 629,000 people) attempted suicide in

the past year.

Substance Use Treatment

• People were classiﬁed as needing substance use treatment

if they had an SUD in the past year or if they received

substance use treatment at a specialty facility in the

past year. Among people aged 12 or older in 2020,

14.9 percent (or 41.1 million people) needed substance

use treatment in the past year.

• Among people aged 12 or older in 2020, 1.4 percent (or

4.0 million people) received any substance use treatment

in the past year, and 1.0 percent (or 2.7 million people)

received substance use treatment at a specialty facility in

the past year.

• Among the 38.4 million people aged 12 or older

in 2020 with an SUD in the past year who did not

receive treatment at a specialty facility, 97.5 percent

(or 37.5 million people) did not feel that they needed

treatment, 1.9 percent (or 737,000 people) felt that

they needed treatment but did not make an eﬀort to

get treatment, and 0.5 percent (or 211,000 people) felt

that they needed treatment and made an eﬀort to get

treatment.

Treatment for Depression

• Among the 4.1 million adolescents aged 12 to 17 in 2020

who had a past year MDE, 41.6 percent (or 1.7 million

people) received treatment for depression in the past year.

• Among the 21.0 million adults aged 18 or older in 2020

who had a past year MDE, 66.0 percent (or 13.8 million

people) received treatment for depression in the past year.

Mental Health Services

• In 2020, 17.3 percent of adolescents aged 12 to 17 (or

4.2 million people) received mental health services in a

specialty setting, including 16.6 percent (or 4.1 million

people) who received mental health treatment in an

outpatient setting and 2.1 percent (or 510,000 people)

who received mental health treatment in an inpatient

setting.

• In 2020, 16.9 percent of adults aged 18 or older (or

41.4 million people) received inpatient or outpatient

mental health services or took prescription medication

in the past year for a mental health issue, including

0.9 percent (or 2.2 million people) who received inpatient

services, 8.8 percent (or 21.5 million people) who received

outpatient services, and 13.8 percent (or 33.8 million

people) who took prescription medication.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 5

• Among the 52.9 million adults aged 18 or older in 2020

with AMI in the past year, 46.2 percent (or 24.3 million

people) received inpatient or outpatient mental health

services or took prescription medication in the past

year for a mental health issue. However, among the

14.2 million adults aged 18 or older in 2020 with SMI in

the past year, 35.5 percent (or 5.0 million people) did not

receive any of these services in the past year.

Perceived Unmet Need for Mental Health Services

among Adults with Mental Illness

• Among the 52.9 million adults aged 18 or older in 2020

with AMI in the past year, 30.5 percent (or 16.1 million

people) perceived an unmet need for mental health

services in the past year.

• Among the 14.2 million adults aged 18 or older in 2020

with SMI in the past year, 49.7 percent (or 7.0 million

people) perceived an unmet need for mental health

services in the past year.

Receipt of Services for Co‑Occurring Substance Use

Disorder and Mental Health Issues

• Among the 644,000 adolescents aged 12 to 17 in

2020 with a co-occurring SUD and an MDE in the

past year, 69.0 percent (or 438,000 people) received

either substance use treatment at a specialty facility or

mental health services in the past year, 66.8 percent (or

424,000 people) received only mental health services, and

0.9 percent (or 6,000 people) received both substance use

treatment at a specialty facility and mental health services.

• Among the 17.0 million adults aged 18 or older in 2020

with a co-occurring SUD and AMI in the past year,

50.5 percent (or 8.5 million people) received either

substance use treatment at a specialty facility or mental

health services in the past year, including 42.3 percent

(or 7.2 million people) who received only mental health

services, 2.5 percent (or 423,000 people) who received

only substance use treatment at a specialty facility, and

5.7 percent (or 960,000 people) who received both

substance use treatment at a specialty facility and mental

health services.

• Among the 5.7 million adults aged 18 or older in 2020

who had a co-occurring SUD and SMI in the past year,

66.4 percent (or 3.7 million people) received either

substance use treatment at a specialty facility or mental

health services in the past year, including 55.4 percent

(or 3.1 million people) who received only mental health

services, 1.6 percent (or 89,000 people) who received

only substance use treatment at a specialty facility, and

9.3 percent (or 529,000 people) who received both

substance use treatment at a specialty facility and mental

health services.

Substance Use, Mental Health Issues, and the

COVID‑19 Pandemic

• In Quarter 4 of 2020, most adolescents aged 12 to 17

perceived at least some negative eﬀect of the COVID-19

pandemic on their mental health, including about 1 in

5 (18.3 percent or 4.5 million people) who perceived

that the COVID-19 pandemic negatively aﬀected their

mental health “quite a bit or a lot.” Adolescents who

had a past year MDE or a past year MDE with severe

impairment were more likely than those without a

past year MDE to perceive that the COVID-19 pandemic

negatively aﬀected their mental health “quite a bit or a

lot.”

• Similar to adolescents, most adults aged 18 or older in

Quarter 4 of 2020 perceived at least some negative eﬀect

of the COVID-19 pandemic on their mental health,

including about 1 in 5 (18.3 percent or 45.2 million

people) who perceived that the COVID-19 pandemic

negatively aﬀected their mental health “quite a bit or a

lot.” Adults with AMI or SMI in the past year were more

likely than those who did not have mental illness in the

past year to perceive that the COVID-19 pandemic

negatively aﬀected their mental health “quite a bit or a

lot.”

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health6 | October 2021

• Among people aged 12 or older in Quarter 4 of 2020

who drank alcohol in the past year, most perceived

that they drank “about the same” amount as they did

before the COVID-19 pandemic began (59.4 percent or

100.0 million people), but 15.4 percent (or 25.9 million

people) perceived that they drank “a little more or much

more.” e percentage of young adult alcohol users aged

18 to 25 who perceived that they drank “a little more

or much more” than they did before the COVID-19

pandemic began (18.2 percent or 3.7 million people)

was higher than the corresponding percentage among

adults aged 26 or older who used alcohol in the past year

(15.0 percent or 21.8 million people).

• Among people aged 12 or older in Quarter 4 of 2020 who

used drugs other than alcohol in the past year, more than

half (57.5 percent or 60.6 million people) perceived that

they used these drugs “about the same” as they did before

the COVID-19 pandemic began, but 10.3 percent (or

10.9 million people) perceived that they used these drugs

“a little more or much more.” e percentage of past year

users of drugs other than alcohol who perceived that they

used these drugs “a little more or much more” than they

did before the COVID-19 pandemic was higher among

adolescents aged 12 to 17 (15.2 percent or 665,000

people) and young adults aged 18 to 25 (18.7 percent or

2.5 million people) than among adults aged 26 or older

(8.8 percent or 7.7 million people).

• Among people aged 12 or older in Quarter 4 of 2020,

nearly 1 in 3 (31.3 percent or 84.6 million people)

had medical appointments moved from in person

to telehealth, and more than 1 in 4 (29.4 percent or

79.4 million people) experienced delays or cancellations

in medical appointments or preventive services. About

1 in 11 people (8.9 percent or 23.9 million people)

experienced delays in getting prescriptions, and 1 in 20

(5.6 percent or 15.1 million people) were unable to access

needed medical care resulting in a perceived moderate or

severe impact on health.

• Among adults aged 18 or older in Quarter 4 of 2020

who received mental health services in the past year,

more than half (58.3 percent or 26.6 million people)

had appointments moved from in person to telehealth,

more than 1 in 3 (38.7 percent or 17.7 million people)

experienced delays or cancellations in appointments,

about 1 in 6 (16.0 percent or 7.3 million people)

experienced delays in getting prescriptions, and about

1 in 10 (10.7 percent or 4.9 million people) were unable

to access needed care resulting in a perceived moderate to

severe impact on health.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 7

Introduction

Substance use and mental health issues have signiﬁcant

impacts on people, families, communities, and societies.

1,2,3,4

e National Survey on Drug Use and Health (NSDUH),

conducted annually by the Substance Abuse and Mental Health

Services Administration (SAMHSA), provides nationally

representative data on use of tobacco, alcohol, and illicit

drugs; substance use disorders (SUDs); receipt of substance

use treatment; mental health issues; and use of mental health

services among the civilian, noninsti

tu tionalized population

aged 12 or older in the United States. NSDUH estimates allow

researchers, clinicians, policymakers, and the general public to

better understand and improve the nation’s behavioral health.

Based on 2020 and earlier NSDUH data, this report

contains ﬁndings on key substance use and mental health

indicators in the United States. e 2020 NSDUH detailed

tables showing comprehensive substance use and mental

health-related estimates are available separately at https://

www.samhsa.gov/data/.

5

Survey Background

NSDUH is an annual survey sponsored by SAMHSA

within the U.S. Department of Health and Human Services

(HHS). NSDUH covers residents of households and

people in noninstitutional group settings (e.g., shelters,

boarding houses, college dormitories, migratory workers’

camps, halfway houses). e survey excludes people with

no ﬁxed address (e.g., people who are homeless and not in

shelters), military personnel on active duty, and residents

of institutional group settings, such as jails, nursing homes,

mental health institutions, and long-term care hospitals.

Data Collection in the First Quarter of 2020

NSDUH employs a stratiﬁed multistage area probability

sample designed to be representative of both the nation as

a whole and for each of the 50 states and the District of

Columbia. e 2020 NSDUH target sample of 67,500

people was allocated across three age groups, with 25 percent

allocated to adolescents aged 12 to 17, 25 percent allocated

to young adults aged 18 to 25, and 50 percent allocated to

adults aged 26 or older.

6

From January to March 2020 (i.e., the ﬁrst quarter of

2020), NSDUH was a face-to-face household interview

survey conducted in two phases: the screening phase and

the interview phase. Interviewers conducted a screening of a

sampled household with an adult resident (aged 18 or older)

in order to determine whether zero, one, or two household

residents aged 12 or older should be selected for the interview.

NSDUH collected in-person data using audio computer-

assisted self-interviewing (ACASI), in which respondents read

or listened to the questions on headphones and entered their

answers directly into a NSDUH laptop computer. ACASI was

designed for accurate reporting of information by providing

respondents with a highly private and conﬁdential mode for

responding to questions about illicit drug use, mental health

issues, and other sensitive behaviors. For certain sections of

the survey, in-person NSDUH interviews also used computer-

assisted personal interviewing (CAPI), in which interviewers

read less sensitive questions to respondents and entered the

respondents’ answers into a NSDUH laptop computer.

From January to March 2020, screening was completed at

35,304 addresses, and 15,628 completed interviews were

obtained, including 3,936 interviews from adolescents aged

12 to 17 and 11,692 interviews from adults aged 18 or older.

Weighted response rates for household screening and for

interviewing were 67.8 and 63.2 percent, respectively, for an

overall response rate of 42.9 percent for people aged 12 or

older. e weighted interview response rates were 70.5 percent

for adolescents and 62.5 percent for adults.

7

In-person data

collection was suspended on March 16, 2020, because of the

coronavirus disease 2019 (COVID-19) pandemic.

Changes to Data Collection Methods Because of the

COVID‑19 Pandemic

To protect the safety of ﬁeld staﬀ and survey participants

during the COVID-19 pandemic, SAMHSA decided to

suspend in-person NSDUH data collection on March

16, 2020. With administrative approval, a small-scale

data collection eﬀort was conducted from July 16 to 22,

2020, to assess the feasibility of safely resuming in-person

data collection. e small-scale data collection eﬀort was

conducted in selected counties of two states where data

collection was deemed safe based on state- and county-level

COVID-19 metrics collected by Johns Hopkins University.

8

For the remainder of 2020, however, it became clear that

conventional in-person data collection would be severely

limited due to the COVID-19 pandemic.

To reduce the impact on NSDUH data collection due to

the COVID-19 pandemic, SAMHSA approved the addition

of web-based data collection on September 11, 2020. In

Quarter 4 of 2020 (i.e., October to December), web-based

screening and interviewing became the primary forms of

NSDUH data collection. Conventional in-person data

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health8 | October 2021

collection was carried out wherever it was considered safe to

do so based on county- and state-level COVID-19 metrics.

6

In July 2020 for a small number of interviews, and

principally in October to December 2020, screening was

completed for 55,633 addresses, and 20,656 completed

interviews were obtained, including 2,401 interviews from

adolescents aged 12 to 17 and 18,255 interviews from adults

aged 18 or older. Weighted response rates for household

screening and for interviewing were 11.1 and 59.5 percent,

respectively, for an overall response rate of 6.6 percent for

people aged 12 or older. e weighted interview response

rates were 25.6 percent for adolescents and 62.9 percent for

adults.

7

Approximately 93 percent of these interviews were

completed via the web because of limitations on where it was

considered safe to conduct interviews in person.

Altogether for 2020, then, screening was completed for 90,937

addresses, and the ﬁnal sample consisted of 36,284 completed

interviews. ere were 6,337 interviews from adolescents

aged 12 to 17 and 29,947 interviews from adults aged 18 or

older. Weighted response rates for household screening and

for interviewing were 25.7 and 60.4 percent, respectively, for

an overall response rate of 15.5 percent for people aged 12 or

older. e weighted interview response rates were 36.8 percent

for adolescents and 62.8 percent for adults.

7,9

Further information about the 2020 NSDUH design and

methods can be found on the web at https://www.samhsa.

gov/data/.

10

Data Presentation and Interpretation

is report focuses on substance use and mental health

indicators in the United States based on NSDUH data

from 2020 and earlier years.

11

Estimates of substance use

and related treatment are presented for people aged 12 or

older, including adolescents and adults.

12

However, estimates

of mental health issues and mental health service use are

presented separately for adolescents aged 12 to 17 and adults

aged 18 or older because the two groups completed diﬀerent

sets of questions regarding mental health and mental health

service utilization. All estimates (e.g., percentages and

numbers) presented in the report are derived from survey

data that are subject to sampling errors and have met the

criteria for statistical precision.

13

Presentation of National Estimates for 2020

Appendix A contains special tables of estimates, including

estimates not found in the 2020 NSDUH detailed tables.

Because some estimates in Appendix A may not be found

in the detailed tables, Appendix A’s tables include standard

errors for the associated estimates.

14

e COVID-19 pandemic has made 2020 a unique year

within the history of NSDUH. Estimates for most measures

have been calculated using data from Quarters 1 and 4 of

2020. As mentioned previously, except for a very brief data

collection eﬀort that tested increased safety measures in

July, no data were collected in Quarters 2 and 3 (i.e., April

to September). e diﬀerence in data collection methods

between Quarter 1 and Quarter 4 aﬀected the procedures for

weighting the 2020 data to produce national estimates.

6

With the introduction of web-based interviewing, data

processing took into account the potential eﬀects of

survey mode

15

on responses.

10

In addition, questions were

developed to assess the speciﬁc eﬀects of the COVID-19

pandemic on respondents. Because these questions were

asked of respondents only in Quarter 4, only data from

Quarter 4 are available for these estimates. Sections of the

report indicate when estimates use data from Quarter 4 only.

Otherwise, the default for the report is to present estimates

using data from Quarters 1 and 4.

16

Interpretation of Estimates for 2020

NSDUH underwent some major methodological changes

for 2020. As noted previously, the COVID-19 pandemic

necessitated the introduction of web-based interviewing.

In addition, 2020 marked the ﬁrst year in which SUDs

were evaluated using criteria deﬁned in the Diagnostic

and Statistical Manual of Mental Disorders, 5th edition

(DSM-5),

17

as opposed to criteria speciﬁed in the

Diagnostic and Statistical Manual of Mental Disorders, 4th

edition (DSM-IV).

18

ere were additional changes to

the questionnaire itself (e.g., new questions about vaping

and the use of synthetic marijuana or synthetic stimulants,

additional questions to measure SUDs based on the DSM-5

criteria, new questions in Quarter 4 to assess the impact of

COVID-19 on people’s lives). Finally, there was a signiﬁcant

gap in data collection that might have missed seasonality

eﬀects on some estimates. erefore, care must be taken

when attempting to disentangle the eﬀects on estimates

due to real changes in the population (e.g., the COVID-19

pandemic, other events) from these methodological changes.

Researchers have raised concerns that the COVID-19

pandemic could have negative eﬀects on substance use and

mental health outcomes.

19,20,21

However, the methodological

changes for the 2020 NSDUH also can aﬀect the 2020

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 9

estimates. erefore, direct comparison of NSDUH

estimates in 2020 with those from prior years can be

misleading. An additional caveat is that events in the United

States related to the COVID-19 pandemic were not the only

ones in 2020 that could have aﬀected people’s substance

use and mental health. To that end, NSDUH estimates

principally describe conditions in the population but may not

explain the reasons behind the estimates.

Statistical tests for comparisons are presented in this

report where appropriate. Of note, statistical testing was

performed for comparisons of estimates across age groups

within 2020.

22

In these instances, statistically signiﬁcant

diﬀerences resulting from this testing are described using

terms such as “higher” or “lower.” Statements use terms

such as “similar” or “the same” when a diﬀerence was not

statistically signiﬁcant. However, the methodological changes

in 2020 because of the COVID-19 pandemic have created

major challenges for survey researchers and other data users

in interpreting estimates from the 2020 NSDUH. Particular

caution must be taken for multiyear trend analysis and the

comparison of the results from 2020 with those from any

prior survey years. Eﬀorts were made to present the results

by deﬁning measures for 2020 consistently with measures

in previous years wherever possible. Meanwhile, eﬀorts were

also made to point out the uniqueness of 2020 and the need

for caution when making comparisons.

General Substance Use in the Past Month

is section provides an overview of estimates according

to whether respondents aged 12 or older reported using

nicotine products (using tobacco products or nicotine

vaping), alcohol, or illicit drugs in the 30 days before the

NSDUH interview (i.e., in the past month, also referred to

as “current use”). Due to the very small amount of data that

are available from April to September 2020, caution must

be taken when interpreting estimates of substance use in the

past month. Additional information on the use of tobacco

products, alcohol, and illicit drugs is provided in other

sections of this report.

14

Past month tobacco use includes any use of the four tobacco

products in NSDUH: cigarettes, smokeless tobacco (such

as snuﬀ, dip, chewing tobacco, or snus), cigars, and pipe

tobacco. Past month nicotine vaping refers to the use of

an e-cigarette or other vaping device to vape nicotine or

tobacco. Past month alcohol use refers to having more

than a sip or two of any type of alcoholic drink (e.g., a

can or a bottle of beer, a glass of wine or a wine cooler,

a shot of liquor, or a mixed drink with liquor in it). Past

month illicit drug use includes any use of marijuana,

cocaine (including crack), heroin, hallucinogens, inhalants,

or methamphetamine, as well as misuse of prescription

stimulants, tranquilizers or sedatives (e.g., benzodiazepines),

or pain relievers. (See the section on the Misuse of

Psychotherapeutic Drugs for the deﬁnition of “misuse.”)

Tables in Appendix A also include estimates of past

month use for the following other substances: gamma

hydroxybutyrate (GHB), the misuse of nonprescription

cold and cough medicine, kratom, synthetic marijuana (fake

weed, K2, or Spice), and synthetic stimulants (“bath salts”

or ﬂakka). Estimates for the use or misuse of these other

substances are discussed later in the report for the past year

(rather than the past month) because of low prevalence

estimates in the past month for many of these substances.

Among people aged 12 or older in 2020, 58.7 percent (or

162.5 million people) used tobacco, alcohol, or an illicit drug

in the past month, 50.0 percent (or 138.5 million people)

drank alcohol in the past month, 18.7 percent (or 51.7 million

people) used a tobacco product in the past month, and

13.5 percent (or 37.3 million people) used an illicit drug in the

past month (Figure 1 and Table A.1B). Estimates for tobacco,

alcohol, or illicit drugs are not mutually exclusive because

respondents could have used more than one type of substance

(e.g., tobacco products and alcohol) in the past month.

Figure 1. Past Month General Substance Use and Nicotine Vaping:

Among People Aged 12 or Older; 2020

138.5M

51.7M

10.4M

32.8M

2.5M

2.2M

1.8M

1.7M

1.5M

904,000

513,000

0 50 100 150

Alcohol

Tobacco Products

Nicotine Vaping

Marijuana

Rx Pain Reliever Misuse

Rx Tranquilizer or Sedative Misuse

Cocaine

Hallucinogens

Methamphetamine

Rx Stimulant Misuse

Inhalants

Heroin

Number of Past Month Users

Rx = prescription.

Note: General Substance Use includes any illicit drug, alcohol, and tobacco product use. Tobacco

products are defined as cigarettes, smokeless tobacco, cigars, and pipe tobacco.

Note: The estimated numbers of current users of different substances are not mutually exclusive

because people could have used more than one type of substance in the pastmonth.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health10 | October 2021

Tobacco Use or Nicotine Vaping in the

Past Month

Before 2020, NSDUH assessed tobacco use but did not

include questions on nicotine vaping. However, recent

increases in nicotine vaping have resulted in changes in

adolescent tobacco use. Findings from the 2019 National

Youth Tobacco Survey (NYTS) and the 2019 Monitoring

the Future (MTF) study indicated increases in nicotine

vaping.

23,24,25

NYTS data indicate that e-cigarettes have

been the most commonly used nicotine product among

youths since 2014, including in 2020, and that e-cigarette

use has reached epidemic proportions among youths.

25

In

addition, vaping of nicotine products among adolescents

has been identiﬁed as a risk factor for future cigarette use,

24

which may aﬀect long-term cigarette use trends. However,

the 2020 MTF study found similar estimates between 2019

and 2020 in nicotine vaping in the past month among 8th,

10th, and 12th graders.

26

e 2020 NYTS also indicated

a reversal of previous trends, with e-cigarette use among

adolescents declining from 2019 to 2020 and returning to

levels similar to those in 2018. Nevertheless, e-cigarette use

remained the most common form of nicotine product use

among adolescents in the 2020 NYTS. Despite the decline

in e-cigarette use between 2019 and 2020, NYTS researchers

stressed the need for continued eﬀort to sustain this apparent

progress.

27

An issue with the MTF and NYTS data for 2020

is that sample sizes were smaller in 2020. School closures in

the spring in response to the COVID-19 pandemic led to

the early conclusion of data collection for both surveys.

26,27

e 2020 NSDUH included questions to assess the use

of nicotine vaping in both adolescents and adults. As

noted previously, however, caution must be taken when

interpreting estimates in this section due to the very small

amount of data that are available from April to September.

As noted in the section on General Substance Use in the Past

Month

, past month tobacco use in NSDUH includes any use

of four tobacco products: cigarettes, smokeless tobacco (such as

snuﬀ, dip, chewing tobacco, or snus), cigars, and pipe tobacco.

Past month nicotine vaping refers to the use of an e-cigarette

or other vaping device to vape nicotine or tobacco. Aggregate

estimates for the past month use of tobacco or nicotine vaping

(also referred to as current use of nicotine products) are

presented for people who used any of these tobacco products

or vaped nicotine in the past month (or both).

Among people aged 12 or older in 2020, 20.7 percent

(or 57.3 million people) used tobacco products or vaped

nicotine in the past month (Figure 2 and Table A.1B). e

percentage of people who used tobacco products or vaped

nicotine in the past month was highest among young adults

aged 18 to 25 (25.1 percent or 8.4 million people), followed

by adults aged 26 or older (21.6 percent or 47.2 million

people), then by adolescents aged 12 to 17 (6.5 percent or

1.6 million people) (Tables A.2B to A.4B).

Among current nicotine product users, the use of speciﬁc

nicotine products varied by age group. Nearly two thirds of

adolescents aged 12 to 17 who used nicotine products in the

past month (63.1 percent) vaped nicotine but did not use

tobacco products (Table A.5B). An additional 15.7 percent

of adolescents who used nicotine products in the past month

vaped nicotine and used tobacco products. About half of

young adults aged 18 to 25 who used nicotine products in

the past month (53.4 percent) used tobacco products but

did not vape nicotine, 23.6 percent vaped nicotine but did

not use tobacco products, and 22.9 percent vaped nicotine

Figure 2. Past Month Tobacco Use and Nicotine Vaping: Among People Aged 12 or Older; 2020

41.4M

10.6M

7.0M

1.8M

10.4M

0 20 40 60

Cigarettes

Cigars

Smokeless Tobacco

Pipe Tobacco

Nicotine Vaping

Number of Past Month Users

Past Month

Tobacco Use or

Nicotine Vaping

57.3 Million People

(20.7%)

No Past Month

Tobacco Use or

Nicotine Vaping

219.6 Million People

(79.3%)

Note: The estimated numbers of current users of different tobacco products or nicotine vaping are not mutually exclusive because people could have used more than one

type of tobacco product or used tobacco products and vaped nicotine in the pastmonth.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 11

and used tobacco products. Among adults aged 26 or older

who used nicotine products in the past month, however,

88.9 percent used only tobacco products.

Tobacco Product Use

In 2020, of the 51.7 million current (i.e., past month)

tobacco users (Figure 1), the majority were current cigarette

smokers (41.4 million; Figure 2). is pattern has been the

case historically.

28

Additionally, 10.6 million people were

current cigar smokers, 7.0 million people were current

smokeless tobacco users, and 1.8 million people were current

pipe tobacco smokers.

Among people aged 12 or older in 2020 who used any

tobacco product in the past month (regardless of whether

they vaped nicotine), 65.3 percent smoked cigarettes but

did not use other tobacco products, 14.8 percent smoked

cigarettes and used some other type of tobacco product, and

19.9 percent used only noncigarette tobacco products (i.e.,

other tobacco products but not cigarettes) (Table A.6B).

Among adults who used tobacco products in the past month,

adults aged 26 or older were more likely than young adults

aged 18 to 25 to have used only cigarettes in the past month

(68.0 vs. 49.3 percent). However, the majority of young

adults who were past month tobacco users smoked cigarettes,

either as the only tobacco product they used or in addition

to other tobacco products. Estimates among adolescents aged

12 to 17 who used tobacco products in the past month could

not be calculated with suﬃcient precision for the use of only

cigarettes or the use of only noncigarette tobacco products.

e remainder of this section on tobacco use focuses on

cigarette smoking because most current tobacco users aged

12 or older were cigarette smokers. Information on the

use of cigars, pipe tobacco, and smokeless tobacco in the

past month among people aged 12 or older and by age group

can be found in Tables A.1B to A.4B in Appendix A.

Cigarette Use

Among people aged 12 or older in 2020, 15.0 percent (or

41.4 million people) smoked cigarettes in the past month

(Figure 3). e percentage of people who smoked cigarettes

in the past month was highest among adults aged 26 or older

(16.7 percent or 36.4 million people), followed by young

adults aged 18 to 25 (13.9 percent or 4.7 million people), then

by adolescents aged 12 to 17 (1.4 percent or 350,000 people).

Daily Cigarette Use

Among the 41.4 million current cigarette smokers aged

12 or older in 2020 (see the section on Cigarette Use),

24.9 million people (or 60.1 percent) were daily cigarette

smokers (Figure 4), and 9.4 million people (or 37.8 percent)

smoked 16 or more cigarettes per day (i.e., approximately

one pack or more per day). Among current cigarette

smokers, adults aged 26 or older were more likely than

young adults aged 18 to 25 to be daily smokers (64.1 vs.

33.1 percent) (Tables A.3B and A.4B).

Nicotine Vaping

In 2020, 10.4 million people aged 12 or older (or 3.8 percent)

used an e-cigarette or other vaping device to vape nicotine in

the past month (Figures 2 and 5). e percentage of people

who vaped nicotine was highest among young adults aged 18 to

25 (11.7 percent or 3.9 million people), followed by adolescents

aged 12 to 17 (5.1 percent or 1.3 million people), then by

adults aged 26 or older (2.4 percent or 5.2 million people).

Underage Tobacco Use or Nicotine Vaping

Legislation in December 2019 amending the Federal Food,

Drug, and Cosmetic Act raised the federal minimum age

for sale of tobacco products (including e-cigarettes) from

Figure 3. Past Month Cigarette Use: Among People Aged 12 or

Older; 2002-2020

Percent Using in Past Month

0

10

20

30

40

50

20191817161514131211100908070605040302

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 3 Table. Past Month Cigarette Use: Among People Aged 12 or Older;

2002-2020

Age 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

≥12

26.0 25.4 24.9 24.9 25.0 24.3 24.0 23.3 23.0 22.1 22.1 21.3 20.8 19.4 19.1 17.9 17.2 16.7

15.0

12-17

13.0 12.2 11.9 10.8 10.4 9.9 9.2 9.0 8.4 7.8 6.6 5.6 4.9 4.2 3.4 3.2 2.7 2.3

1.4

18-25

40.8 40.2 39.5 39.0 38.5 36.2 35.7 35.8 34.3 33.5 31.8 30.6 28.4 26.7 23.5 22.3 19.1 17.5

13.9

≥26

25.2 24.7 24.1 24.3 24.7 24.1 23.8 23.0 22.8 21.9 22.4 21.6 21.5 20.0 20.2 18.9 18.5 18.2

16.7

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates

between 2020 and prior years because of methodological changes for 2020. Due to these changes,

significance testing between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health12 | October 2021

18 to 21 years.

29

All 50 states and the District of Columbia now

prohibit the sale of tobacco products to people younger than 21.

Among people aged 12 to 20, 11.8 percent (or 4.4 million

people) used tobacco products or used an e-cigarette or other

vaping device to vape nicotine (Table A.7B). Among people

in this age group, 7.7 percent (or 2.9 million people) vaped

nicotine, 6.7 percent (or 2.5 million people) used tobacco

products, and 4.1 percent (or 1.5 million people) smoked

cigarettes in the past month.

Alcohol Use in the Past Month

As noted in the section on General Substance Use in the Past

Month, the 2020 NSDUH asked respondents aged 12 or older

about their alcohol use in the 30 days before the interview. In

addition to asking about any alcohol use, NSDUH collected

information on past month binge alcohol use and heavy

alcohol use. Binge drinking for males was deﬁned as drinking

ﬁve or more drinks

30

on the same occasion on at least 1 day

in the past 30 days, which has remained unchanged from

the threshold prior to 2015. Since 2015, binge alcohol use

for females has been deﬁned as drinking four or more drinks

on the same occasion on at least 1 day in the past 30 days.

31

is deﬁnition of binge alcohol use is consistent with federal

deﬁnitions.

32

Heavy alcohol use was deﬁned as binge drinking

on 5 or more days in the past 30 days based on the thresholds

described previously for males and females. Also, as noted

previously, caution must be taken when interpreting estimates

of alcohol use in the past month due to the very small amount

of data that are available from April to September.

Among the 138.5 million current alcohol users aged 12 or

older in 2020, 61.6 million people (or 44.4 percent) were

past month binge drinkers (Figure 6). Among past month

Figure 4. Daily Cigarette Use: Among Past Month Cigarette Smokers Aged 12 or Older;

Smoking of One or More Packs of Cigarettes per Day: Among Current Daily Smokers; 2020

15.4 Million

Smokers of

Less Than a

Pack per Day

(62.2%)

9.4 Million

Smokers of

One or More

Packs per Day

(37.8%)

16.5 Million

Less Than

Daily Smokers

(39.9%)

24.9 Million

Daily Smokers

(60.1%)

Note: Current daily smokers with unknown data about the number of cigarettes smoked per day were excluded from the pie chart on the right.

Figure 5. Past Month Nicotine Vaping: Among People Aged 12 or

Older; 2020

3.8

5.1

11.7

2.4

0

2

4

6

8

10

12

14

12 or Older 12 to 17 18 to 25 26 or Older

Percent Using in Past Month

Figure 6. Current, Binge, and Heavy Alcohol Use: Among People

Aged 12 or Older; 2020

138.5 Million

Alcohol Users

61.6 Million

Binge Alcohol Users

(44.4% of Alcohol Users)

17.7 Million

Heavy Alcohol Users

(28.8% of Binge Alcohol

Users and 12.8% of

Alcohol Users)

Note: Binge Alcohol Use is defined as drinking five or more drinks (for males) or four or more drinks

(for females) on the same occasion on at least 1 day in the past 30 days. Heavy Alcohol Use is

defined as binge drinking on the same occasion on 5 or more days in the past 30 days; all heavy

alcohol users are also binge alcohol users.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 13

binge drinkers, 17.7 million people (28.8 percent of current

binge drinkers and 12.8 percent of current alcohol users)

were past month heavy drinkers.

33

Any Alcohol Use

Among people aged 12 or older in 2020, 50.0 percent (or

138.5 million people) drank alcohol in the past month

(Figure 6 and Table A.1B). e percentage was highest

among adults aged 26 or older (54.6 percent or 119.2 million

people), followed by young adults aged 18 to 25 (51.5 percent

or 17.3 million people), then by adolescents aged 12 to 17

(8.2 percent or 2.1 million people) (Tables A.2B to A.4B).

Binge Alcohol Use

Among people aged 12 or older in 2020, 22.2 percent

(or 61.6 million people) were binge alcohol users in the

past month (Figures 6 and 7). e percentage was highest

among young adults aged 18 to 25 (31.4 percent or

10.5 million people), followed by adults aged 26 or older

(22.9 percent or 50.0 million people), then by adolescents

aged 12 to 17 (4.1 percent or 1.0 million people).

Heavy Alcohol Use

Among people aged 12 or older in 2020, 6.4 percent

(or 17.7 million people) were heavy alcohol users in

the past month (Figures 6 and 8). e percentage was

highest among young adults aged 18 to 25 (8.6 percent or

2.9 million people), followed by adults aged 26 or older

(6.7 percent or 14.7 million people), then by adolescents

aged 12 to 17 (0.6 percent or 140,000 people).

Underage Alcohol Use

As of 2020, all 50 states and the District of Columbia prohibited

the possession of alcoholic beverages by people younger than

21 (although some states may have had exceptions). Most states

also prohibited underage consumption (i.e., consumption of

alcoholic beverages prior to the age of 21).

34

Among people

aged 12 to 20 in 2020, 16.1 percent (or 6.0 million people)

were past month alcohol users (Table A.7B). Estimates of binge

alcohol use and heavy alcohol use in the past month among

underage people were 9.2 percent (or 3.4 million people) and

1.8 percent (or 669,000 people), respectively.

Figure 7. Past Month Binge Alcohol Use: Among People Aged 12

or Older; 2015-2020

Percent Using in Past Month

0

5

10

15

20

25

30

35

40

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 7 Table. Past Month Binge Alcohol Use: Among People Aged 12 or

Older; 2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older

24.9 24.2 24.5 24.5 23.9 22.2

12 to 17

5.8 4.9 5.3 4.7 4.9 4.1

18 to 25

39.0 38.4 36.9 34.9 34.3 31.4

26 or Older

24.8 24.2 24.7 25.1 24.5 22.9

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Figure 8. Past Month Heavy Alcohol Use: Among People Aged 12

or Older; 2015-2020

Percent Using in Past Month

0

2

4

6

8

10

12

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 8 Table. Past Month Heavy Alcohol Use: Among People Aged 12 or

Older; 2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older

6.5 6.0 6.1 6.1 5.8 6.4

12 to 17

0.9 0.8 0.7 0.5 0.8 0.6

18 to 25

10.9 10.1 9.6 9.0 8.4 8.6

26 or Older

6.4 6.0 6.2 6.2 6.0 6.7

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health14 | October 2021

Illicit Drug Use in the Past Year

e 2020 NSDUH obtained illicit drug use information

for the use of marijuana, cocaine (including crack), heroin,

hallucinogens, inhalants, and methamphetamine, as well

as for the misuse of prescription stimulants, tranquilizers,

sedatives,

35

and pain relievers (see the section on the Misuse of

Psychotherapeutic Drugs for the deﬁnition of “misuse”). is

report presents estimates of past year (rather than past month)

illicit drug use because of low prevalence estimates for some

illicit drugs (e.g., heroin). Moreover, the 2020 NSDUH

collected only past year (rather than past month) data on

the misuse of benzodiazepines and speciﬁc subtypes of

prescription pain relievers (e.g., fentanyl products).

Among people aged 12 or older in 2020, 59.3 million

people used illicit drugs in the past year (Figure 9). e most

commonly used illicit drug in the past year was marijuana,

which was used by 49.6 million people. e second most

common type of illicit drug use in the past year was the

misuse of prescription pain relievers, which were misused by

9.3 million people. Smaller numbers of people were past year

users of other illicit drugs, as shown in Figure 9.

36

Any Illicit Drug Use

Among people aged 12 or older in 2020, 21.4 percent

(or 59.3 million people) used illicit drugs in the past year

(Figures 9 and 10). e percentage was highest among

young adults aged 18 to 25 (37.0 percent or 12.4 million

people), followed by adults aged 26 or older (19.9 percent

or 43.4 million people), then by adolescents aged 12 to 17

(13.8 percent or 3.4 million people).

Marijuana Use

In 2020, 17.9 percent of people aged 12 or older (or

49.6 million people) used marijuana in the past year

(Figures 9 and 11). e percentage was highest among

young adults aged 18 to 25 (34.5 percent or 11.6 million

Figure 9. Past Year Illicit Drug Use: Among People Aged 12 or Older; 2020

49.6M

9.3M

7.1M

6.2M

5.2M

5.1M

2.5M

2.4M

902,000

0 10 20 30 40 50 60

Marijuana

Rx Pain Reliever Misuse

Hallucinogens

Rx Tranquilizer or Sedative Misuse

Cocaine

Rx Stimulant Misuse

Methamphetamine

Inhalants

Heroin

Number of Past Year Users

Past Year

Illicit Drug Use

59.3 Million People

(21.4%)

No Past Year

Illicit Drug Use

217.6 Million People

(78.6%)

Rx = prescription.

Note: The estimated numbers of pastyear users of different illicit drugs are not mutually exclusive because people could have used more than one type of illicit drug in the pastyear.

Figure 10. Past Year Illicit Drug Use: Among People Aged 12 or

Older; 2015-2020

Percent Using in Past Year

0

10

20

30

40

50

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 10 Table. Past Year Illicit Drug Use: Among People Aged 12 or Older;

2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older 17.8 18.0 19.0 19.4 20.8 21.4

12 to 17 17.5 15.8 16.3 16.7 17.2 13.8

18 to 25 37.5 37.7 39.4 38.7 39.1 37.0

26 or Older 14.6 15.0 16.1 16.7 18.3 19.9

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 15

people), followed by adults aged 26 or older (16.3 percent

or 35.5 million people), then by adolescents aged 12 to 17

(10.1 percent or 2.5 million people).

Cocaine Use

Cocaine use includes the use of crack cocaine. Estimates of

crack use are presented separately as well. Among people

aged 12 or older in 2020, 1.9 percent (or 5.2 million people)

used cocaine in the past year (Figure 9 and Table A.12B).

e percentage was highest among young adults aged 18 to

25 (4.3 percent or 1.4 million people), followed by adults

aged 26 or older (1.7 percent or 3.6 million people), then

by adolescents aged 12 to 17 (0.3 percent or 84,000 people)

(Tables A.13B to A.15B).

In 2020, an estimated 0.2 percent of people aged 12 or

older (or 657,000 people) used crack in the past year. e

percentage was lowest among adolescents aged 12 to 17

(less than 0.1 percent or 2,000 people). is percentage

increased with age (0.1 percent of young adults aged 18 to 25

or 49,000 people; 0.3 percent of adults aged 26 or older or

606,000 people).

Heroin Use

Among people aged 12 or older in 2020, 0.3 percent (or

902,000 people) used heroin in the past year (Figure 9

and Table A.12B). Estimates of past year heroin use were

0.2 percent (or 62,000 people) among young adults aged

18 to 25 and 0.4 percent (or 840,000 people) among adults

aged 26 or older (Tables A.14B and A.15B). Estimates of

past year heroin use among adolescents aged 12 to 17 could

not be calculated with suﬃcient precision (Table A.13B).

Methamphetamine Use

Although methamphetamine is legally available by

prescription (Desoxyn

®

), most methamphetamine used in

the United States is produced and distributed illicitly rather

than through the pharmaceutical industry. erefore, the

2015 to 2020 NSDUHs have included separate sections

for methamphetamine use and the use and misuse of

prescription stimulants.

Among people aged 12 or older in 2020, 0.9 percent (or

2.5 million people) used methamphetamine in the past year

(Figures 9 and 12). Adolescents aged 12 to 17 had the lowest

Figure 11. Past Year Marijuana Use: Among People Aged 12 or

Older; 2002-2020

Percent Using in Past Year

0

10

20

30

40

50

20191817161514131211100908070605040302

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 11 Table. Past Year Marijuana Use: Among People Aged 12 or Older;

2002-2020

Age 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

≥12

11.0 10.6 10.6 10.4 10.3 10.1 10.4 11.4 11.6 11.5 12.1 12.6 13.2 13.5 13.9 15.0 15.9 17.5

17.9

12-17

15.8 15.0 14.5 13.3 13.2 12.5 13.1 13.7 14.0 14.2 13.5 13.4 13.1 12.6 12.0 12.4 12.5 13.2

10.1

18-25

29.8 28.5 27.8 28.0 28.1 27.5 27.8 30.8 30.0 30.8 31.5 31.6 31.9 32.2 33.0 34.9 34.8 35.4

34.5

≥26

7.0 6.9 7.0 6.9 6.9 6.8 7.0 7.7 8.0 7.9 8.6 9.2 10.1 10.4 11.0 12.2 13.3 15.2

16.3

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Figure 12. Past Year Methamphetamine Use: Among People Aged

12 or Older; 2015-2020

Percent Using in Past Year

0.0

0.5

1.0

1.5

2.0

2.5

3.0

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 12 Table. Past Year Methamphetamine Use: Among People Aged 12 or

Older; 2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older 0.6 0.5 0.6 0.7 0.7 0.9

12 to 17 0.2 0.1 0.2 0.2 0.2 0.1

18 to 25 0.9 0.8 1.1 0.8 0.8 0.5

26 or Older 0.6 0.5 0.6 0.7 0.8 1.1

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health16 | October 2021

estimate of past year methamphetamine use (0.1 percent or

21,000 people). Percentages increased with age (0.5 percent

of young adults aged 18 to 25 or 171,000 people;

1.1 percent of adults aged 26 or older or 2.4 million people).

Hallucinogen Use

Several drugs are grouped under the category of hallucinogens,

including LSD, PCP, peyote, mescaline, psilocybin

mushrooms, “Ecstasy” (MDMA or “Molly”), ketamine,

DMT/AMT/“Foxy,” and Salvia divinorum.

37

In 2020,

2.6 percent of people aged 12 or older (or 7.1 million people)

used hallucinogens in the past year (Figures 9 and 13). e

percentage among young adults aged 18 to 25 (7.3 percent or

2.4 million people) was higher than the percentages among

adolescents aged 12 to 17 (1.5 percent or 370,000 people) or

adults aged 26 or older (2.0 percent or 4.3 million people).

Inhalant Use

Inhalants include volatile solvents (e.g., paint thinners and

removers, dry cleaning ﬂuids, degreasers, gasoline, glues, shoe

polish, correction ﬂuids, felt-tip markers), aerosols (e.g., spray

paints, deodorant and hair sprays, fabric protector sprays,

computer keyboard cleaner), gases (e.g., ether, halothane,

nitrous oxide, butane, propane), and nitrites (e.g., amyl

nitrite, “poppers,” locker room deodorizers, “rush”). NSDUH

respondents were asked to report the use of inhalants to get

high but not to include accidental inhalation of a substance.

Among people aged 12 or older in 2020, 0.9 percent (or

2.4 million people) used inhalants in the past year (Figures 9

and 14). Unlike other illicit drug use estimates, the percentage

was highest among adolescents aged 12 to 17 (2.7 percent or

683,000 people). Percentages decreased with age (1.5 percent

of young adults aged 18 to 25 or 507,000 people; 0.5 percent

of adults aged 26 or older or 1.2 million people).

Misuse of Psychotherapeutic Drugs

e 2020 NSDUH assessed the use and misuse of

psychotherapeutic drugs currently or recently available by

prescription in the United States, including prescription

stimulants, tranquilizers or sedatives (e.g., benzodiazepines),

Figure 13. Past Year Hallucinogen Use: Among People Aged 12 or

Older; 2015-2020

Percent Using in Past Year

0

1

2

3

4

5

6

7

8

9

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 13 Table. Past Year Hallucinogen Use: Among People Aged 12 or

Older; 2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older

1.8 1.8 1.9 2.0 2.2 2.6

12 to 17

2.1 1.8 2.1 1.5 1.8 1.5

18 to 25

7.0 6.9 7.0 6.9 7.2 7.3

26 or Older

0.8 1.0 1.0 1.3 1.5 2.0

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Figure 14. Past Year Inhalant Use: Among People Aged 12 or

Older; 2015-2020

Percent Using in Past Year

0.0

0.5

1.0

1.5

2.0

2.5

3.0

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 14 Table. Past Year Inhalant Use: Among People Aged 12 or Older;

2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older

0.7 0.6 0.6 0.7 0.8 0.9

12 to 17

2.7 2.2 2.3 2.7 3.0 2.7

18 to 25

1.4 1.4 1.6 1.5 1.7 1.5

26 or Older

0.3 0.3 0.3 0.4 0.4 0.5

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 17

and pain relievers. In NSDUH, misuse of prescription drugs

was deﬁned as use in any way not directed by a doctor,

including use without a prescription of one’s own; use in

greater amounts, more often, or longer than told to take

a drug; or use in any other way not directed by a doctor.

Misuse of over-the-counter (OTC) drugs was not included.

Among people aged 12 or older in 2020, 5.8 percent (or

16.1 million people) misused prescription psychotherapeutic

drugs in the past year (Table A.12B). e percentage was

highest among young adults aged 18 to 25 (9.5 percent

or 3.2 million people), followed by adults aged 26 or

older (5.6 percent or 12.2 million people), then by

adolescents aged 12 to 17 (2.8 percent or 688,000 people)

(Tables A.13B to A.15B).

Of the prescription drugs presented in this report,

prescription pain relievers were the most commonly misused

by people aged 12 or older. e 16.1 million people in

2020 who misused prescription psychotherapeutic drugs

in the past year included 9.3 million people who misused

prescription pain relievers, 6.2 million people who misused

prescription tranquilizers or sedatives (including 4.8 million

past year misusers of benzodiazepines), and 5.1 million

people who misused prescription stimulants (Figure 9).

Stimulant Misuse

e 2020 NSDUH assessed the misuse of prescription

stimulants in the following categories: amphetamine

products, methylphenidate products, anorectic (weight-loss)

stimulants, Provigil

®

, or any other prescription stimulant.

e amphetamine and methylphenidate products included in

the NSDUH questionnaire are primarily prescribed for the

treatment of attention-deﬁcit/hyperactivity disorder (ADHD).

Since 2015, methamphetamine has not been included as

a prescription stimulant, unless respondents speciﬁed the

prescription form of methamphetamine (Desoxyn

®

) as some

other stimulant they had misused in the past year.

38

Among people aged 12 or older in 2020, 1.8 percent

(or 5.1 million people) misused prescription stimulants

in the past year (Figures 9 and 15). e percentage was

higher among young adults aged 18 to 25 (4.8 percent or

1.6 million people) than among adolescents aged 12 to 17

(1.2 percent or 288,000 people) or adults aged 26 or older

(1.5 percent or 3.2 million people).

Tranquilizer or Sedative Misuse

Estimates of the misuse of prescription tranquilizers or

sedatives are presented together because prescription drugs in

both categories have a common eﬀect on speciﬁc activity in

the brain. Prescription tranquilizers include benzodiazepine

tranquilizers (e.g., as alprazolam, lorazepam, clonazepam,

or diazepam products), muscle relaxants, or any other

prescription tranquilizer. Prescription sedatives include

zolpidem products, eszopiclone products, zaleplon products,

benzodiazepine sedatives (e.g., as ﬂurazepam and temazepam

products or triazolam products), barbiturates, or any other

prescription sedative.

Among people aged 12 or older in 2020, 2.2 percent (or

6.2 million people) misused tranquilizers or sedatives in the

past year (Figure 9 and Table A.12B). e percentage was

highest among young adults aged 18 to 25 (3.7 percent or

1.2 million people), followed by adults aged 26 or older

(2.2 percent or 4.7 million people), then by adolescents aged

12 to 17 (0.9 percent or 226,000 people) (Tables A.13B to

A.15B).

Figure 15. Past Year Prescription Stimulant Misuse: Among

People Aged 12 or Older; 2015-2020

Percent Misusing in Past Year

0

1

2

3

4

5

6

7

8

9

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 15 Table. Past Year Prescription Stimulant Misuse: Among People

Aged 12 or Older; 2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older

2.0 2.1 2.1 1.9 1.8 1.8

12 to 17

2.0 1.7 1.8 1.5 1.7 1.2

18 to 25

7.3 7.5 7.4 6.5 5.8 4.8

26 or Older

1.1 1.3 1.3 1.2 1.2 1.5

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health18 | October 2021

Benzodiazepine Misuse

Prescription benzodiazepines are a subcategory of drugs

that may be prescribed either as tranquilizers for the

relief of anxiety or as sedatives for the relief of insomnia.

Benzodiazepines prescribed as tranquilizers are typically

metabolized more slowly than benzodiazepines prescribed

as sedatives.

39

Nevertheless, benzodiazepines are chemically

similar, regardless of whether they are prescribed as

tranquilizers or sedatives.

Among people aged 12 or older in 2020, 1.7 percent (or

4.8 million people) misused prescription benzodiazepines

in the past year (Table A.12B). e percentage was highest

among young adults aged 18 to 25 (3.3 percent or 1.1 million

people), followed by adults aged 26 or older (1.6 percent

or 3.5 million people), then by adolescents aged 12 to 17

(0.6 percent or 157,000 people) (Tables A.13B to A.15B).

Pain Reliever Misuse

e 2020 NSDUH assessed the misuse of prescription pain

relievers in the following categories: products containing

hydrocodone, oxycodone, tramadol, codeine, morphine,

prescription fentanyl,

40

buprenorphine, oxymorphone,

and hydromorphone, as well as Demerol

®

, methadone, or

any other prescription pain reliever. is section provides

estimates of the misuse of any prescription pain reliever

and speciﬁc subtypes of prescription pain relievers, the

main reason for the most recent misuse of prescription pain

relievers, and where people obtained the prescription pain

relievers that they most recently misused in the past year.

Among people aged 12 or older in 2020, 3.3 percent (or

9.3 million people) misused prescription pain relievers

in the past year (Figures 9 and 16). e percentage was

highest among young adults aged 18 to 25 (4.1 percent or

1.4 million people), followed by adults aged 26 or older

(3.4 percent or 7.5 million people), then by adolescents aged

12 to 17 (1.6 percent or 396,000 people).

Misuse of Subtypes of Pain Relievers

e 2020 NSDUH asked respondents to identify speciﬁc

prescription pain relievers they used in the past year, then

asked whether they misused those pain relievers in the

past year. e speciﬁc pain relievers people misused in the

past year were categorized into subtypes, such as hydrocodone

products. For example, respondents who reported misusing

the pain relievers Vicodin

®

or hydrocodone were classiﬁed as

misusers of hydrocodone products.

is section presents two ways of examining the misuse of

subtypes of pain relievers. First, it presents estimates of the

misuse of subtypes among the total population aged 12 or

older. en it presents estimates of the misuse of subtypes

of pain relievers among people who used that subtype in the

past year.

Among people aged 12 or older in 2020, 1.7 percent (or

4.7 million people) misused hydrocodone products in the

past year (Figure 17). Hydrocodone products were the most

commonly misused subtype of prescription pain relievers

for 2020, including Vicodin

®

, Lortab

®

, Norco

®

, Zohydro

®

ER, and generic hydrocodone. In addition, 1.1 percent (or

3.2 million people) misused oxycodone products in the

past year, including OxyContin

®

, Percocet

®

, Percodan

®

,

Roxicodone

®

, and generic oxycodone. Also, 0.2 percent

of people aged 12 or older (or 690,000 people) misused

buprenorphine products in the past year.

Figure 16. Past Year Prescription Pain Reliever Misuse: Among

People Aged 12 or Older; 2015-2020

Percent Misusing in Past Year

0

1

2

3

4

5

6

7

8

9

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 16 Table. Past Year Prescription Pain Reliever Misuse: Among People

Aged 12 or Older; 2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older

4.7 4.3 4.1 3.6 3.5 3.3

12 to 17

3.9 3.5 3.1 2.8 2.3 1.6

18 to 25

8.5 7.1 7.2 5.5 5.2 4.1

26 or Older

4.1 3.9 3.7 3.4 3.4 3.4

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 19

An estimated 0.1 percent of people aged 12 or older (or

356,000 people) misused prescription fentanyl products.

Because NSDUH respondents were asked only about

the misuse of prescription forms of fentanyl, estimates of

fentanyl misuse for 2020 may underrepresent people who

used illicitly manufactured fentanyl (IMF) from clandestine

laboratories (i.e., as opposed to the misuse of diverted

prescription fentanyl produced by the pharmaceutical

industry) and may not include those who used IMF mixed

with heroin or sold as heroin (but contained only IMF).

Although prescription pain reliever misuse was the

second most common form of illicit drug use for 2020

(

Figure 9), most past year users of prescription pain relievers

did not misuse them in the past year (Figure 17). For

example, among past year users of hydrocodone products,

12.6 percent misused them in the past year. Among past year

users of buprenorphine products, 26.5 percent misused

them. Stated another way, almost three fourths of past year

users of buprenorphine products did not misuse them in that

period.

Main Reasons for the Last Misuse of Pain Relievers

Respondents in the 2020 NSDUH who reported

prescription pain reliever misuse in the past year were asked

to report the reasons for misusing the last prescription pain

reliever they misused. Respondents who reported more than

one reason for misusing the last prescription pain reliever

were asked to report their main reason for misusing it.

Among people aged 12 or older in 2020 who misused

prescription pain relievers in the past year, the most common

main reason for their last misuse of a pain reliever was to

relieve physical pain (64.6 percent) (Table A.16B). Based on

the NSDUH deﬁnition, use without a prescription of one’s

own or overuse of prescribed medication (e.g., use at a higher

dosage or more often than prescribed) are both classiﬁed as

misuse even if the use was for the purpose of pain relief.

Other common main reasons for misuse were to feel good

or get high (11.3 percent) and to relax or relieve tension

(8.1 percent). Less common main reasons among past year

misusers of pain relievers included to help with feelings or

emotions (5.6 percent), to help with sleep (4.5 percent),

because they were “hooked” or needed to have the drug

(2.3 percent), to experiment or see what the drug was like

(1.4 percent), and to increase or decrease the eﬀects of other

drugs (0.9 percent).

Source of the Last Pain Reliever That Was Misused

Among people aged 12 or older in 2020 who misused

prescription pain relievers in the past year, the most common

source for the last pain reliever they misused was from a

friend or relative in some way (i.e., being given them, buying

them, or taking them without asking) (

Figure 18). A little

less than half (47.2 percent) of people who misused pain

relievers in the past year obtained the pain relievers the last

time from a friend or relative in some way. Speciﬁcally,

34.4 percent of people who misused pain relievers in the

past year obtained pain relievers the last time by getting them

from a friend or relative for free, 9.2 percent bought their

last pain reliever from a friend or relative, and 3.7 percent

took their last pain reliever from a friend or relative without

asking. About two ﬁfths of people who misused pain relievers

in the past year (43.6 percent) obtained pain relievers the

last time through prescription(s) or stole pain relievers from

a health care provider, typically getting the pain relievers

through a prescription from one doctor (42.0 percent).

About 1 in 16 people who misused pain relievers in the

past year (6.2 percent) bought the last pain reliever they

misused from a drug dealer or other stranger.

Figure 17. Past Year Prescription Pain Reliever Misuse: Among

People Aged 12 or Older; by Selected Pain Reliever Subtype, 2020

3.3

1.7

1.1

0.9

0.5

0.2

0.1

0.0

0.01.02.03.04.0

Any Misuse

Hydrocodone

Oxycodone

Codeine

Tramadol

Buprenorphine

Morphine

Fentanyl

Hydromorphone

Demerol

Percent among Total Population

12.3

12.6

14.5

12.2

9.0

26.5

8.9

14.8

16.6

*

0 10 20 30

Any Misuse

Hydrocodone

Oxycodone

Codeine

Tramadol

Buprenorphine

Morphine

Fentanyl

Hydromorphone

Demerol

Percent among Past Year Any Users

Any Pain

Reliever Misuse

Hydrocodone

Oxycodone

Codeine

Tramadol

Buprenorphine

Morphine

Fentanyl

Hydromorphone

Demerol

* Low precision; no estimate reported.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health20 | October 2021

Opioid Misuse

Opioids are a group of chemically similar drugs that include

heroin and prescription opioids, such as hydrocodone (e.g.,

Vicodin

®

), oxycodone (e.g., OxyContin

®

), and morphine. In

this report, opioid misuse includes the misuse of prescription

pain relievers or the use of heroin. Prescription pain relievers

could include some nonopioids because respondents could

occasionally specify the misuse of other prescription pain

relievers that are not opioids.

Among people aged 12 or older in 2020, 3.4 percent (or

9.5 million people) misused opioids in the past year (Figure 19

and Table A.12B). e percentage was highest among young

adults aged 18 to 25 (4.1 percent or 1.4 million people),

followed by adults aged 26 or older (3.5 percent or 7.7 million

people), then by adolescents aged 12 to 17 (1.6 percent or

396,000 people) (Tables A.13B to A.15B).

e vast majority of people who misused opioids in the

past year misused prescription pain relievers (Figure 19).

Speciﬁcally, 9.3 million people aged 12 or older misused

prescription pain relievers in the past year compared with

902,000 people who used heroin. In 2020, the majority

of the 9.3 million misusers of prescription pain relievers

misused only prescription pain relievers in the past year

(8.6 million people), but they had not used heroin. An

estimated 667,000 people misused prescription pain

relievers and used heroin in the past year, and 235,000

people had used heroin in the past year but had not misused

prescription pain relievers.

Central Nervous System Stimulant Misuse

Central nervous system (CNS) stimulants are a group

of drugs that include cocaine, methamphetamine, and

prescription stimulants. ese drugs act in similar ways to

stimulate the brain. ey produce stimulant eﬀects, such

Figure 18. Source Where Pain Relievers Were Obtained for Most Recent Misuse: Among People Aged

12 or Older Who Misused Pain Relievers in the Past Year; 2020

9.3 Million People Aged 12 or Older Who Misused Pain Relievers in the Past Year

Given by, Bought from, or Took from

a Friend or Relative

47.2%

Bought from Drug Dealer or Other Stranger

6.2%

Some Other Way

3.1%

Got through Prescription(s) or

Stole from a Health Care Provider

43.6%

Prescription from One Doctor (42.0%)

Prescriptions from More Than One Doctor (1.0%) Stole from Doctor's Ofﬁce, Clinic, Hospital, or Pharmacy (0.6%)

From Friend or Relative for Free (34.4%)

Took from Friend or Relative without Asking (3.7%)

Bought from Friend or Relative (9.2%)

Note: Respondents with unknown data for the Source for Most Recent Misuse or who reported Some Other Way but did not specify a valid way were excluded.

Note: The percentages do not add to 100percent due to rounding.

Figure 19. Past Year Opioid Misuse: Among People Aged 12 or

Older; 2020

8.6 Million People with Pain

Reliever Misuse Only

(90.5% of Opioid Misusers)

9.3 Million People

with Pain Reliever Misuse

(97.5% of Opioid Misusers)

667,000 People with

Pain Reliever Misuse and

Heroin Use

(7.0% of Opioid Misusers)

902,000 People

with Heroin Use

(9.5% of Opioid Misusers)

235,000 People with

Heroin Use Only

(2.5% of Opioid Misusers)

9.5 Million People Aged 12 or Older with Past Year Opioid Misuse

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 21

as increased alertness, wakefulness, or energy. ey also can

produce physical side eﬀects of rapid or irregular heartbeat

or increased blood pressure and body temperature.

41,42,43

In this report, CNS stimulant misuse includes the use of

cocaine or methamphetamine or the misuse of prescription

stimulants.

Among people aged 12 or older in 2020, 3.7 percent (or

10.3 million people) misused CNS stimulants in the past year

(Figure 20 and Table A.12B). e percentage was highest

among young adults aged 18 to 25 (7.7 percent or 2.6 million

people), followed by adults aged 26 or older (3.4 percent

or 7.4 million people), then by adolescents aged 12 to 17

(1.4 percent or 346,000 people) (Tables A.13B to A.15B).

Of the 10.3 million people in 2020 who misused CNS

stimulants in the past year, 353,000 used or misused all

three CNS stimulants in the past year (3.4 percent of

people who misused CNS stimulants) (Figure 20).

13

About

one third of people who misused CNS stimulants in the

past year used only cocaine (32.4 percent of CNS stimulant

misusers or 3.3 million people), about one third misused

only prescription stimulants (32.3 percent of CNS stimulant

misusers or 3.3 million people), and about 1 in 7 used

only methamphetamine (14.4 percent of CNS stimulant

misusers or 1.5 million people). In addition to the 353,000

people who used or misused all three CNS stimulants in

the past year, 1.1 million people used cocaine and misused

prescription stimulants but did not use methamphetamine

(10.5 percent of CNS stimulant misusers), 391,000

used cocaine and methamphetamine but did not misuse

prescription stimulants (3.8 percent of CNS stimulant

misusers), and 326,000 used methamphetamine and misused

prescription stimulants but did not use cocaine (3.2 percent

of CNS stimulant misusers).

Other Substance Use in the Past Year

e 2020 NSDUH obtained information for the use and

misuse of additional substances that can produce mind-

altering eﬀects. Not including these substances in estimates

from prior years has allowed the creation of consistent illicit

drug use measures over time. ese substances include

GHB, the misuse of nonprescription cold and cough

medicine, kratom, synthetic marijuana (fake weed, K2, or

Spice), and synthetic stimulants (“bath salts” or ﬂakka).

e 2020 NSDUH marks the ﬁrst time that information

was collected on the use of synthetic cannabinoids (referred

to in the NSDUH questionnaire as “synthetic marijuana”)

and synthetic cathinones (referred to in the questionnaire as

“synthetic stimulants”).

GHB Use

Gamma hydroxybutyrate (GHB, also called “G,” “Georgia

Home Boy,” “Grievous Bodily Harm,” or “Liquid G,”)

is a CNS depressant. GHB can produce hallucinations,

euphoria, drowsiness, decreased anxiety, and excited and

aggressive behavior. It also is addictive. GHB that is not

produced as a pharmaceutical product with approval from

the U.S. Food and Drug Administration is classiﬁed as a

Schedule I controlled substance in the United States.

44,45

Among people aged 12 or older in 2020, 0.1 percent (or

183,000 people) used GHB in the past year (Table A.8B).

In addition, 0.1 percent each of young adults aged 18 to

25 and adults aged 26 or older used GHB in the past year

(Tables A.10B and A.11B). Corresponding estimated

numbers of people who used GHB in the past year were

24,000 young adults and 158,000 adults aged 26 or older.

Estimates for adolescents aged 12 to 17 could not be

calculated with suﬃcient precision (

Table A.9B).

Nonprescription Cough and Cold Medicine Misuse

e cough suppressant dextromethorphan (DXM) is

found in many cough and cold medicines. ese medicines

are available without a prescription (i.e., OTC) in the

United States and are generally considered safe when used

Figure 20. Past Year Central Nervous System (CNS) Stimulant

Misuse: Among People Aged 12 or Older; 2020

5.2 Million People

Used Cocaine

Cocaine

Use Only

Prescription

Stimulant

Misuse Only

5.1 Million People

Misused Prescription

Stimulants

3.3

Million

1.5

Million

3.3

Million

10.3 Million People Aged 12 or Older with Past Year CNS Stimulant Misuse

Methamphetamine

Use Only

2.5 Million People Used

Methamphetamine

391K

353K

326K

1.1

Million

Cocaine and

Methamphetamine Use,

but Not Prescription

Stimulant Misuse

Methamphetamine

Use and Prescription

Stimulant Misuse, but

Not Cocaine Use

Cocaine and Prescription Stimulant

Misuse, but Not Methamphetamine Use

Cocaine and

Methamphetamine Use and

Prescription Stimulant Misuse

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health22 | October 2021

appropriately. When taken in large amounts, however,

DXM can produce hallucinations or dissociative, “out-

of-body” experiences. ese eﬀects are similar to those

caused by the hallucinogens PCP and ketamine. Other

drugs found in OTC cough and cold medicines also

can have psychoactive eﬀects. For example, the OTC

antihistamine diphenhydramine (found in the brand-name

drug Benadryl

®

) can produce sedative side eﬀects, such as

drowsiness.

46

e OTC decongestant phenylephrine (found

in the brand-name drug Sudafed PE

®

) can produce stimulant

side eﬀects, such as nervousness and sleeplessness.

47

e 2020 NSDUH questionnaire asked respondents aged

12 or older about their use of nonprescription cough or cold

medicines in the past 12 months for the purpose of getting

high (i.e., “misuse”). Respondents who reported that they

used nonprescription (i.e., OTC) cough or cold medicines

to get high in the past 12 months could specify the names of

up to ﬁve OTC medicines that they had misused.

Among people aged 12 or older in 2020, 0.9 percent (or

2.4 million people) misused nonprescription cough and

cold medicines in the past year (Table A.8B). Similar

percentages of people in each age group misused cough and

cold medicines in the past year (0.9 percent of adolescents

aged 12 to 17, 1.2 percent of young adults aged 18 to 25,

and 0.8 percent of adults aged 26 or older) (Tables A.9B to

A.11B). Corresponding estimated numbers of people who

misused cough and cold medicines in the past year were

223,000 adolescents, 389,000 young adults, and 1.8 million

adults aged 26 or older.

Kratom Use

Kratom is an herbal extract from the leaves of the Mitragyna

speciosa tree that is native to Southeast Asia. e leaves

contain chemicals with mind-altering eﬀects. Kratom can

come in forms such as powders, pills, or leaves.

48,49

e

2020 NSDUH asked respondents aged 12 or older about

their use of kratom in the 12 months before the interview.

Among people aged 12 or older in 2020, 0.8 percent

(or 2.1 million people) used kratom in the past year

(Table A.8B). e percentage was lower among adolescents

aged 12 to 17 (0.2 percent or 48,000 people) than among

young adults aged 18 to 25 (0.9 percent or 286,000 people)

or adults aged 26 or older (0.8 percent or 1.8 million people)

(Tables A.9B to A.11B).

Synthetic Marijuana Use

Synthetic cannabinoids are human-made chemicals that

are similar to chemicals found in the marijuana plant. For

this reason, these drugs are sometimes called “synthetic

marijuana” or “fake weed.” ey can be contained in plant

material that is later smoked. ey are also sold as liquids

to be vaporized (i.e., vaped) and inhaled in e-cigarettes and

other devices.

44,50

Several synthetic cannabinoids have been

categorized as Schedule I controlled substances.

45

For simplicity, the 2020 NSDUH questionnaire asked

respondents about their use of “synthetic marijuana” and

included the slang terms “fake weed,” “K2,” and “Spice.”

e 2020 NSDUH asked respondents aged 12 or older

about their use of synthetic marijuana or fake weed in the

12 months before the interview.

Among people aged 12 or older in 2020, 0.4 percent (or

1.1 million people) used synthetic marijuana in the past year

(Table A.8B). e percentage was lower among adults aged

26 or older (0.3 percent or 546,000 people) than among

adolescents aged 12 to 17 (0.8 percent or 207,000 people) or

young adults aged 18 to 25 (0.9 percent or 313,000 people)

(Tables A.9B to A.11B).

Synthetic Stimulant Use

Synthetic cathinones are human-made CNS stimulants that

are chemically related to cathinone, a substance found in

the khat plant. ese substances can be marketed as “bath

salts” or “ﬂakka.”

44,51

Several synthetic cathinones have been

categorized as Schedule I controlled substances.

45

For simplicity, the 2020 NSDUH questionnaire asked

respondents about their use of “synthetic stimulants” and

included the slang terms “bath salts” and “ﬂakka.” e 2020

NSDUH asked respondents aged 12 or older about their use

of synthetic stimulants, also called “bath salts” or ﬂakka, in

the 12 months before the interview.

Among people aged 12 or older in 2020, less than

0.1 percent (or 118,000 people) used synthetic stimulants

in the past year (Table A.8B). Similar percentages of people

in each age group used synthetic stimulants (less than

0.1 percent each of adolescents aged 12 to 17 and adults

aged 26 or older; 0.1 percent of young adults aged 18 to 25)

(Tables A.9B to A.11B). In each age group, 75,000 or fewer

people used synthetic stimulants.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 23

Initiation of Substance Use

e 2020 NSDUH included questions to measure the

initiation of substance use, that is, use of particular substances

for the ﬁrst time during a person’s lifetime.

52

is report

presents the estimated number of recent substance use initiates

or prescription drug misuse initiates.

53

Recent initiates were

substance users or prescription drug misusers who reported

ﬁrst using or misusing, respectively, a particular substance in

the 12 months before the NSDUH interview.

14,54,55

In particular, this report presents estimates for past year

initiation of heroin use, prescription pain reliever misuse,

prescription tranquilizer misuse, and prescription sedative

misuse, separately. e report does not present estimates for

past year initiation of any opioid (heroin or prescription pain

reliever) misuse, any illicit drug use (including prescription

drug misuse), and any prescription tranquilizer or sedative

misuse because respondents who underreported lifetime

(but not past year) misuse of prescription drugs might

not truly be past year initiates of the use or misuse of any

drug in these aggregate categories.

56

Estimates for the past

year initiation of benzodiazepine misuse are not presented

because some benzodiazepines in NSDUH were included as

tranquilizers, and others were included as sedatives.

57

Because only limited data were collected from April to

September 2020, this report does not present estimates for

2020 for the average numbers of initiates per day. In prior

years, these averages were calculated by dividing the total

number of past year initiates by 365 days and assumed

generally continuous data collection across the entire

12 months. Estimates from the 2020 NSDUH for the

average number of initiates per day also could be misleading

because 2020 included periods when people in certain states

and localities were under increased restrictions to contain

the spread of COVID-19. ese periods of restrictions could

have changed the opportunities to initiate substance use

among members of certain subgroups.

Figure 21 provides an overview of the numbers of people

aged 12 or older in 2020 who were past year initiates for the

substances discussed in this section. In the past 12 months,

4.1 million people initiated alcohol use and 1.3 million

people tried a cigarette for the ﬁrst time in their lifetime.

58

ere also were 2.8 million new marijuana users, 1.4 million

new hallucinogen users, 1.2 million new misusers of

prescription pain relievers, 950,000 new misusers of

prescription tranquilizers, and 734,000 new misusers of

prescription stimulants.

Initiation of Cigarette Use

Among people aged 12 or older in 2020, 1.3 million people

initiated cigarette smoking in the past year (i.e., never

smoked cigarettes before the past 12 months) (Figure 21).

Relatively few people (approximately 10 percent of past year

initiates) tried cigarettes for the ﬁrst time after age 25.

Corresponding numbers of initiates of cigarette smoking by

age group were 385,000 adolescents aged 12 to 17, 752,000

young adults aged 18 to 25, and 127,000 adults aged 26 or

older (

Tables A.19A to A.21A).

Initiation of Alcohol Use

Among people aged 12 or older in 2020, 4.1 million people

initiated alcohol use in the past year, not counting sips from

another person’s drink (Figure 22). Among young adults

aged 18 to 25 in 2020, 2.1 million people initiated alcohol

use in the past year. Corresponding numbers for initiation

of alcohol use for adolescents aged 12 to 17 and adults aged

26 or older were 1.8 million people and 176,000 people,

respectively (Table A.21A). Consistent with the pattern of

cigarette smoking initiation, relatively few people in 2020

started to use alcohol after age 25.

Initiation of Marijuana Use

Among people aged 12 or older in 2020, 2.8 million people

initiated marijuana use in the past year (Figure 23). Among

adolescents aged 12 to 17, 1.0 million people initiated

marijuana use in the past year. Corresponding numbers

for young adults aged 18 to 25 and adults aged 26 or older

Figure 21. Past Year Initiates of Substances: Among People Aged

12 or Older; 2020

4.1M

1.3M

2.8M

1.4M

1.2M

950,000

734,000

678,000

489,000

343,000

153,000

103,000

0 1 2 3 4 5

Alcohol

Cigarettes

Marijuana

Hallucinogens

Rx Pain Reliever Misuse

Rx Tranquilizer Misuse

Rx Stimulant Misuse

Inhalants

Cocaine

Rx Sedative Misuse

Methamphetamine

Heroin

Past Year Initiates

Rx = prescription.

Note: Estimates for prescription pain relievers, prescription tranquilizers, prescription stimulants, and

prescription sedatives are for the initiation of misuse.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health24 | October 2021

were 1.1 million people and 664,000 people, respectively

(Table A.21A). Unlike people who initiated cigarette or

alcohol use, almost 25 percent of people in 2020 who

initiated marijuana use in the past year were aged 26 or older.

Initiation of Cocaine Use

Among people aged 12 or older in 2020, 489,000 people

initiated cocaine use in the past year (Figure 21).

59

Approximately 70 percent of past year initiates tried cocaine

for the ﬁrst time between ages 18 and 25. Among young

adults aged 18 to 25, 341,000 people initiated cocaine

use (

Table A.20A). Corresponding numbers of initiates

for adolescents aged 12 to 17 and adults aged 26 or older

were 82,000 people and 66,000 people, respectively

(

Tables A.19A and A.21A).

Initiation of Heroin Use

Among people aged 12 or older in 2020, 103,000 people

initiated heroin use in the past year (Figure 21). Among

adolescents aged 12 to 17, the number of people who

initiated heroin use in the past year was not reported due to

low statistical precision (Table A.19A). Nearly 90 percent of

past year initiates in 2020 tried heroin for the ﬁrst time after

age 25. Among young adults aged 18 to 25, 12,000 people

initiated heroin use in the past year (Table A.20A). Among

adults aged 26 or older, 91,000 people initiated heroin use in

the past year (Table A.21A).

Initiation of Methamphetamine Use

Among people aged 12 or older in 2020, 153,000 people

initiated methamphetamine use in the past year (Figure 21).

Relative to people in other age groups, few adolescents aged

12 to 17 initiated methamphetamine use in the past year.

Numbers of initiates of methamphetamine use by age

group were 6,000 adolescents aged 12 to 17, 51,000 young

adults aged 18 to 25, and 97,000 adults aged 26 or older

(

Tables A.19A to A.21A).

Initiation of Hallucinogen Use

Among people aged 12 or older in 2020, 1.4 million people

initiated hallucinogen use in the past year (Figure 21).

59

Corresponding numbers of initiates of hallucinogen use by

Figure 23. Past Year Marijuana Initiates: Among People Aged 12

or Older; 2002-2020

Past Year Initiates (in Millions)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

20191817161514131211100908070605040302

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 23 Table. Past Year Marijuana Initiates: Among People Aged 12 or

Older (in Millions); 2002-2020

Age 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

≥12

2.2 2.0 2.1 2.1 2.1 2.1 2.2 2.4 2.4 2.6 2.4 2.4 2.6 2.6 2.6 3.0 3.1 3.5

2.8

12-17

1.4 1.2 1.3 1.1 1.2 1.2 1.2 1.3 1.3 1.4 1.3 1.2 1.2 1.2 1.2 1.2 1.3 1.4

1.0

18-25

0.7 0.7 0.7 0.7 0.7 0.8 0.8 1.0 0.9 1.1 1.0 1.0 1.1 1.0 1.0 1.3 1.2 1.2

1.1

≥26

0.1 0.1 0.2 0.3 0.1 0.1 0.2 0.0 0.2 0.2 0.2 0.2 0.3 0.4 0.4 0.5 0.5 0.9

0.7

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Note: Estimates of less than 0.05million round to 0.0million when shown to the nearest tenth of a million.

Figure 22. Past Year Alcohol Initiates: Among People Aged 12 or

Older; 2002-2020

Past Year Initiates (in Millions)

0

1

2

3

4

5

20191817161514131211100908070605040302

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 22 Table. Past Year Alcohol Initiates: Among People Aged 12 or Older

(in Millions); 2002-2020

Age 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

≥12

3.9 4.1 4.4 4.3 4.4 4.6 4.5 4.6 4.7 4.7 4.6 4.6 4.7 4.8 4.6 4.9 4.9 4.9

4.1

12-17

2.6 2.6 2.7 2.7 2.7 2.7 2.6 2.7 2.5 2.6 2.4 2.4 2.3 2.4 2.3 2.3 2.4 2.3

1.8

18-25

1.2 1.4 1.5 1.4 1.6 1.7 1.7 1.8 2.0 2.0 1.9 2.1 2.2 2.2 2.2 2.4 2.4 2.4

2.1

≥26

0.1 0.1 0.2 0.1 0.1 0.1 0.2 0.1 0.2 0.1 0.2 0.1 0.1 0.2 0.2 0.1 0.1 0.2

0.2

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 25

age group were 251,000 adolescents aged 12 to 17, 785,000

young adults aged 18 to 25, and 376,000 adults aged 26 or

older (

Tables A.19A to A.21A).

Initiation of Inhalant Use

Among people aged 12 or older in 2020, 678,000 people

initiated inhalant use in the past year (Figure 21). About half

of past year initiates tried inhalants for the ﬁrst time between

age 12 and 17. Numbers of initiates of inhalant use by age

group were 360,000 adolescents aged 12 to 17, 201,000

young adults aged 18 to 25, and 117,000 adults aged 26 or

older (

Tables A.19A to A.21A).

Initiation of Prescription Stimulant Misuse

Among people aged 12 or older in 2020, 734,000 initiated

prescription stimulant misuse in the past year (Figure 21).

Among adults aged 26 or older, 324,000 people initiated

prescription stimulant misuse in the past year (Table A.21A).

Corresponding numbers for young adults aged 18 to 25 and

adolescents aged 12 to 17 were 294,000 people and 116,000

people, respectively (

Tables A.19A and A.20A).

Initiation of Prescription Tranquilizer or Sedative

Misuse

Although this report includes combined estimates for the

past year misuse of prescription tranquilizers or sedatives,

estimates for the initiation of misuse of these substances are

presented separately in this section. As noted previously, it

cannot be determined unambiguously whether respondents

were past year initiates for the aggregate category of any

tranquilizer or sedative misuse because of the potential for

respondents to underreport the misuse of prescription drugs

that occurred more than 12 months ago.

Initiation of Prescription Tranquilizer Misuse

Among people aged 12 or older in 2020, 950,000 people

initiated prescription tranquilizer misuse in the past year

(Figure 21). Among adults aged 26 or older, 557,000 people

initiated prescription tranquilizer misuse (Table A.21A).

Among young adults aged 18 to 25 and adolescents

aged 12 to 17, 290,000 and 103,000 people initiated

prescription tranquilizer misuse in the past year, respectively

(Tables A.19A and A.20A).

Initiation of Prescription Sedative Misuse

Among people aged 12 or older in 2020, 343,000 people

initiated prescription sedative misuse (Figure 21). Nearly

three fourths of past year initiates tried prescription sedatives

for the ﬁrst time after age 25. Corresponding numbers of

initiates of prescription sedative misuse by age group were

18,000 adolescents aged 12 to 17, 77,000 young adults aged

18 to 25, and 249,000 adults aged 26 or older (

Tables A.19A

to A.21A).

Initiation of Prescription Pain Reliever Misuse

Among people aged 12 or older in 2020, 1.2 million people

initiated prescription pain reliever misuse in the past year

(Figure 24). Nearly two thirds of past year initiates tried

prescription pain relievers for the ﬁrst time after age 25.

Among adults aged 26 or older, 774,000 people initiated

prescription pain reliever misuse. Among young adults

aged 18 to 25 and adolescents aged 12 to 17, the numbers

of people who initiated prescription pain reliever misuse

in the past year were 290,000 people and 158,000 people,

respectively.

Figure 24. Past Year Prescription Pain Reliever Misuse Initiates:

Among People Aged 12 or Older; 2015-2020

Past Year Initiates (in Thousands)

0

500

1,000

1,500

2,000

2,500

202020192018201720162015

12 or OlderAge Category: 12 to 17

Years

18 to 25 26 or Older

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 24 Table. Past Year Prescription Pain Reliever Misuse Initiates:

Among People Aged 12 or Older; 2015-2020

Age 2015 2016 2017 2018 2019 2020

12 or Older

2,126 2,139 2,010 1,908 1,607 1,223

12 to 17

415 423 316 310 245 158

18 to 25

596 585 465 464 404 290

26 or Older

1,114 1,130 1,229 1,134 958 774

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health26 | October 2021

Perceived Risk from Substance Use

One factor that can inﬂuence whether people will use

tobacco, alcohol, or illicit drugs is the extent to which

they believe that using these substances might cause harm.

In 2020, NSDUH respondents were asked how much they

thought people risk harming themselves physically and

in other ways when they use various substances in certain

amounts or frequencies. Response choices for these items

were “great risk,” “moderate risk,” “slight risk,” or “no risk.”

Depending on the substance, respondents were asked about

their perceived risk of harm from using a substance daily or

using a substance once or twice a week (i.e., weekly use).

Figure 25 presents the percentages of people aged 12 or older

in 2015 to 2020 who perceived great risk of harm from the

use of various substances. Risk perceptions across substances

are not compared because of variations in the quantity

and frequency of use across these substances.

60

e 2020

NSDUH detailed tables include additional measures of risk

perceptions from substance use.

Among people aged 12 or older in 2020, 70.7 percent of

people perceived great risk of harm from smoking one or

more packs of cigarettes a day, and 68.7 percent perceived

great risk from having four or ﬁve alcoholic drinks nearly

every day. (For brevity, this level of alcohol consumption

on a single day is subsequently referred to as “daily binge

drinking.”) Percentages of people who perceived great risk

from cocaine or heroin use once or twice a week were 84.7

and 93.2 percent, respectively. In contrast, about one fourth

of people (27.4 percent) perceived great risk from smoking

marijuana once or twice a week.

In 2020, perceptions of great risk of harm from substance

use varied by substance and age. For example, adults aged

26 or older were more likely than adolescents aged 12 to

17 or young adults aged 18 to 25 to perceive great risk of

harm from smoking one or more packs of cigarettes per day

or to perceive great risk of harm from daily binge drinking

(

Tables A.23B to A.25B).

Young adults aged 18 to 25 in 2020 were less likely than

adolescents aged 12 to 17 or adults aged 26 or older to

perceive great risk of harm from smoking marijuana weekly.

Research has identiﬁed associations among adults between

decreases in perceptions of great risk of harm from smoking

marijuana weekly and increases in marijuana use.

61,62

Nevertheless, people can experience adverse eﬀects from

marijuana use, such as marijuana use disorder or injury

resulting from operating a motor vehicle while impaired by

marijuana.

63,64

erefore, it is necessary to educate young

adults about adverse eﬀects of marijuana use.

Finally, adolescents aged 12 to 17 in 2020 were less likely

than young adults aged 18 to 25 or adults aged 26 or older

to perceive great risk from using heroin or cocaine weekly.

Additional data on ﬁner age group categories that can be

found in the 2020 detailed tables (available at https://www.

samhsa.gov/data/) indicate that the lower likelihood of

adolescents than adults to perceive great risk of harm from

cocaine and heroin use may be attributable to a general lack

of knowledge about these substances among adolescents

because younger adolescents aged 12 or 13 tended to have

lower perceptions of the risk of harm compared with older

adolescents or adults. us, age-speciﬁc communications are

imperative from a public health perspective to help people

fully understand important harms associated with the use of

speciﬁc substances.

Figure 25. Perceived Great Risk from Substance Use: Among

People Aged 12 or Older; 2015-2020

Smoking Marijuana Weekly

Using Cocaine Weekly

Using Heroin Weekly

Having 4 or 5 Drinks of

Alcohol Daily

Smoking One or More

Packs of Cigarettes per Day

Percent Perceived Great Risk

Years

Substance Use:

0

20

40

60

80

100

202020192018201720162015

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 25 Table. Perceived Great Risk from Substance Use: Among People

Aged 12 or Older; 2015-2020

Substance Use 2015 2016 2017 2018 2019 2020

Smoking Marijuana Once or Twice a Week

36.3 34.0 31.9 30.6 29.2 27.4

Using Cocaine Once or Twice a Week

87.4 87.1 86.8 86.5 85.7 84.7

Using Heroin Once or Twice a Week

94.2 94.1 94.5 94.3 93.8 93.2

Having 4 or 5 Drinks of Alcohol Nearly Every Day

68.7 68.3 68.9 68.5 67.9 68.7

Smoking One or More Packs of Cigarettes per Day

72.8 72.8 71.6 71.8 71.2 70.7

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 27

Substance Use Disorders in the Past Year

Substance use disorders (SUDs) are characterized by

impairment caused by the recurrent use of alcohol or other

drugs (or both), including health problems, disability, and

failure to meet major responsibilities at work, school, or

home. e 2020 NSDUH included a series of questions

to estimate the percentage of the population aged 12 or

older who had at least one SUD in the past 12 months

(subsequently referred to as “an SUD” or “a past year SUD,”

except when “SUDs” refer to more than one substance,

such as SUDs for the misuse of speciﬁc prescription drugs).

e SUD questions assess the presence of an SUD in the

past 12 months based on criteria speciﬁed in the Diagnostic

and Statistical Manual of Mental Disorders, 5th edition

(DSM-5).

17,65

Respondents were asked SUD questions

for any alcohol or illicit drugs they used in the 12 months

prior to the survey. Illicit drugs include marijuana, cocaine

(including crack), heroin, hallucinogens, inhalants, and

methamphetamine, as well as the misuse of prescription

stimulants, tranquilizers or sedatives (e.g., benzodiazepines),

and pain relievers.

14

e 2020 NSDUH marked the ﬁrst year in which SUDs

were assessed using the DSM-5 criteria as opposed to the

DSM-IV criteria.

18,66,67

In DSM-IV, the criteria are grouped

into the diagnoses of dependence and abuse. Respondents

were categorized as having an SUD if they met either of the

following: (1) the presence of three or more of the diagnostic

criteria of dependence for a given substance or substance

class (e.g., prescription tranquilizers), or (2) they met one

or more criteria of abuse for that substance or substance

class. Although DSM-5 assesses many of the same criteria as

DSM-IV, it does not include the diagnoses of dependence

and abuse. A DSM-5 SUD diagnosis requires the presence

of two or more of the following criteria (as measured in the

2020 NSDUH) in a 12-month period:

1. e substance is often taken in larger amounts or over

a longer period than intended.

2. ere is a persistent desire or unsuccessful eﬀorts to

cut down or control substance use.

3. A great deal of time is spent in activities necessary to

obtain the substance, use the substance, or recover

from its eﬀects.

4. ere is a craving, or a strong desire or urge, to use the

substance.

5. ere is recurrent substance use resulting in a failure

to fulﬁll major role obligations at work, school, or

home.

6. ere is continued substance use despite having

persistent or recurrent social or interpersonal problems

caused by or exacerbated by the eﬀects of the

substance.

7. Important social, occupational, or recreational

activities are given up or reduced because of substance

use.

8. ere is recurrent substance use in situations in which

it is physically hazardous.

9. Substance use is continued despite knowledge

of having a persistent or recurrent physical or

psychological problem that is likely to have been

caused or exacerbated by the substance.

10. ere is a need for markedly increased amounts of the

substance to achieve intoxication or the desired eﬀect,

or markedly diminished eﬀect with continued use of

the same amount of the substance (i.e., tolerance).

11. ere are a required number of withdrawal symptoms

that occur when substance use is cut back or stopped

following a period of prolonged use.

68

(Hallucinogen

use disorder and inhalant use disorder do not have a

withdrawal syndrome associated with discontinued

use. erefore, withdrawal is not a criterion of either

of these two disorders.)

Questions were added to the 2020 NSDUH questionnaire

to assess craving, marijuana withdrawal, and tranquilizer

withdrawal. Craving and marijuana withdrawal were not

assessed in prior surveys because they are not part of the

DSM-IV SUD criteria. Although tranquilizer withdrawal

is part of the DSM-IV criteria, this symptom had not

been assessed in prior NSDUHs because some substances

previously included in the questionnaire that were classiﬁed

as tranquilizers do not have a withdrawal component.

is change from DSM-IV to DSM-5 criteria for assessing

SUDs led to breaks in the comparability of 2020 SUD

estimates with estimates from prior years. Consequently,

this section presents SUD estimates for 2020 only. Readers

are cautioned that apparent diﬀerences between 2020 SUD

estimates based on DSM-5 criteria and published SUD

estimates from prior years based on DSM-IV criteria could

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health28 | October 2021

reﬂect changes in deﬁnitions and measurement rather than

real changes in SUD in the population.

For example, Goldstein and colleagues demonstrated the

lack of concordance between estimates of SUD derived using

the DSM-IV criteria and those derived using the DSM-5

criteria.

69

Using data from the National Epidemiologic

Survey on Alcohol and Related Conditions-III (NESARC-

III) that were scored using both the DSM-IV and DSM-5

criteria, the authors found that the past year prevalence

estimates for DSM-5 alcohol use disorder, sedative/

tranquilizer use disorder, opioid use disorder, and heroin

use disorder were higher than the corresponding DSM-IV

prevalence estimates for those disorders. Conversely, the

past year prevalence estimates for cannabis use disorder,

cocaine use disorder, and stimulant use disorder were lower

than the respective DSM-IV estimates for those disorders.

In 2020, 40.3 million people aged 12 or older (or 14.5 percent

of this population) had an SUD in the past year, including

28.3 million who had alcohol use disorder and 18.4 million

who had an illicit drug use disorder (Figures 26 and 27).

Among the 28.3 million people with past year alcohol use

disorder, 21.9 million had alcohol use disorder but not an

illicit drug use disorder. Among the 18.4 million people with

a past year illicit drug use disorder, 11.9 million had an illicit

drug use disorder but not alcohol use disorder. Among people

with a past year SUD, 16.0 percent (or 6.5 million people) had

both alcohol use disorder and an illicit drug use disorder in the

past year (Figure 28).

33

e percentage of people in 2020 with a past year SUD

diﬀered by age group. e percentage was highest among

young adults aged 18 to 25 (24.4 percent or 8.2 million

people), followed by adults aged 26 or older (14.0 percent

or 30.5 million people), then by adolescents aged 12 to 17

(6.3 percent or 1.6 million people) (Figure 26).

Alcohol Use Disorder

Respondents who used alcohol on 6 or more days in the

past 12 months were classiﬁed as having alcohol use disorder

if they met two or more of the DSM-5 criteria for alcohol

use disorder. Relevant criteria for alcohol use disorder can be

found in a glossary of key deﬁnitions for the 2020 NSDUH.

10

Among people aged 12 or older in 2020, 10.2 percent

(28.3 million people) had a past year alcohol use disorder

(Figures 26 and 27). e percentage of people who had

past year alcohol use disorder was highest among young

adults aged 18 to 25 (15.6 percent or 5.2 million people),

followed by adults aged 26 or older (10.3 percent or

22.4 million people), then by adolescents aged 12 to 17

(2.8 percent or 712,000 people). Age group diﬀerences in

the percentage of people with alcohol use disorder in the

past year were consistent with the age group diﬀerences in

the 2020 detailed tables for alcohol use in the past year

70

and

diﬀerences described previously for binge and heavy alcohol

use in the past month.

Illicit Drug Use Disorder

is section presents overall estimates for illicit drug use

disorder, then provides SUD estimates for selected speciﬁc

illicit drugs. Illicit drug use disorder was deﬁned as meeting

DSM-5 SUD criteria for one or more of the following illicit

drugs: marijuana, cocaine, heroin, hallucinogens, inhalants,

methamphetamine, or prescription psychotherapeutic

drugs that were misused (i.e., stimulants, tranquilizers or

sedatives, and pain relievers).

71

Respondents were classiﬁed

as having an opioid use disorder if they met DSM-5 criteria

for heroin use disorder or prescription pain reliever use

disorder (or both). Respondents were classiﬁed as having

a central nervous system (CNS) stimulant use disorder

if they met DSM-5 criteria for cocaine use disorder,

Figure 26. Substance Use Disorder, Alcohol Use Disorder, and

Illicit Drug Use Disorder in the Past Year: Among People Aged 12

or Older; 2020

14.5

10.2

6.6

6.3

2.8

4.9

24.4

15.6

14.6

14.0

10.3

5.6

0

5

10

15

20

25

30

Substance Use Disorder Alcohol Use Disorder Illicit Drug Use Disorder

Percent with Disorder in Past Year

12 or Older 12 to 17 18 to 25 26 or Older

Age Category:

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 29

methamphetamine use disorder, or prescription stimulant

use disorder (or more than one of these disorders). Relevant

deﬁnitions for SUDs for speciﬁc illicit drugs can be found in

a glossary of key deﬁnitions for the 2020 NSDUH.

10

Among people aged 12 or older in 2020, 6.6 percent (or

18.4 million people) had at least one illicit drug use disorder

in the past year (Figures 26 and

27

). e percentage of

young adults aged 18 to 25 (14.6 percent or 4.9 million

people) was higher than the percentages of adolescents aged

12 to 17 (4.9 percent or 1.2 million people) or adults aged

26 or older (5.6 percent or 12.3 million people). e higher

percentage of young adults with at least one illicit drug use

disorder was consistent with the higher percentage among

this age group for illicit drug use in the past year.

Marijuana Use Disorder

Among people aged 12 or older in 2020, 5.1 percent (or

14.2 million people) had a marijuana use disorder in the past

year (Figures 27 and 29). e percentage of young adults aged

18 to 25 (13.5 percent or 4.5 million people) was higher than

the percentages of adolescents aged 12 to 17 (4.1 percent or

1.0 million people) or adults aged 26 or older (4.0 percent or

8.7 million people). e higher percentage of young adults

with a marijuana use disorder was consistent with the higher

percentage among this age group for marijuana use in the

past year.

Cocaine Use Disorder

Among people aged 12 or older in 2020, 0.5 percent

(or 1.3 million people) had a cocaine use disorder in the

past year (Figure 27 and Table A.26B). e percentage of

adolescents aged 12 to 17 (0.1 percent or 28,000 people)

was lower than the percentages of young adults aged 18 to

25 (0.7 percent or 234,000 people) or adults aged 26 or

older (0.5 percent or 1.0 million people).

Heroin Use Disorder

Among people aged 12 or older in 2020, 0.2 percent (or

691,000 people) had a heroin use disorder in the past year

(Figure 27 and Table A.26B). Estimates for adolescents

aged 12 to 17 who had a heroin use disorder in the

past year could not be calculated with suﬃcient precision.

Among young adults aged 18 to 25 in 2020, 0.1 percent

(or 40,000 people) had a heroin use disorder in the

past year. Among adults aged 26 or older in 2020,

0.3 percent (or 652,000 people) had a heroin use disorder in

the past year.

Figure 27. People Aged 12 or Older with a Past Year Substance Use Disorder (SUD); 2020

28.3M

18.4M

14.2M

2.3M

1.5M

1.3M

758,000

691,000

0 10 20 30

Alcohol Use Disorder

Illicit Drug Use Disorder

Marijuana Use Disorder

Pain Reliever Use Disorder

Methamphetamine Use Disorder

Cocaine Use Disorder

Stimulant Use Disorder

Heroin Use Disorder

Number of People with Speciﬁc Past Year SUD

Past Year SUD

40.3 Million People

(14.5%)

No Past Year SUD

236.6 Million People

(85.5%)

Note: The estimated numbers of people with substance use disorders are not mutually exclusive because people could have use disorders for more than one substance.

Figure 28. Alcohol Use Disorder (AUD) and Illicit Drug Use

Disorder (IDUD) in the Past Year: Among People Aged 12 or Older

with a Past Year Substance Use Disorder (SUD); 2020

People with

AUD Only

(54.3% of People

with SUD)

28.3 Million People

with AUD

(70.3% of People

with SUD)

People with AUD and IDUD

(16.0% of People with SUD)

18.4 Million People

with IDUD

(45.7% of People

with SUD)

People with

IDUD Only

(29.7% of People

with SUD)

40.3 Million People Aged 12 or Older with Past Year SUD

21.9

Million

6.5

Million

11.9

Million

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health30 | October 2021

Methamphetamine Use Disorder

Among people aged 12 or older in 2020, 0.6 percent (or

1.5 million people) had a methamphetamine use disorder in

the past year (Figures 27 and 29). e percentage of people

who had a methamphetamine use disorder in the past year

was highest among adults aged 26 or older (0.6 percent or

1.4 million people), followed by young adults aged 18 to 25

(0.3 percent or 95,000 people), then by adolescents aged 12

to 17 (0.1 percent or 21,000 people). Age group diﬀerences

in the percentage of people with a methamphetamine use

disorder in the past year were consistent with the age group

diﬀerences described previously for methamphetamine use in

the past year.

Prescription Stimulant Use Disorder

Among people aged 12 or older in 2020, 0.3 percent (or

758,000 people) had a prescription stimulant use disorder

in the past year (Figure 27 and Table A.26B). Among

adolescents aged 12 to 17 in 2020, 0.2 percent (or 43,000

people) had a prescription stimulant use disorder in the

past year. Among young adults aged 18 to 25 in 2020,

0.4 percent (or 141,000 people) had a prescription stimulant

use disorder in the past year. Among adults aged 26 or older

in 2020, 0.3 percent (or 574,000 people) had a prescription

stimulant use disorder in the past year.

Prescription Tranquilizer Use Disorder

or Sedative Use Disorder

Among people aged 12 or older in 2020, 0.4 percent

(or 1.2 million people) had a prescription tranquilizer

use disorder or sedative use disorder in the past year

(Table A.26B). e percentage of young adults aged 18 to

25 (0.7 percent or 235,000 people) was higher than the

percentages of adolescents aged 12 to 17 (0.3 percent or

73,000 people) or adults aged 26 or older (0.4 percent or

845,000 people). e higher percentage of young adults

with a prescription tranquilizer use disorder or sedative use

disorder was consistent with the higher percentage among

this age group for prescription tranquilizer or sedative misuse

in the past year.

Prescription Pain Reliever Use Disorder

Among people aged 12 or older in 2020, 0.8 percent (or

2.3 million people) had a prescription pain reliever use

disorder in the past year (Figures 27 and 29). e percentage

of adolescents aged 12 to 17 (0.3 percent or 80,000 people)

was lower than the percentages of young adults aged 18 to

25 (0.8 percent or 269,000 people) or adults aged 26 or

older (0.9 percent or 2.0 million people).

Opioid Use Disorder

Among people aged 12 or older in 2020, 1.0 percent (or

2.7 million people) had an opioid use disorder in the

past year (Table A.26B). e percentage of adolescents aged

12 to 17 (0.3 percent or 80,000 people) was lower than the

percentages of young adults aged 18 to 25 (0.9 percent or

286,000 people) or adults aged 26 or older (1.1 percent or

2.3 million people).

Central Nervous System Stimulant Use Disorder

Among people aged 12 or older in 2020, 1.1 percent (or

3.2 million people) had a CNS stimulant use disorder in the

past year (Table A.26B). e percentage of adolescents aged

12 to 17 (0.4 percent or 88,000 people) was lower than the

percentages of young adults aged 18 to 25 (1.3 percent or

423,000 people) or adults aged 26 or older (1.2 percent or

2.7 million people).

Figure 29. Marijuana Use Disorder, Pain Reliever Use Disorder,

and Methamphetamine Use Disorder in the Past Year: Among

People Aged 12 or Older; 2020

5.1

0.8

0.6

4.1

0.3

0.1

13.5

0.8

0.3

4.0

0.9

0.6

0

2

4

6

8

10

12

14

16

Marijuana Use Disorder Pain Reliever

Use Disorder

Methamphetamine

Use Disorder

Percent with Disorder in the Past Year

12 or Older 12 to 17 18 to 25 26 or Older

Age Category:

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 31

Major Depressive Episode in the Past Year

In the 2020 NSDUH, respondents were classiﬁed as

having had a major depressive episode (MDE) in the

past 12 months if (1) they had at least one period of 2 weeks

or longer in the past year when for most of the day nearly

every day, they felt depressed, or lost interest or pleasure in

daily activities; and (2) they also had problems with sleeping,

eating, energy, concentration, self-worth, or having recurrent

thoughts of death or recurrent suicidal ideation. e MDE

questions are based on diagnostic criteria from the DSM-5,

which require the presence of ﬁve or more symptoms during

the same 2-week period.

17

e wording for some depression

questions asked of adolescent respondents aged 12 to 17

diﬀered from the wording for similar questions asked of

adult respondents aged 18 or older. erefore, the MDE

estimates for adults and youths are not directly comparable

and are presented separately.

14,72,73

e 2020 NSDUH also collected data on whether an MDE

in the past year caused respondents to experience severe

impairment in four major life activities or role domains.

ese domains were deﬁned separately for youths aged 12

to 17 and adults aged 18 or older to reﬂect the diﬀerent

roles associated with the two age groups. Adolescents were

classiﬁed as having an MDE with severe impairment if their

depression caused severe problems with their ability to do

chores at home, do well at work or school, get along with

their family, or have a social life.

74

Adults were classiﬁed as

having an MDE with severe impairment if their depression

caused severe problems with their ability to manage at home

or work, have relationships with others, or have a social

life.

75

As noted in the section titled Changes to Data Collection

Methods Because of the COVID-19 Pandemic, Quarter

4 of 2020 (i.e., October to December) marked the ﬁrst

time that NSDUH used web-based interviewing. However,

the number of adult web respondents in Quarter 4 who

provided usable information on their substance use

76

but

did not complete the mental health or later questions (i.e.,

“break-oﬀs”) raised concerns about the 2020 mental health

estimates for adults. Speciﬁcally, mental health estimates

for adults could be biased

77

if the characteristics of adult

respondents who broke oﬀ the interview without completing

the mental health questions diﬀered from the characteristics

of respondents who completed these questions. To reduce

the potential for bias, a set of break-oﬀ analysis weights was

developed for estimates of adults’ mental health data for

2020, including the estimates for MDE among adults.

78

MDE and MDE with Severe Impairment among

Adolescents

Among adolescents aged 12 to 17 in 2020, 17.0 percent (or

4.1 million people) had a past year MDE (Figure 30). An

estimated 12.0 percent of adolescents (or 2.9 million people)

in 2020 had a past year MDE with severe impairment.

MDE and MDE with Severe Impairment among Adults

Among adults aged 18 or older in 2020, 8.4 percent (or

21.0 million people) had a past year MDE (Table A.28B).

e percentage was highest among young adults aged 18 to

25 (17.0 percent or 5.6 million people), followed by adults

aged 26 to 49 (9.1 percent or 9.2 million people), then by

adults aged 50 or older (5.4 percent or 6.2 million people).

An estimated 6.0 percent of adults aged 18 or older

(or 14.8 million people) in 2020 had a past year MDE

with severe impairment (Figure 31). e percentage was

highest among young adults aged 18 to 25 (12.1 percent

or 4.0 million people), followed by adults aged 26 to 49

(6.5 percent or 6.5 million people), then by adults aged 50

or older (3.8 percent or 4.4 million people).

Figure 30. Major Depressive Episode (MDE) and MDE with Severe

Impairment in the Past Year: Among Youths Aged 12 to 17;

2004-2020

Percent with MDE or MDE with

Severe Impairment in Past Year

0

5

10

15

20

2019181716151413121110090807060504

MDE Status:

Years

MDE

MDE with Severe Impairment

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 30 Table. Major Depressive Episode (MDE) and MDE with Severe

Impairment in the Past Year: Among Youths Aged 12 to 17; 2004-2020

MDE Status 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

MDE

9.0 8.8 7.9 8.2 8.3 8.1 8.0 8.2 9.1 10.7 11.4 12.5 12.8 13.3 14.4 15.7 17.0

MDE with Severe

Impairment

N/A N/A 5.5 5.5 6.0 5.8 5.7 5.7 6.3 7.7 8.2 8.8 9.0 9.4 10.0 11.1 12.0

N/A = not available.

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health32 | October 2021

Any Mental Illness among Adults in the Past Year

e 2020 NSDUH provided estimates of any mental illness

(AMI) and serious mental illness (SMI) for adults aged 18 or

older. Adults aged 18 or older were classiﬁed as having AMI

if they had any mental, behavioral, or emotional disorder

in the past year of suﬃcient duration to meet DSM-IV

criteria (excluding developmental disorders and SUDs).

18,79

Adults who were classiﬁed as having AMI were classiﬁed as

having SMI if they had any mental, behavioral, or emotional

disorder that substantially interfered with or limited one or

more major life activities. Statistical prediction models that

were developed using clinical interview data from a subset

of NSDUH adult respondents in 2008 to 2012 were used

to classify whether respondents in the 2008 to 2020 adult

samples had AMI or SMI in the past year.

80

As noted previously, a set of break-oﬀ analysis weights was

developed for adults’ mental health data for 2020. Estimates

of AMI and SMI for 2020 used these break-oﬀ analysis

weights.

Among adults aged 18 or older in 2020, 21.0 percent

(or 52.9 million people) had AMI in the past year

(Table A.29B). e percentage was highest among young

adults aged 18 to 25 (30.6 percent or 10.2 million

people), followed by adults aged 26 to 49 (25.3 percent

or 25.7 million people), then by adults aged 50 or older

(14.5 percent or 16.9 million people).

Serious Mental Illness among Adults in the

Past Year

Among adults aged 18 or older in 2020, 5.6 percent (or

14.2 million people) had SMI in the past year (Figure 32).

Consistent with the age group pattern for AMI, the

percentage of adults with SMI was highest among young

adults aged 18 to 25 (9.7 percent or 3.3 million people),

followed by adults aged 26 to 49 (6.9 percent or 7.0 million

people), then by adults aged 50 or older (3.4 percent or

4.0 million people).

Figure 32. Serious Mental Illness in the Past Year: Among Adults

Aged 18 or Older; 2008-2020

Percent with Serious Mental Illness

in Past Year

0

2

4

6

8

10

20191817161514131211100908

18 or Older 18 to 25 26 to 49 50 or Older

Age Category:

Years

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 32 Table. Serious Mental Illness in the Past Year: Among Adults Aged

18 or Older; 2008-2020

Age 08 09 10 11 12 13 14 15 16 17 18 19 20

18 or Older

3.7 3.7 4.1 3.9 4.1 4.2 4.1 4.0 4.2 4.5 4.6 5.2 5.6

18 to 25

3.8 3.3 3.9 3.8 4.1 4.2 4.8 5.0 5.9 7.5 7.7 8.6 9.7

26 to 49

4.8 4.9 5.2 5.0 5.2 5.3 4.9 5.0 5.3 5.6 5.9 6.8 6.9

50 or Older

2.5 2.5 3.0 2.8 3.0 3.2 3.1 2.8 2.7 2.7 2.5 2.9 3.4

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Figure 31. Major Depressive Episode with Severe Impairment in

the Past Year: Among Adults Aged 18 or Older; 2009-2020

Percent with Major Depressive Episode

with Severe Impairment in Past Year

0

5

10

15

202020192018201720162015201420132012201120102009

18 or Older 18 to 25 26 to 49 50 or Older

Age Category:

Years

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 31 Table. Major Depressive Episode with Severe Impairment in the

Past Year: Among Adults Aged 18 or Older; 2009-2020

Age 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

18 or Older

4.0 4.2 4.2 4.5 4.3 4.3 4.3 4.3 4.5 4.7 5.3 6.0

18 to 25

5.2 5.2 5.2 5.8 5.7 6.0 6.5 7.0 8.5 8.9 10.3 12.1

26 to 49

4.8 4.7 5.2 5.1 4.9 4.6 4.9 4.7 5.0 5.3 6.1 6.5

50 or Older

2.6 3.5 2.9 3.4 3.2 3.5 3.0 3.0 2.8 2.9 3.2 3.8

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 33

Co‑Occurring MDE and SUD among Adolescents

Adolescents aged 12 to 17 who had both a past year MDE

and a past year SUD (i.e., illicit drug use disorder, alcohol use

disorder, or both) were classiﬁed as having co-occurring MDE

and SUD. e order of the onset of an SUD relative to the

onset of an MDE among adolescents cannot be established

based on the NSDUH data (e.g., whether the onset of an

SUD preceded the onset of an MDE, or vice versa).

As noted previously, the 2020 NSDUH marked the ﬁrst year

in which SUDs were evaluated based on DSM-5 criteria as

opposed to DSM-IV criteria.

17,18

e Substance Use Disorders

in the Past Year section in this report brieﬂy describes the

DSM-5 criteria and highlights key diﬀerences between the

DSM-5 and DSM-IV criteria. e breaks in the comparability

of 2020 SUD estimates with estimates from prior years also

aﬀected the comparability of 2020 estimates with previous

years’ estimates for co-occurring MDE and SUD among

adolescents. Consequently, estimates of co-occurring MDE

and SUD among adolescents are presented for 2020 only.

Among adolescents aged 12 to 17 in 2020, 20.9 percent (or

5.1 million people) had either an SUD or an MDE in the

past year, 14.4 percent (or 3.5 million people) had an MDE

but not an SUD, 3.7 percent (or 900,000 people) had an

SUD but not an MDE, and 2.7 percent (or 644,000 people)

had both an MDE and an SUD in the past year (Figure 33

and Table A.30AB).

In addition, among adolescents aged 12 to 17 in 2020,

1.8 percent (or 447,000 people) had both an MDE with

severe impairment and an SUD in the past year.

Substance Use among Adolescents with MDE

Adolescents aged 12 to 17 who had a past year MDE

were more likely to use some substances in the past year

or past month compared with their counterparts who did

not have an MDE in the past year. In 2020, adolescents

with a past year MDE were more likely than adolescents

without a past year MDE to be past year illicit drug users

(28.6 vs. 10.7 percent) or past year marijuana users (22.0 vs.

7.9 percent) (Figure 34). Adolescents with a past year MDE

also were more likely than those without a past year MDE

to be past month binge alcohol users (6.2 vs. 3.8 percent).

Adolescents with a past year MDE also were more likely than

those without a past year MDE to use tobacco products or

vape nicotine in the past month (12.9 vs. 5.1 percent).

Figure 33. Past Year Substance Use Disorder (SUD) and Major

Depressive Episode (MDE): Among Youths Aged 12 to 17; 2020

1.6 Million Youths

Had SUD

Youths Had

SUD but

Not MDE

Youths Had SUD and MDE

Youths Had

MDE but

Not SUD

4.1 Million Youths

Had MDE

900,000 644,000

3.5

Million

5.1 Million Youths Had Either SUD or MDE

Note: Youth respondents with unknown MDE data were excluded.

Figure 34. Substance Use: Among Youths Aged 12 to 17; by Past

Year Major Depressive Episode (MDE) Status, 2020

28.6

+

22.0

+

2.3

6.2

+

12.9

+

10.7

7.9

1.4

3.8

5.1

0

5

10

15

20

25

30

35

Illicit Drugs,

Past Year

Marijuana,

Past Year

Opioids,

Past Year

Binge Alcohol,

Past Month

Tobacco

Products or

Nicotine Vaping,

Past Month

Percent Using

Had MDE

Did Not Have MDE

+

Difference between this estimate and the estimate for youths without MDE is statistically significant

at the .05 level.

Note: Youth respondents with unknown MDE data were excluded.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health34 | October 2021

Co‑Occurring Mental Health Issues and SUD

among Adults

Among adults aged 18 or older, having AMI and an SUD

in the past year is referred to as having co-occurring AMI

and SUD. Adults having SMI and an SUD in the past year

are referred to as having co-occurring SMI and SUD.

However, the order of the onset of SUDs relative to the

onset of mental disorders cannot be established based on the

NSDUH data for adults (e.g., whether the onset of SUDs

preceded the onset of mental disorders, or vice versa).

As noted previously, the 2020 NSDUH marked the ﬁrst

year in which SUDs were evaluated based on DSM-5

criteria as opposed to DSM-IV criteria.

17,18

e Substance

Use Disorders in the Past Year section in this report brieﬂy

describes the DSM-5 criteria and highlights key diﬀerences

between the DSM-5 and DSM-IV criteria. e breaks in the

comparability of 2020 SUD estimates with estimates from

prior years also aﬀected the comparability of 2020 estimates

of co-occurring mental health issues and SUD among adults.

Consequently, estimates of co-occurring mental health issues

and SUD among adults are presented for 2020 only.

Co‑Occurring AMI and SUD

Among adults aged 18 or older in 2020, 29.3 percent (or

73.8 million people) had either AMI or an SUD in the

past year, 14.2 percent (or 35.9 million people) had AMI but

not an SUD, 8.3 percent (or 20.9 million people) had an

SUD but not AMI, and 6.7 percent (or 17.0 million people)

had both AMI and an SUD (Figure 35 and Table A.32B).

Co‑Occurring SMI and SUD

Among adults aged 18 or older in 2020, 18.4 percent (or

46.5 million people) had either SMI or an SUD in the

past year, 3.4 percent (or 8.5 million people) had SMI but

not an SUD, 12.8 percent (or 32.3 million people) had an

SUD but not SMI, and 2.2 percent (or 5.7 million people)

had both SMI and an SUD (Figure 36 and Table A.32B).

Substance Use among Adults, byMental

Illness Status

is section discusses how the prevalence of substance use

among adults aged 18 or older diﬀered based on past year

mental illness status. Among adults aged 18 or older in 2020,

those with SMI or AMI in the past year were more likely than

those without mental illness in the past year to be past year

users of illicit drugs (47.8 percent for SMI and 39.8 percent

for AMI vs. 17.0 percent for adults with no mental illness),

past year users of marijuana (39.2 and 32.8 percent vs.

14.6 percent), or past year misusers of opioids (i.e., heroin

users or misusers of prescription pain relievers) (11.6 and

8.1 percent vs. 2.3 percent). In addition, adults with SMI or

AMI were more likely than adults with no mental illness in

the past year to be past month binge alcohol users (30.9 and

28.5 percent vs. 22.8 percent). Adults with SMI or AMI were

more likely to use tobacco products or vape nicotine in the

past month than adults with no mental illness in the past year

(37.4 and 30.9 percent vs. 19.6 percent) (Figure 37).

Figure 35. Past Year Substance Use Disorder (SUD) and Any

Mental Illness (AMI): Among Adults Aged 18 or Older; 2020

37.9 Million

Adults Had SUD

but Not AMI

Adults Had SUD

and AMI

Adults Had AMI

but Not SUD

52.9 Million Adults

Had AMI

20.9

Million

17.0

Million

35.9

Million

73.8 Million Adults Had Either SUD or AMI

Figure 36. Past Year Substance Use Disorder (SUD) and Serious

Mental Illness (SMI): Among Adults Aged 18 or Older; 2020

37.9 Million

Adults Had SUD

Adults Had

SUD but

Not SMI

Adults Had SUD and SMI

Adults Had

SMI but

Not SUD

14.2 Million

Adults Had SMI

32.3

Million

5.7

Million

8.5

Million

46.5 Million Adults Had Either SUD or SMI

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 35

Suicidal Thoughts and Behaviors among Adults

Suicide is a leading cause of death and an important public

health problem in the United States.

81

It is a tragedy

for all involved—the people and their families, friends,

neighbors, colleagues, and communities. Provisional data

from the National Vital Statistics System indicate that in

2020, 44,834 people in the United States died by suicide.

82

Moreover, suicide rates increased in most states between

1999 and 2016, including increases by more than 30 percent

in 25 states over this period.

83

Furthermore, suicide rates

continued to increase nationally from 2016 to 2018.

84,85

More than 90 percent of deaths by suicide in 2018 and 2019

were among adults aged 20 or older.

86

However, people who

die by suicide represent a fraction of those who consider

or attempt suicide.

87

Out of every 31 adults in 2008 to

2011 in the United States who attempted suicide in the

past 12 months, there was 1 death by suicide.

88

Since 2008, NSDUH respondents aged 18 or older have

been asked if at any time during the past 12 months they

had thought seriously about trying to kill themselves (serious

thoughts of suicide). Adults who had serious thoughts of

suicide in the past 12 months were asked whether they

made a plan to kill themselves (suicide plan) or tried to kill

themselves (suicide attempt) in that period. is information

helps guide suicide prevention programs and clinical

intervention eﬀorts.

Serious Thoughts of Suicide among Adults

Among adults aged 18 or older in 2020, 4.9 percent (or

12.2 million people) had serious thoughts of suicide in

the past year (Figures 38 and 39). e percentage was

highest among young adults aged 18 to 25 (11.3 percent

or 3.8 million people), followed by adults aged 26 to 49

(5.3 percent or 5.3 million people), then by adults aged 50

or older (2.7 percent or 3.1 million people).

Suicide Plans among Adults

Among adults aged 18 or older in 2020, 1.3 percent (or

3.2 million people) made a suicide plan in the past year

(Figures 38 and 39). e percentage was highest among

young adults aged 18 to 25 (4.0 percent or 1.3 million

people), followed by adults aged 26 to 49 (1.3 percent

or 1.4 million people), then by adults aged 50 or older

(0.4 percent or 519,000 people).

Suicide Attempts among Adults

Among adults aged 18 or older in 2020, 0.5 percent (or

1.2 million people) attempted suicide in the past 12 months

(Figures 38 and 39). e percentage was highest among

young adults aged 18 to 25 (1.9 percent or 627,000 people),

followed by adults aged 26 to 49 (0.4 percent or 452,000

people), then by adults aged 50 or older (0.1 percent or

124,000 people).

Suicidal Thoughts and Behaviors among Adults

Because of COVID‑19

During the COVID-19 pandemic, people with mental

illness may experience worsening mental health problems

Figure 37. Substance Use: Among Adults Aged 18 or Older; by

Mental Illness Status, 2020

39.8

+

32.8

+

8.1

+

28.5

+

30.9

+

47.8

+

39.2

+

11.6

+

30.9

+

37.4

+

17.0

14.6

2.3

22.8

19.6

0

10

20

30

40

50

60

Illicit Drugs,

Past Year

Marijuana,

Past Year

Opioids,

Past Year

Binge Alcohol,

Past Month

Tobacco

Products or

Nicotine Vaping,

Past Month

Percent Using

Any Mental Illness

Serious Mental Illness

No Mental Illness

+

Difference between this estimate and the estimate for adults without mental illness is statistically

significant at the .05 level.

Figure 38. Adults Aged 18 or Older with Serious Thoughts of

Suicide, Suicide Plans, or Suicide Attempts in the Past Year; 2020

3.2 Million

Made

Suicide Plans

12.2 Million Adults Had Serious Thoughts of Suicide

1.2 Million

Attempted

Suicide

920,000

Made Plans

and Attempted

Suicide

283,000

Made No Plans

and Attempted

Suicide

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health36 | October 2021

and associated symptoms, such as thoughts of suicide. Other

people may develop new mental health problems, such as

depression, anxiety, or posttraumatic stress disorder, all of

which are associated with increased suicide risk.

89

To better understand the potential impact of the COVID-19

pandemic on suicidal thoughts and behaviors among adults

in the United States, new questions were added to the

NSDUH questionnaire for Quarter 4 of 2020. erefore,

estimates are limited to data that were collected from adult

respondents from October to December 2020. If adult

respondents reported that they thought seriously about

trying to kill themselves in the past 12 months, they were

asked if they had these suicidal thoughts because of the

COVID-19 pandemic. Adult respondents who reported

plans to kill themselves or who tried to kill themselves were

also asked if they made these plans or tried to kill themselves

because of the COVID-19 pandemic.

Among adults aged 18 or older in 2020 who had serious

thoughts of suicide in the past year, 21.1 percent (or

2.5 million people) had serious thoughts of suicide because

of the COVID-19 pandemic. Among adults who made a

suicide plan in the past year, 8.5 percent (or 266,000 people)

made a suicide plan because of the COVID-19 pandemic

(Table A.35B).

Among adults in 2020 who had serious thoughts of suicide

in the past year, similar percentages of young adults aged

18 to 25 and adults aged 26 to 49 had serious thoughts of

suicide because of the COVID-19 pandemic (22.6 percent

or 802,000 young adults aged 18 to 25 and 19.1 percent or

1.0 million adults aged 26 to 49). Corresponding estimates

of adults aged 50 or older with serious thoughts of suicide

because of the COVID-19 pandemic are not presented due

to low statistical precision.

13

Suicidal Thoughts and Behaviors among

Adolescents

Trends in suicide attempts and deaths by suicide have

been increasing among adolescents.

90,91

ese trends in

suicidal behaviors among adolescents are major public

health concerns in the United States.

92,93

Vulnerable

adolescent populations exposed to adverse childhood

experiences (ACEs) are at greater risk of suicide and related

behaviors.

94,95,96

In the midst of the COVID-19 pandemic,

preliminary data suggest a rise in suicide-related emergency

department visits, particularly among adolescents.

97

To better understand suicidal thoughts and behaviors

among adolescents, new questions were added to the

NSDUH questionnaire for Quarter 4 of 2020. erefore,

estimates are limited to data that were collected from

adolescent respondents from October to December 2020.

In Quarter 4, adolescent respondents were asked if they

seriously thought about trying to kill themselves, if they

made plans to kill themselves, and if they had tried to kill

themselves in the past 12 months. Unlike the questions for

adults, the questions for adolescent respondents included

the response options “I’m not sure” and “I don’t want to

answer.”

e new follow-up questions were such that if adolescent

respondents reported that they thought seriously about trying

to kill themselves in the past 12 months, they were asked if

they had these suicidal thoughts because of the COVID-19

pandemic. Adolescent respondents who reported plans to kill

themselves or who tried to kill themselves were also asked

if they had these plans or tried to kill themselves because of

the COVID-19 pandemic. Due to low statistical precision,

however, estimates are not presented for suicidal thoughts and

behaviors because of the COVID-19 pandemic among all

adolescents who reported suicidal thoughts and behaviors.

13

Among adolescents aged 12 to 17 in 2020, 12.0 percent

(or 3.0 million people) had serious thoughts of suicide,

5.3 percent (or 1.3 million people) made a suicide plan, and

2.5 percent (or 629,000 people) attempted suicide in the

past year (Figure 40 and Table A.36B).

Figure 39. Had Serious Thoughts of Suicide, Made a Suicide Plan,

or Attempted Suicide in the Past Year: Among Adults Aged 18 or

Older; 2020

4.9

1.3

0.5

11.3

4.0

1.9

5.3

1.3

0.4

2.7

0.4

0.1

0

2

4

6

8

10

12

Had Serious Thoughts

of Suicide

Made a Suicide Plan Attempted Suicide

Percent with Thought or Behavior in the Past Year

18 or Older 18 to 25 26 to 49 50 or Older

Age Category:

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 37

Substance Use Treatment in the Past Year

Substance use treatment is intended to help people address

problems associated with their use of alcohol or illicit drugs

(i.e., not counting tobacco use), including medical problems

associated with the use of alcohol or illicit drugs.

98

e

2020 NSDUH provided two principal measures related to

substance use treatment in the past year: (a) the need for

substance use treatment and (b) the receipt of substance

use treatment. e survey also collected information on the

types of settings where people received treatment and issues

associated with people needing substance use treatment but

not receiving it.

14

As noted in the Substance Use Disorders in the Past Year

section, the change from DSM-IV

18

to DSM-5

17

criteria

for estimating SUD led to breaks in the comparability

of 2020 SUD estimates with estimates from prior years;

therefore, data prior to 2020 are not shown. Also, because

some estimates for substance use treatment (e.g., need for

substance use treatment) are based on whether people had

an SUD in the past year, this report presents substance use

treatment estimates for 2020 only.

Before the COVID-19 pandemic, substance use treatment

was typically delivered in person. e COVID-19 pandemic

required changes in substance use treatment to include

expansion of virtual treatments. To support this need,

regulations for opioid treatment were relaxed for take-home

medications and requirements for in-person treatment.

99,100

Although reimbursement for some virtual behavioral

health services was allowed before 2020, reimbursement for

additional virtual services (including substance use treatment)

was expanded during the COVID-19 pandemic, including

reimbursement for services delivered over the phone (i.e.,

using only audio).

101

Virtual substance use treatment has

been shown to be eﬀective

102,103

and has been proposed as an

alternative to in-person services for some time, particularly

in instances where access to such services is limited.

104

In

light of these changes to substance use treatment delivery and

reimbursement, questions were added to the 2020 NSDUH

questionnaire for Quarter 4 (i.e., October to December) to

assess the use of virtual substance use treatment services. e

Receipt of Virtual (Telehealth) Services for Substance Use

Treatment section presents estimates from Quarter 4 on the

receipt of virtual services for substance use treatment.

Need for Substance Use Treatment

SAMHSA classiﬁes people as having a need for substance

use treatment if they had an SUD in the past year or if they

received substance use treatment at a specialty facility

105

in

the past year (regardless of whether they had an SUD).

106,107

Among people aged 12 or older in 2020, 14.9 percent (or

41.1 million people) needed substance use treatment in the

past year (Figure 41 and Table A.38AB). Consistent with

SUD data, the percentage of people needing substance use

treatment was highest among young adults aged 18 to 25

(24.6 percent or 8.2 million people), followed by adults aged

26 or older (14.3 percent or 31.3 million people), then by

adolescents aged 12 to 17 (6.4 percent or 1.6 million people).

Figure 40. Youths Aged 12 to 17 with Serious Thoughts of Suicide, Suicide Plans, or Suicide

Attempts in the Past Year; 2020

3.0 Million Youths Had Serious

Thoughts of Suicide

Had Serious Thoughts

of Suicide Only

Made Suicide Plans Only (30K)

1.3 Million Youths

Made Suicide Plans

1.6

Million

3.0 Million Youths Aged 12 to 17 Had Serious Thoughts of Suicide, Made Suicide Plans, or Attempted Suicide in the Past Year

Attempted Suicide Only (8K)

629,000 Youths

Attempted Suicide

85K

502K

733K

Had Serious Thoughts of Suicide and

Attempted Suicide, but Did Not Make

Suicide Plans

Made Suicide Plans and Attempted Suicide, but

Did Not Have Serious Thoughts of Suicide (35K)

Had Serious Thoughts of Suicide

and Made Suicide Plans, but Did

Not Attempt Suicide

Had Serious Thoughts of Suicide, Made

Suicide Plans, and Attempted Suicide

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health38 | October 2021

Receipt of Substance Use Treatment

NSDUH respondents who used alcohol or illicit drugs

in their lifetime were asked whether they ever received

substance use treatment, and those who received substance

use treatment in their lifetime were asked whether they

received treatment in the 12 months prior to the survey

interview (i.e., in the past year). Receipt of any substance

use treatment includes substance use treatment received in

the past year at any location, such as a hospital (inpatient),

rehabilitation facility (outpatient or inpatient), mental

health center, emergency room, private doctor’s oﬃce, prison

or jail, or self-help group (e.g., Alcoholics Anonymous or

Narcotics Anonymous). Also, respondents in Quarter 4 of

2020 who reported receiving substance use treatment in the

past year were asked if they received professional counseling,

medication, or treatment in the past 12 months for their

alcohol or drug use over the phone, by e-mail, or through

video calling (i.e., virtual or telehealth services).

e 2020 NSDUH also collected information on the receipt

of substance use treatment at a specialty facility. Substance

use treatment at a specialty facility is included in the

estimates of any substance use treatment because a subset of

the treatment locations was categorized as specialty facilities.

Receipt of substance use treatment at a specialty facility was

deﬁned as substance use treatment received by a respondent

at a hospital (only as an inpatient), a drug or alcohol

rehabilitation facility (as an inpatient or outpatient), or a

mental health center. Substance use treatment at a specialty

facility did not include virtual services that Quarter 4

respondents reported receiving. Substance use treatment at a

specialty facility also excluded self-help groups (regardless of

when data were collected).

Receipt of Any Substance Use Treatment

Among people aged 12 or older in 2020, 1.4 percent (or

4.0 million people) received any substance use treatment

in the past year (Table A.38AB). An estimated 1.8 million

people aged 12 or older received substance use treatment

in the past year at a self-help group, 1.8 million received

treatment at a rehabilitation facility as an outpatient,

1.4 million received treatment at a mental health center as an

outpatient, 1.1 million received treatment at a rehabilitation

facility as an inpatient, and 1.1 million received treatment

at a private doctor’s oﬃce (Figure 42). Smaller numbers of

people received treatment at a hospital as an inpatient, in an

emergency room, or in a prison or jail.

In 2020, 1.6 percent of adults aged 26 or older (or

3.4 million people) and 1.3 percent of young adults aged

18 to 25 (or 445,000 people) received any substance use

treatment in the past year. ese percentages were higher

than the corresponding percentage among adolescents aged

12 to 17 (0.7 percent or 169,000 people).

Receipt of Any Substance Use Treatment

among People with a Past Year SUD

Among people aged 12 or older in 2020 with a past year

SUD, 6.5 percent (or 2.6 million people) received any

substance use treatment in the past year (Figure 43 and

Table A.38AB). Percentages were similar among age groups:

7.6 percent of adolescents aged 12 to 17, 4.4 percent of

young adults aged 18 to 25, and 7.0 percent of adults aged

26 or older with a past year SUD. Corresponding numbers of

people with a past year SUD who received any substance use

Figure 42. Locations Where Substance Use Treatment in the Past

Year Was Received: Among People Aged 12 or Older; 2020

1.8M

1.4M

1.1M

801,000

732,000

181,000

0.0 0.5 1.0 1.5 2.0

Self-Help Group

Outpatient Rehabilitation

Outpatient Mental Health Center

Inpatient Rehabilitation

Private Doctor's Ofﬁce

Hospital Inpatient

Emergency Room

Prison or Jail

Number of People

Note: Locations where people received substance use treatment are not mutually exclusive because

respondents could report that they received treatment in more than one location in the pastyear.

Figure 41. Need for Substance Use Treatment in the Past Year:

Among People Aged 12 or Older; 2020

14.9

6.4

24.6

14.3

0

5

10

15

20

25

30

12 or Older 12 to 17 18 to 25 26 or Older

Percent Needing Substance Use

Treatment in Past Year

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 39

treatment in the past year were 120,000 adolescents, 363,000

young adults, and 2.1 million adults aged 26 or older.

Receipt of Substance Use Treatment at a Specialty Facility

Among people aged 12 or older in 2020, 1.0 percent (or

2.7 million people) received substance use treatment at a

specialty facility in the past year (Table A.38AB). Among

adolescents aged 12 to 17, 0.2 percent (or 55,000 people)

received substance use treatment at a specialty facility in the

past year. is percentage among adolescents was somewhat

lower than corresponding percentages for young adults aged

18 to 25 (0.9 percent or 301,000 people) and for adults aged

26 or older (1.1 percent or 2.3 million people). As noted

previously, however, adolescents were less likely than young

adults or adults aged 26 or older to need substance use

treatment in the past year.

Receipt of Substance Use Treatment at a Specialty Facility

among People Who Needed Substance Use Treatment

Among the 41.1 million people aged 12 or older in 2020

who needed substance use treatment in the past year,

6.5 percent (or 2.7 million people) received substance use

treatment at a specialty facility in the past year (Figure 44

and Table A.38AB). Adults aged 26 or older who needed

substance use treatment in the past year were more likely

than their counterparts aged 12 to 17 or aged 18 to 25 to

have received substance use treatment at a specialty facility

in the past year. Among the 31.3 million adults aged 26

or older in 2020 who needed substance use treatment in

the past year, 7.4 percent (or 2.3 million people) received

substance use treatment at a specialty facility in the past year.

In comparison, among the 1.6 million adolescents aged 12

to 17 in 2020 who needed substance use treatment in the

past year, 3.5 percent (or 55,000 people) received substance

use treatment at a specialty facility in the past year. Among

the 8.2 million young adults aged 18 to 25 in 2020 who

needed substance use treatment in the past year, 3.7 percent

(or 301,000 people) received substance use treatment at a

specialty facility in the past year.

Receipt of Virtual (Telehealth) Services

for Substance Use Treatment

Among people aged 12 or older in Quarter 4 of 2020

who received substance use treatment in the past year,

58.0 percent (or 2.2 million people) received virtual

(i.e., telehealth) services for substance use treatment

(Table A.39AB). In addition, 58.4 percent of adults aged 26

or older in Quarter 4 who received substance use treatment

in the past year (or 1.9 million people) received virtual

substance use services. Estimates for adolescents aged 12

to 17 and for young adults aged 18 to 25 who received

substance use treatment in the past year could not be

calculated with suﬃcient precision.

Perceived Need for Substance Use Treatment

NSDUH respondents were classiﬁed as having a perceived

need for substance use treatment (i.e., treatment for

problems related to their use of alcohol or illicit drugs)

if they indicated that they felt they needed substance

use treatment in the past year. Respondents may have a

perceived need for substance use treatment, regardless of

whether they had an SUD in the past year. In this report,

Figure 43. Received Any Substance Use Treatment in the Past

Year: Among People Aged 12 or Older Who Had a Substance Use

Disorder in the Past Year; 2020

6.5

7.6

4.4

7.0

0

2

4

6

8

12 or Older 12 to 17 18 to 25 26 or Older

Percent Receiving Any Substance

Use Treatment in Past Year

Figure 44. Received Substance Use Treatment at a Specialty

Facility in the Past Year: Among People Aged 12 or Older Who

Needed Substance Use Treatment in the Past Year; 2020

6.5

3.5

3.7

7.4

0

2

4

6

8

10

12 or Older 12 to 17 18 to 25 26 or Older

Percent Receiving Substance Use Treatment

at a Specialty Facility in Past Year

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health40 | October 2021

estimates for the perceived need for substance use treatment

are discussed only among people aged 12 or older who were

classiﬁed as having an SUD in the past year

108

but did not

receive substance use treatment at a specialty facility.

106,107

Among the 38.4 million people aged 12 or older in 2020 with

an SUD in the past year who did not receive substance use

treatment at a specialty facility, 97.5 percent (or 37.5 million

people) did not feel they needed treatment, 1.9 percent (or

737,000 people) felt they needed treatment but did not make

an eﬀort to get treatment, and 0.5 percent (or 211,000 people)

felt they needed treatment and made an eﬀort to get treatment

(Figure 45 and Table A.40AB).

109

Similar patterns were

observed by age group. For example, among people in diﬀerent

age groups in 2020 with a past year SUD who did not receive

substance use treatment at a specialty facility, 98.4 percent of

adolescents aged 12 to 17 (or 1.5 million people), 98.1 percent

of young adults aged 18 to 25 (or 7.8 million people), and

97.3 percent of adults aged 26 or older (or 28.2 million

people) did not feel they needed treatment.

Reasons for Not Receiving Substance Use Treatment

NSDUH respondents who did not receive substance use

treatment in the past 12 months but felt they needed

treatment were asked to report the reasons for not receiving

treatment.

110

As noted in the previous section, among people

aged 12 or older in 2020 who were classiﬁed as having

an SUD and did not receive substance use treatment at a

specialty facility, only 2.5 percent perceived that they needed

treatment.

109

For people who perceived a need for treatment,

information on common reasons for not receiving substance

use treatment is important for identifying and addressing

barriers to treatment receipt.

Among people aged 12 or older in 2020 with a past year

SUD who did not receive treatment at a specialty facility and

perceived a need for treatment, the following were common

reasons for not receiving substance use treatment:

• having no health care coverage and not being able to

aﬀord the cost of treatment (19.1 percent),

• not ﬁnding a program that oﬀered the type of treatment

they wanted (14.4 percent), and

• being concerned that getting treatment might cause their

neighbors or community to have a negative opinion of

them (11.9 percent) (Table A.44B).

Medication‑Assisted Treatment for Alcohol Use or

Opioid Misuse

Beginning with the 2019 NSDUH, questions were included

in the interview to assess the receipt of medication-assisted

treatment (MAT) for problems with alcohol use or opioid

misuse. NSDUH respondents aged 12 or older who reported

receiving any treatment in the past year for problems

related to their use of alcohol were asked to report whether

a doctor or other health professional prescribed them

medication in the past year to help reduce or stop their use

of alcohol. Questions on MAT for opioid misuse were asked

if respondents aged 12 or older reported ever using heroin

or ever misusing prescription pain relievers and reported

receiving any treatment in the past year for illicit drug use

problems. ese respondents were asked whether a doctor or

other health professional prescribed them medication in the

past year to help reduce or stop their use of heroin, misuse

of prescription pain relievers, or both. Respondents also were

informed that MAT for opioid misuse was diﬀerent from

medications given to stop a drug overdose.

Medication-Assisted Treatment for Alcohol Use

Among the 28.3 million people aged 12 or older in 2020

with a past year alcohol use disorder, 1.0 percent (or

292,000 people) received MAT in the past year for their

alcohol use (Table A.45AB). Among the 2.1 million people

aged 12 or older in 2020 who received alcohol use treatment

at any location in the past year

111

(regardless of whether

Figure 45. Perceived Need for Substance Use Treatment: Among

People Aged 12 or Older with a Past Year Substance Use Disorder

(SUD) Who Did Not Receive Substance Use Treatment at a

Specialty Facility in the Past Year; 2020

38.4 Million People with an SUD Who Did Not Receive Substance Use

Treatment at a Specialty Facility

37.5 Million

Did Not Feel They

Needed Treatment

(97.5%)

211,000 Felt They Needed

Treatment and Made an Effort

to Get Treatment

(0.5%)

737,000 Felt They Needed

Treatment and Did Not Make

an Effort to Get Treatment

(1.9%)

Note: People who had an SUD were classified as needing substance use treatment.

Note: The percentages do not add to 100percent due to rounding.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 41

they had a past year alcohol use disorder), 17.2 percent (or

362,000 people) received MAT in the past year for alcohol

use. Estimates in 2020 for people who received MAT in

the past year for alcohol use among those with a past year

alcohol use disorder and who received alcohol use treatment

at any location in the past year could not be calculated with

suﬃcient precision.

Medication-Assisted Treatment for Opioid Misuse

Among the 2.6 million people aged 12 or older in 2020 who

received illicit drug use treatment (i.e., not necessarily for

opioid misuse) in the past year, 30.5 percent (or 798,000

people) received MAT in the past year for opioid misuse

(Table A.46AB). Among the 2.5 million people aged 12 or

older with a past year opioid use disorder, 11.2 percent (or

278,000 people) received MAT in the past year for opioid

misuse.

111

Mental Health Service Use in the Past Year

e 2020 NSDUH included questions to estimate the use

of mental health services in the United States among the

adolescent and adult populations. In addition to estimating

the use of mental health services among the overall

adolescent and adult populations, these questions allowed

for the estimation of the use of mental health services among

adolescents and adults with mental health issues (i.e., MDE,

AMI, and SMI).

14

Similar to its eﬀect on substance use treatment, the

COVID-19 pandemic has aﬀected the availability of

services and the modes of mental health service delivery.

Even before then, virtual (i.e., telehealth) mental health care

has been proposed as an alternative to in-person mental

health services as a means to increase access, particularly

in areas where services are limited.

112

Mental health care

delivered virtually has been shown to be eﬀective.

113

In light

of these changes to the delivery of mental health services,

questions were added to the 2020 NSDUH questionnaire

for Quarter 4 (i.e., October to December) to assess the use

of virtual mental health services. e following subsections

present estimates of the receipt of virtual mental health

services: Receipt of Virtual (Telehealth) Mental Health

Services among Adolescents, Receipt of Virtual (Telehealth)

Mental Health Services among Adults, Receipt of Virtual

(Telehealth) Mental Health Services among Adults with

AMI, and Receipt of Virtual (Telehealth) Mental Health

Services among Adults with SMI.

Treatment for Depression among Adolescents

Adolescents aged 12 to 17 who had met the criteria for

having a past year MDE were asked whether they had

received treatment for their depression in the past year.

Adolescents were classiﬁed as having received treatment

for their depression in the past year if they reported seeing

or talking to a health professional or taking prescription

medication for their depression in that period.

114

Among the 4.1 million adolescents aged 12 to 17 in 2020 who

had a past year MDE, 41.6 percent (or 1.7 million people)

received treatment for depression in the past year (Figure 46).

Among the 2.9 million adolescents in 2020 who had a past year

MDE with severe impairment, 46.9 percent (or 1.4 million

people) received treatment for depression in the past year.

Stated another way, however, most adolescents in 2020 who

had a past year MDE or an MDE with severe impairment did

not receive treatment for depression in the past year.

Figure 46. Received Treatment in the Past Year for Depression:

Among Youths Aged 12 to 17 with a Past Year Major Depressive

Episode (MDE) or MDE with Severe Impairment; 2004-2020

Percent Who Received Treatment

for Depression in Past Year

Years

MDE Status:

MDE

MDE with Severe Impairment

0

20

40

60

80

100

2019181716151413121110090807060504

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 46 Table. Received Treatment in the Past Year for Depression: Among

Youths Aged 12 to 17 with a Past Year Major Depressive Episode (MDE) or

MDE with Severe Impairment; 2004-2020

MDE

Status

04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

MDE

40.3 37.8 38.8 39.0 37.7 34.6 37.8 38.4 37.0 38.1 41.2 39.3 40.9 41.5 41.4 43.3 41.6

MDE with

Severe

Impairment

N/A N/A 46.5 43.9 42.6 38.8 41.1 43.5 41.0 45.0 44.7 44.6 46.7 47.5 46.9 49.7 46.9

N/A = not available.

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health42 | October 2021

Treatment for Depression among Adults

Adults aged 18 or older who had met the criteria for having

a past year MDE were asked whether they had received

treatment for their depression in the past year. Adults were

classiﬁed as having received treatment for their depression

in the past year if they reported seeing or talking to a health

professional or taking prescription medication for their

depression in that period.

114

Among the 21.0 million adults aged 18 or older in 2020

who had a past year MDE, 66.0 percent (or 13.8 million

people) received treatment for depression in the past year

(Figure 47). Among the 14.8 million adults aged 18 or older

in 2020 who had a past year MDE with severe impairment,

71.0 percent (or 10.5 million people) received treatment for

depression in the past year (Table A.48B).

e percentage of adults in 2020 with a past year MDE

or a past year MDE with severe impairment who received

treatment for depression in the past year increased with

age. Speciﬁcally, the percentage of adults with a past year

MDE who received treatment for depression in the past year

was highest among adults aged 50 or older (75.3 percent

or 4.7 million people out of 6.2 million people with an

MDE), followed by adults aged 26 to 49 (64.8 percent

or 5.9 million people out of 9.2 million people with an

MDE), then by young adults aged 18 to 25 (57.6 percent or

3.2 million people out of 5.6 million people with an MDE).

Similarly, the percentage of adults in 2020 with a past year

MDE with severe impairment who received treatment for

depression in the past year was highest among adults aged

50 or older (80.9 percent or 3.5 million people out of

4.4 million people with an MDE with severe impairment),

followed by adults aged 26 to 49 (68.7 percent or

4.5 million people out of 6.5 million people with an MDE

with severe impairment), then by young adults (63.8 percent

or 2.5 million people out of 4.0 million people with an

MDE with severe impairment).

Mental Health Service Use among Adolescents

In addition to asking adolescents aged 12 to 17 about

treatment for depression, the 2020 NSDUH included

questions for adolescents that asked about the receipt of

any service for emotional or behavioral problems (i.e., not

just depression) not caused by substance use. e youth

mental health service utilization section of the interview

asked respondents aged 12 to 17 whether they received

any treatment or counseling within the 12 months prior

to the interview for problems with emotions or behavior

in the following settings: (a) specialty mental health

settings,

115

(b) education settings (talked with a school social

worker, psychologist, or counselor about an emotional or

behavioral problem; participated in a program for students

with emotional or behavioral problems while in a regular

school; or attended a school for students with emotional

or behavioral problems), (c) general medical settings (care

from a pediatrician or family physician for emotional or

behavioral problems), (d) juvenile justice settings (services for

an emotional or behavioral problem in a detention center,

prison, or jail), or (e) child welfare settings (foster care or

therapeutic foster care).

116

Also, adolescents in Quarter 4 of 2020 (i.e., October to

December) were asked new questions on the receipt of

any professional counseling, medication, or treatment in

the past 12 months for their mental health, emotions, or

behavior over the phone, by e-mail, or through video calling

(i.e., virtual or telehealth services). Virtual mental health

Figure 47. Received Treatment in the Past Year for Depression:

Among Adults Aged 18 or Older with a Past Year Major

Depressive Episode; 2009-2020

Percent Who Received Treatment

for Depression in Past Year

0

20

40

60

80

100

201918171615141312111009

18 or Older 18 to 25 26 to 49 50 or Older

Age Category:

Years

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 47 Table. Received Treatment in the Past Year for Depression: Among

Adults Aged 18 or Older with a Past Year Major Depressive Episode; 2009-

2020

Age 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

18 or Older

64.3 68.2 68.1 68.0 68.6 68.6 67.2 65.3 66.8 64.8 66.3 66.0

18 to 25

47.0 48.7 47.8 49.8 50.8 49.5 46.8 44.1 50.7 49.6 50.9 57.6

26 to 49

64.8 68.1 68.1 68.8 66.7 67.9 67.4 67.4 67.3 64.4 68.9 64.8

50 or Older

73.8 78.4 80.0 76.8 81.3 80.8 80.9 77.3 79.7 78.9 76.5 75.3

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 43

services were categorized separately from the mental health

settings described in the preceding paragraph.

Receipt of Mental Health Services in Specialty and

Nonspecialty Settings among Adolescents

In 2020, 17.3 percent of adolescents aged 12 to 17 (or

4.2 million people) received mental health services in a

specialty setting, including 16.6 percent (or 4.1 million

people) who received mental health treatment in an

outpatient setting and 2.1 percent (or 510,000 people) who

received mental health treatment in an inpatient setting

(Figure 48 and Table A.49B). An estimated 15.0 percent of

adolescents (or 3.7 million people) received mental health

services in a nonspecialty setting, including 12.8 percent (or

3.1 million people) who received mental health services in

an educational setting (such as from a school social worker,

school psychologist, or school counselor, or as part of a

special school or program), 3.1 percent (or 762,000 people)

who received mental health services in a general medicine

setting, 0.3 percent (or 66,000 people) who received mental

health services in a child welfare setting, and 0.1 percent

(or 22,000 people) who received mental health services

in a juvenile justice setting.

5

Additionally, 6.9 percent of

adolescents received mental health services in a combination

of specialty and nonspecialty settings.

33

Receipt of Virtual (Telehealth) Mental Health

Services among Adolescents

In Quarter 4 of 2020, 10.1 percent of adolescents aged 12 to

17 received mental health services as virtual (i.e., telehealth)

services (Table A.50B). is percentage corresponds to

2.5 million adolescents.

Mental Health Service Use among Adults

Adult respondents aged 18 or older were asked whether

they received treatment or counseling for any problem

with emotions, “nerves,” or mental health in the past year

in any inpatient or outpatient setting or if they used

prescription medication in the past year for a mental or

emotional condition. All adult respondents (i.e., not just

those with mental illness) were asked these questions about

their use of mental health services. Respondents were asked

not to include treatment for their use of alcohol or illicit

drugs. Unlike the previously discussed questions about

treatment for depression, general questions about the

receipt of treatment or counseling for mental health issues

among adults did not ask about treatment for a particular

mental disorder. Consequently, references in this section to

treatment or counseling for any problem with emotions,

nerves, or mental health are described broadly as “mental

health services” or “mental health care.”

Also, adults in Quarter 4 of 2020 (i.e., October to

December) were asked if they received any professional

counseling, medication, or treatment for their mental health,

emotions, or behavior over the phone, by e-mail, or through

video calling in the past 12 months (i.e., virtual or telehealth

services). Virtual mental health services were categorized

separately from services in inpatient or outpatient settings or

the receipt of prescription medication.

Receipt of Inpatient or Outpatient Mental Health

Services or Prescription Medication among Adults

In 2020, 16.9 percent of adults aged 18 or older (or

41.4 million people) received inpatient or outpatient mental

Figure 48. Sources of Mental Health Services in the Past Year:

Among Youths Aged 12 to 17; 2002-2020

Percent Receiving Mental Health

Services in Past Year

0

5

10

15

20

20191817161514131211100908070605040302

Source:

Years

Specialty Mental Health Setting

Education Setting

General Medical Setting

Child Welfare Setting

Juvenile Justice Setting

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 48 Table. Sources of Mental Health Services in the Past Year: Among

Youths Aged 12 to 17; 2002-2020

Source 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

Specialty Mental

Health Setting

11.8

12.4

13.4 13.4 13.0 12.4 12.7 12.0 12.1 12.6 12.7 13.6 13.7 13.3 14.7 14.8 16.0 16.7 17.3

Education Setting

N/A

N/A N/A N/A N/A N/A 12.1 12.4 11.9 12.9 13.0 13.2 13.2 13.1 13.3 14.2 15.4 12.8

General Medical

Setting

2.7

2.9

3.4 3.2 2.8 2.8 2.9 2.5 2.5 2.5 2.5 2.8 2.9 2.7 2.9 3.3 3.1 3.7 3.1

Child Welfare

Setting

N/A

N/A N/A N/A N/A N/A 0.4 0.4 0.6 0.4 0.4 0.4 0.3 0.4 0.4 0.4 0.4 0.3

Juvenile Justice

Setting

N/A

N/A N/A N/A N/A N/A 0.4 0.3 0.4 0.3 0.2 0.3 0.2 0.2 0.2 0.2 0.2 0.1

N/A = not available.

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health44 | October 2021

health services or took prescription medication in the

past year for a mental health issue, including 0.9 percent

(or 2.2 million people) who received inpatient services,

8.8 percent (or 21.5 million people) who received outpatient

services, and 13.8 percent (or 33.8 million people) who

took prescription medication (Figure 49). Adults aged 50

or older were less likely than young adults aged 18 to 25 or

adults aged 26 to 49 to have received any of these mental

health services in the past year (Table A.51B). Speciﬁcally,

15.0 percent of adults aged 50 or older (or 17.1 million

people) received any of these mental health services

compared with 19.5 percent of young adults (or 6.3 million

people) and 18.3 percent of adults aged 26 to 49 (or

18.0 million people).

Receipt of Virtual (Telehealth) Mental

Health Services among Adults

In 2020, 11.0 percent of adults aged 18 or older (or

26.3 million people) received virtual (i.e., telehealth) services

in the past year for a mental health issue (Table A.52B).

111

Adults aged 50 or older were less likely than young adults

aged 18 to 25 or adults aged 26 to 49 to have received

virtual mental health services in the past year. Speciﬁcally,

7.8 percent of adults aged 50 or older (or 8.8 million people)

received virtual mental health services in the past year

compared with 14.9 percent of young adults (or 4.8 million

people) and 13.4 percent of adults aged 26 to 49 (or

12.8 million people).

Mental Health Service Use among Adults with AMI

Receipt of Inpatient or Outpatient Mental Health Services

or Prescription Medication among Adults with AMI

Among the 52.9 million adults aged 18 or older in 2020

with AMI in the past year, 46.2 percent (or 24.3 million

people) received inpatient or outpatient mental health

services or took prescription medication to treat a mental

health condition in the past year (Figure 50). Young adults

aged 18 to 25 with AMI were less likely than adults aged

26 to 49 or adults aged 50 or older with AMI to receive any

of these services in the past year. An estimated 42.1 percent

of young adults with AMI in the past year (or 4.3 million

people) received any of these mental health services in the

past year compared with 46.6 percent of adults aged 26 to

49 with AMI (or 11.9 million people) and 48.0 percent of

adults aged 50 or older with AMI (or 8.1 million people).

Receipt of Virtual (Telehealth) Mental Health

Services among Adults with AMI

In 2020, 33.7 percent of adults aged 18 or older with AMI

in the past year (or 18.5 million people) received virtual

(i.e., telehealth) mental health services in the past year

(Table A.54B). In each age group, similar percentages of

adults with AMI received virtual mental health services in

the past year (35.9 percent of young adults aged 18 to 25,

34.9 percent of adults aged 26 to 49, and 30.9 percent of

adults aged 50 or older).

Figure 49. Type of Mental Health Services Received in the Past

Year: Among Adults Aged 18 or Older; 2002-2020

Percent Receiving Mental Health

Services in Past Year

Mental Health Services

Inpatient

Outpatient

Prescription Medication

Service Type:

0

5

10

15

20

20191817161514131211100908070605040302

Years

Note: Mental Health Services include any combination of inpatient or outpatient services or receipt of

prescription medication.

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 49 Table. Type of Mental Health Services Received in the Past Year:

Among Adults Aged 18 or Older; 2002-2020

Service

Type

02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

Mental

Health

Services

13.0 13.2 12.8 13.0 12.9 13.3 13.5 13.4 13.8 13.6 14.5 14.6 14.8 14.2 14.4 14.8 15.0 16.1 16.9

Inpatient

0.7 0.8 0.9 1.0 0.7 1.0 0.9 0.8 0.8 0.8 0.8 0.9 1.0 0.9 0.9 1.0 1.0 1.0 0.9

Outpatient

7.4 7.1 7.1 6.8 6.7 7.0 6.8 6.4 6.6 6.7 6.6 6.6 6.7 7.1 6.9 7.5 7.9 8.3 8.8

Prescription

Medication

10.5 10.9 10.5 10.7 10.9 11.2 11.4 11.3 11.7 11.5 12.4 12.5 12.6 11.8 12.0 12.1 12.2 13.1 13.8

Note: Mental Health Services include any combination of inpatient or outpatient services or receipt of prescription

medication.

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 45

Mental Health Service Use among Adults with SMI

Receipt of Inpatient or Outpatient Mental Health Services

or Prescription Medication among Adults with SMI

Among the 14.2 million adults aged 18 or older in 2020

with SMI in the past year, 64.5 percent (or 9.1 million

people) received inpatient or outpatient mental health

services or took prescription medication to treat a mental

health condition in the past year (Figure 51). As with adults

with AMI, young adults aged 18 to 25 with SMI in the

past year were less likely than adults aged 26 to 49 or adults

aged 50 or older with SMI to receive any of these services in

the past year. Speciﬁcally, 57.6 percent of young adults with

SMI (or 1.9 million people) received any of these mental

health services in the past year compared with 63.0 percent

of adults aged 26 to 49 with SMI (or 4.4 million people)

and 72.9 percent of adults aged 50 or older with SMI (or

2.9 million people). Adults aged 50 or older with SMI also

were more likely than those aged 26 to 49 with SMI to have

received any of these mental health services in the past year.

Receipt of Virtual (Telehealth) Mental Health

Services among Adults with SMI

In 2020, 49.8 percent of adults aged 18 or older with SMI

in the past year (or 7.2 million people) received virtual

(i.e., telehealth) mental health services in the past year

(Table A.56B). Similar percentages of young adults aged 18

to 25 (49.3 percent) and adults aged 26 to 49 (50.3 percent)

with SMI received virtual mental health services in the

past year. Estimates for adults aged 50 or older with an

SMI in the past year could not be calculated with suﬃcient

precision.

Figure 50. Mental Health Services Received in the Past Year:

Among Adults Aged 18 or Older with Any Mental Illness in the

Past Year; 2008-2020

Percent Receiving Mental Health

Services in Past Year

0

20

40

60

80

20191817161514131211100908

18 or Older 18 to 25 26 to 49 50 or Older

Age Category:

Years

Note: Mental Health Services include any combination of inpatient or outpatient services or receipt of

prescription medication.

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 50 Table. Mental Health Services Received in the Past Year: Among

Adults Aged 18 or Older with Any Mental Illness in the Past Year; 2008-2020

Age 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

18 or Older

40.9 40.2 42.4 40.8 41.0 44.7 44.7 43.1 43.1 42.6 43.3 44.8 46.2

18 to 25

30.3 32.0 32.6 32.9 34.5 34.7 33.6 32.0 35.1 38.4 37.3 38.9 42.1

26 to 49

41.4 40.8 43.3 41.1 42.0 43.5 44.2 43.3 43.1 43.3 43.9 45.4 46.6

50 or Older

45.2 42.8 45.1 43.6 42.4 50.5 49.9 48.3 46.8 44.2 45.8 47.2 48.0

Note: Mental Health Services include any combination of inpatient or outpatient services or receipt of prescription

medication.

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Figure 51. Mental Health Services Received in the Past Year:

Among Adults Aged 18 or Older with Serious Mental Illness in the

Past Year; 2008-2020

Percent Receiving Mental Health

Services in Past Year

0

20

40

60

80

20191817161514131211100908

18 or Older 18 to 25 26 to 49 50 or Older

Age Category:

Years

Note: Mental Health Services include any combination of inpatient or outpatient services or receipt of

prescription medication.

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 51 Table. Mental Health Services Received in the Past Year: Among

Adults Aged 18 or Older with Serious Mental Illness in the Past Year; 2008-2020

Age 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

18 or Older

65.7 66.5 67.5 64.9 62.9 68.5 68.5 65.3 64.8 66.7 64.1 65.5 64.5

18 to 25

45.9 55.0 53.7 52.1 53.1 54.0 53.9 50.7 51.5 57.4 53.8 56.4 57.6

26 to 49

67.2 64.5 67.4 63.6 63.5 68.4 66.2 66.1 66.1 66.2 63.7 65.1 63.0

50 or Older

73.2 76.1 74.0 73.2 66.3 74.9 79.2 72.2 71.5 75.6 74.4 74.3 72.9

Note: Mental Health Services include any combination of inpatient or outpatient services or receipt of prescription

medication.

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health46 | October 2021

Perceived Unmet Need for Mental Health Services

among Adults with Mental Illness

is section discusses estimates of the perceived unmet need

for mental health services among adults aged 18 or older

with AMI or SMI in the past year. e section also discusses

the reasons adults with AMI or SMI did not receive these

services in the past year if they had a perceived unmet need.

Perceived unmet need for mental health services among

adults is estimated from a question that asked all adults

aged 18 or older whether there was any time in the

past 12 months when they thought they needed treatment

or counseling for mental health issues but did not receive

services. However, this section presents estimates of the

perceived unmet need for mental health services among

adults with AMI or SMI, regardless of whether they received

mental health services in the past 12 months. erefore,

this measure for the perceived unmet need for mental

health services includes adults with AMI or SMI who may

have received some type of mental health service in the

past 12 months but felt an unmet need for services before or

after they received services.

Perceived Unmet Need for Mental Health

Services among Adults with AMI

Among the 52.9 million adults aged 18 or older in 2020

with AMI in the past year, 30.5 percent (or 16.1 million

people) perceived an unmet need for mental health services

in the past year (Figure 52). Among these 16.1 million adults

with AMI and a perceived unmet need for mental health

services, 48.0 percent (or 7.7 million people) did not receive

any mental health services in the past year (Table A.58B).

e percentage of adults in 2020 with AMI in the past year

who had a perceived unmet need for mental health services

was highest among young adults aged 18 to 25 (47.1 percent

or 4.8 million people), followed by adults aged 26 to 49

(30.5 percent or 7.8 million people), then by adults aged 50

or older (20.3 percent or 3.4 million people) (Figure 52).

us, nearly half of young adults with AMI had a perceived

unmet need for mental health services. Percentages of adults

in 2020 with AMI and a perceived unmet need for mental

health services who did not receive any mental health

services were similar across age groups (

Table A.58B).

Perceived Unmet Need for Mental Health

Services among Adults with SMI

Among the 14.2 million adults aged 18 or older in 2020

with SMI in the past year, 49.7 percent (or 7.0 million

people) perceived an unmet need for mental health services

in the past year (Figure 53). Among these 7.0 million adults

with SMI and a perceived unmet need for mental health

services, 37.6 percent (or 2.6 million people) did not receive

any mental health services in the past year (Table A.58B).

e percentage of adults in 2020 with SMI in the past year

who had a perceived unmet need for mental health services

was highest among young adults aged 18 to 25 (63.4 percent

or 2.1 million people), followed by adults aged 26 to 49

(48.0 percent or 3.3 million people), then by adults aged 50 or

older (41.4 percent or 1.6 million people) (Figure 53). us,

nearly two thirds of young adults with SMI had a perceived

unmet need for mental health services. Furthermore, nearly half

of adults aged 26 to 49 with SMI and about 2 in 5 adults aged

50 or older with SMI had a perceived unmet need for mental

health services. Similar percentages of young adults and adults

aged 26 to 49 with SMI had a perceived unmet need for mental

health services and did not receive any mental health services

(

Table A.58B). Estimates for adults aged 50 or older with SMI

Figure 52. Perceived Unmet Need for Mental Health Services in

the Past Year: Among Adults Aged 18 or Older with Any Mental

Illness in the Past Year; 2008-2020

Percent with Perceived Unmet Need for

Mental Health Services in Past Year

0

20

40

60

80

20191817161514131211100908

18 or Older 18 to 25 26 to 49 50 or Older

Age Category:

Years

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 52 Table. Perceived Unmet Need for Mental Health Services in the

Past Year: Among Adults Aged 18 or Older with Any Mental Illness in the

Past Year; 2008-2020

Age 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

18 or Older

20.6 22.1 21.0 20.7 20.8 19.3 20.8 20.3 20.7 23.7 23.6 26.0 30.5

18 to 25

30.2 29.4 29.8 28.8 28.1 27.8 28.9 29.0 32.4 35.3 37.9 40.7 47.1

26 to 49

23.3 24.8 22.5 24.6 24.4 21.7 23.3 22.5 23.0 24.5 25.3 28.0 30.5

50 or Older

11.8 14.8 15.2 12.0 13.2 12.6 14.3 13.0 12.3 16.1 13.2 13.9 20.3

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 47

and a perceived unmet need who did not receive any mental

health services could not be calculated with suﬃcient precision.

Reasons for Not Receiving Mental Health Services among

Adults with Mental Illness and a Perceived Unmet Need

Among adults aged 18 or older in 2020 who had mental

illness in the past year and a perceived unmet need for mental

health services but did not receive services in the past year,

the most common reason for not receiving services was they

could not aﬀord the cost of care (44.9 percent for these

adults with AMI and 49.5 percent for these adults with SMI)

(Table A.59B). Other common reasons for not receiving

services included not knowing where to go for services

(32.7 percent for these adults with AMI and 33.5 percent

for these adults with SMI) and believing they could handle

the problem without treatment (29.7 percent for these adults

with AMI and 25.0 percent for these adults with SMI).

In addition, 25.9 percent of these adults with SMI were

concerned about being committed to a psychiatric hospital or

having to take medication.

Receipt of Services for Co‑Occurring Substance

Use Disorder and Mental Health Issues

e relationship between SUDs and mental disorders is

known to be bidirectional. e presence of a mental disorder

may contribute to the development or exacerbation of an

SUD. Likewise, the presence of an SUD may contribute to

the development or exacerbation of a mental disorder. e

combined presence of SUDs and mental disorders (hereafter

referred to as co-occurring disorders) results in more

profound functional impairment; worse treatment outcomes;

higher morbidity and mortality; increased treatment costs;

and higher risk for homelessness, incarceration, and suicide

than if people had only one of these disorders but not

both.

117,118,119

Current treatment guidelines recommend

that people with co-occurring disorders receive treatment for

both disorders.

120,121,122

is section presents estimates of the receipt of services

among adolescents and adults with co-occurring SUD and

mental health issues. Estimates for the receipt of virtual

(i.e., telehealth) services among adolescents and adults with

co-occurring SUD and mental health issues are presented

separately from estimates for the receipt of other services

because data on the receipt of virtual services were only

added during Quarter 4 (i.e., October to December 2020).

Receipt of Services among Adolescents with

Co‑Occurring SUD and an MDE

Among the 644,000 adolescents aged 12 to 17 in 2020

with a co-occurring SUD and an MDE in the past year,

69.0 percent (or 438,000 people) received either substance

use treatment at a specialty facility or mental health services

in the past year, 66.8 percent (or 424,000 people) received

only mental health services, and 0.9 percent (or 6,000

people) received both substance use treatment at a specialty

facility and mental health services (Table A.60B).

Receipt of Services among Adults with Co‑Occurring

SUD and AMI

Among the 17.0 million adults aged 18 or older in 2020

with a co-occurring SUD and AMI in the past year,

50.5 percent (or 8.5 million people) received either substance

use treatment at a specialty facility or mental health services

in the past year, and 49.5 percent (or 8.4 million people)

received neither service (Figure 54). Stated another way,

nearly half of adults with a co-occurring SUD and AMI did

not receive substance use treatment at a specialty facility

Figure 53. Perceived Unmet Need for Mental Health Services

in the Past Year: Among Adults Aged 18 or Older with Serious

Mental Illness in the Past Year; 2008-2020

Percent with Perceived Unmet Need for

Mental Health Services in Past Year

0

20

40

60

80

20191817161514131211100908

18 or Older 18 to 25 26 to 49 50 or Older

Age Category:

Years

Note: There is no connecting line between 2019 and 2020 to indicate caution should be used when

comparing estimates between 2020 and prior years because of methodological changes for 2020.

Due to these changes, significance testing between 2020 and prior years was not performed.

Figure 53 Table. Perceived Unmet Need for Mental Health Services in the

Past Year: Among Adults Aged 18 or Older with Serious Mental Illness in the

Past Year; 2008-2020

Age 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

18 or Older

43.7 46.3 42.0 43.1 41.6 38.6 42.9 38.2 39.7 44.2 45.1 47.7 49.7

18 to 25

50.0 52.2 53.1 55.0 49.8 51.5 53.6 50.3 53.7 55.9 59.5 62.5 63.4

26 to 49

44.8 49.2 44.3 45.2 46.2 42.4 45.4 43.3 39.7 45.2 45.2 47.6 48.0

50 or Older

38.2 37.5 32.7 33.9 30.1 27.1 33.9 23.2 30.4 32.5 31.9 35.1 41.4

Note: The estimate in 2020 is italicized to indicate caution should be used when comparing estimates between

2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing

between 2020 and prior years was not performed.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health48 | October 2021

or mental health services for either condition. In addition,

42.3 percent of adults with a co-occurring SUD and AMI

(or 7.2 million people) received only mental health services,

2.5 percent (or 423,000 people) received only substance use

treatment at a specialty facility, and 5.7 percent (or 960,000

people) received both substance use treatment at a specialty

facility and mental health services.

Among adults aged 18 or older in 2020 with a co-occurring

SUD and AMI in the past year, adults aged 50 or older were

more likely than young adults aged 18 to 25 or adults aged

26 to 49 to have received either substance use treatment at

a specialty facility or mental health services in the past year.

Speciﬁcally, 63.0 percent of adults aged 50 or older with a

co-occurring SUD and AMI (or 2.3 million people) received

either service compared with 44.9 percent of young adults

(or 1.8 million people) and 48.1 percent of adults aged

26 to 49 (or 4.4 million people) with a co-occurring SUD

and AMI.

In addition, young adults aged 18 to 25 in 2020 with a

co-occurring SUD and AMI in the past year were less likely

than corresponding adults in older age groups to have

received both substance use treatment at a specialty facility

and mental health services in the past year. An estimated

2.6 percent of young adults (or 104,000 people) with a

co-occurring SUD and AMI in the past year received both

services in the past year compared with 6.0 percent of adults

aged 26 to 49 (or 560,000 people) and 8.2 percent of adults

aged 50 or older (or 296,000 people) with a co-occurring

SUD and AMI (Table A.62B).

Receipt of Services among Adults with Co‑Occurring

SUD and SMI

Among the 5.7 million adults aged 18 or older in 2020 with

a co-occurring SUD and SMI in the past year, 66.4 percent

(or 3.7 million people) received either substance use

treatment at a specialty facility or mental health services

in the past year, and 33.6 percent (or 1.9 million people)

received neither service (Figure 55). Stated another way,

about one third of adults with a co-occurring SUD and

SMI (representing nearly 2 million people) did not receive

substance use treatment at a specialty facility or mental

health services for either condition. In addition, 55.4 percent

of adults with a co-occurring SUD and SMI (or 3.1 million

people) received only mental health services, 1.6 percent

(or 89,000 people) received only substance use treatment

at a specialty facility, and 9.3 percent (or 529,000 people)

received both substance use treatment at a specialty facility

and mental health services.

Figure 55. Receipt of Substance Use Treatment at a Specialty

Facility and Mental Health Services in the Past Year: Among

Adults Aged 18 or Older with Past Year Substance Use Disorder

and Serious Mental Illness; 2020

SU Tx or

MH Services

3.7 Million Adults

(66.4%)

No Treatment

1.9 Million Adults

(33.6%)

Both SU Tx and MH Services

529,000 Adults (9.3%)

MH Services,

but no SU Tx

3.1 Million Adults

(55.4%)

SU Tx, but no MH Services

89,000 Adults (1.6%)

5.7 Million Adults with a Substance Use Disorder and Serious Mental Illness

Note: Mental Health Services include any combination of inpatient or outpatient services or receipt of

prescription medication.

MH = mental health; SU Tx = substance use treatment.

Note: The percentages do not add to 100percent due to rounding.

Figure 54. Receipt of Substance Use Treatment at a Specialty

Facility and Mental Health Services in the Past Year: Among

Adults Aged 18 or Older with Past Year Substance Use Disorder

and Any Mental Illness; 2020

SU Tx or

MH Services

8.5 Million Adults

(50.5%)

No Treatment

8.4 Million Adults

(49.5%)

Both SU Tx and MH Services

1.0 Million Adults (5.7%)

MH Services,

but no SU Tx

7.2 Million Adults

(42.3%)

SU Tx, but no MH Services

423,000 Adults (2.5%)

17.0 Million Adults with a Substance Use Disorder and Any Mental Illness

Note: Mental Health Services include any combination of inpatient or outpatient services or receipt of

prescription medication.

MH = mental health; SU Tx = substance use treatment.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 49

Perceived Recovery

Since 2018, respondents aged 18 or older have been asked

whether they thought they ever had a problem with their use

of alcohol or other drugs or whether they ever had a problem

with their mental health. Respondents who reported that they

ever had a problem with their alcohol or other drug use were

asked whether they considered themselves (at the time they

were interviewed) to be in recovery or to have recovered from

their alcohol or other drug use problem. Similarly, respondents

aged 18 or older who reported that they had a problem with

their mental health were asked whether they considered

themselves (at the time they were interviewed) to be in

recovery or to have recovered from their mental health issue.

Among adults aged 18 or older in 2020, 11.6 percent (or

29.2 million people) perceived that they ever had a problem

with their use of alcohol or other drugs (Table A.64B). As

noted in prior sections of this report, young adults aged 18

to 25 in 2020 tended to be more likely than adults aged 26

or older to be binge alcohol users in the past month, to have

used illicit drugs in the past year, or to have had an SUD in

the past year. However, only 7.5 percent of young adults (or

2.5 million people) perceived that they ever had a problem with

their use of alcohol or other drugs compared with 12.3 percent

of adults aged 26 or older (or 26.7 million people).

Among the 29.2 million adults in 2020 who perceived that

they ever had a substance use problem, 72.5 percent (or

21.0 million people) considered themselves to be in recovery

or to have recovered from their alcohol or other drug use

problem (Table A.65B). Adults aged 26 or older who

perceived that they ever had a substance use problem were

more likely than corresponding young adults aged 18 to 25

to consider themselves to be in recovery or to have recovered

from their substance use problem. About three fourths of

adults aged 26 or older who perceived that they ever had

a substance use problem considered themselves to be in

recovery or to have recovered (73.4 percent or 19.5 million

people) compared with about two thirds of young adults

who perceived that they ever had a substance use problem

(63.4 percent or 1.6 million people).

In 2020, 22.0 percent of adults aged 18 or older (or

55.0 million people) perceived that they ever had a problem

with their mental health (Table A.64B). Young adults aged

18 to 25 were more likely than adults aged 26 or older to

perceive that they ever had a problem with their mental health

(34.7 percent of young adults or 11.5 million people vs.

20.0 percent of adults aged 26 or older or 43.5 million people).

Among the 55.0 million adults in 2020 who perceived

that they ever had a problem with their mental health,

65.9 percent (or 35.8 million people) considered themselves

to be in recovery or to have recovered from their mental

health issue (Table A.65B). Young adults aged 18 to 25

who perceived that they ever had a problem with their

mental health were somewhat less likely than corresponding

adults aged 26 or older to consider themselves to be in

recovery or to have recovered from their mental health

issue (61.8 percent of young adults or 7.1 million people

vs. 66.9 percent of adults aged 26 or older or 28.8 million

people).

Substance Use, Mental Health Issues, and the

COVID‑19 Pandemic

e COVID-19 pandemic and the requisite measures taken

to combat it created challenges in the everyday lives of

Americans. To describe eﬀects of the COVID-19 pandemic

on people’s substance use, mental health, and other parts

of their lives, SAMHSA added questions to the 2020

NSDUH for Quarter 4 (i.e., October to December). ese

questions asked respondents to describe how the COVID-19

pandemic aﬀected their mental health; substance use;

ﬁnancial security; housing; and access to substance use

treatment, mental health services, and medical care. is

section provides an overview of estimates of the eﬀect of the

COVID-19 pandemic on substance use and mental health

issues according to how NSDUH respondents aged 12 or

older answered these questions during Quarter 4.

14

Data from most of these questions reﬂect respondents’

subjective perceptions of how their lives changed during the

COVID-19 pandemic. e questions concerning mental

health and substance use asked respondents to rate the eﬀects

of the COVID-19 pandemic on their mental or emotional

health using a scale of responses (“not at all,” “a little,”

“some,” “quite a bit,” or “a lot”). Similarly, respondents were

asked how much the COVID-19 pandemic aﬀected their

substance use, with responses for using a substance “much

less,” “a little less,” “about the same,” “a little more,” or “a lot

more” than they did before the COVID-19 pandemic began.

However, there are no objective indicators to deﬁne the

categories on these subjective measures. For example,

one respondent could deﬁne the same negative eﬀects

on mental health as having “some” negative eﬀect, and

another respondent could deﬁne these eﬀects as negatively

aﬀecting their mental health “quite a bit.” Similarly, one

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health50 | October 2021

respondent could deﬁne the same change in substance use

as “much less,” and another respondent could deﬁne the

change as “a little less.” Also, these are sensitive questions,

and some respondents may have given responses they felt

were more socially desirable. Some respondents may have

been reluctant to report increased mental health issues, and

some respondents whose substance use increased during the

COVID-19 pandemic might have been reluctant to report

that they were using substances more than they did before

the COVID-19 pandemic began.

An additional consideration is that data from the Centers

for Disease Control and Prevention showed three peaks in

the number of new COVID-19 cases in the United States

in 2020: (1) in March and April, (2) in July, and (3) in late

November and December.

123

erefore, these NSDUH

data from Quarter 4 could depend on the period(s) of the

COVID-19 pandemic respondents recalled when answering

the questions.

Perceived Negative Effects on Mental Health Because

of the COVID‑19 Pandemic

As mentioned previously, respondents were asked to rate the

COVID-19 pandemic’s negative eﬀect on their mental health

on a scale ranging from “not at all” to “a lot.” To facilitate

analysis, responses were collapsed into three categories:

“not at all,” “a little or some,” and “quite a bit or a lot.” As

also noted previously, the resulting data reﬂect respondents’

subjective perceptions and are not objective indicators

of mental health issues. In addition, asking respondents

how much (if at all) the COVID-19 pandemic negatively

aﬀected their mental health presupposes that the COVID-19

pandemic had a negative eﬀect. Respondents were not

oﬀered a choice to indicate improvement in mental health

(for whatever reason) since the COVID-19 pandemic began.

Perceived Negative Effects on Mental Health Because of the

COVID-19 Pandemic among Adolescents Aged 12 to 17

In Quarter 4 of 2020, most adolescents aged 12 to 17

perceived a negative eﬀect of the COVID-19 pandemic on

their mental health. About 1 in 5 adolescents (18.3 percent or

4.5 million people) perceived that the COVID-19 pandemic

negatively aﬀected their mental health “quite a bit or a lot,”

and an additional 50.8 percent (or 12.5 million people)

perceived “a little or some” negative eﬀect on their mental

health (Figure 56). About 1 in 3 adolescents (30.8 percent

or 7.6 million people) perceived no negative eﬀect on their

mental health because of the COVID-19 pandemic.

Adolescents aged 12 to 17 who had a past year MDE or a

past year MDE with severe impairment were more likely

than those without a past year MDE to perceive that the

COVID-19 pandemic negatively aﬀected their mental

health “quite a bit or a lot.” Among adolescents with a

past year MDE, nearly half (48.7 percent or 1.9 million

people) perceived that the COVID-19 pandemic negatively

aﬀected their mental health “quite a bit or a lot,” as did more

than half of adolescents who had a past year MDE with

severe impairment (55.3 percent or 1.5 million people).

In comparison, 12.7 percent of adolescents without a

past year MDE (or 2.6 million people) perceived this level

of a negative eﬀect on their mental health because of the

COVID-19 pandemic. For adolescents who had a past year

MDE or a past year MDE with severe impairment, however,

it is not known from these data whether they had an MDE

before the COVID-19 pandemic or a new MDE that began

during the COVID-19 pandemic.

In addition, about half of adolescents who did not have

a past year MDE (52.2 percent or 10.6 million people),

40.8 percent (or 1.5 million people) of adolescents with a

past year MDE, and 35.1 percent (or 944,000 people) of

adolescents with a past year MDE with severe impairment

perceived that the COVID-19 pandemic negatively aﬀected

their mental health “a little or some.” It is unclear whether

these negative eﬀects were temporary or longer lasting.

Even if adolescents did not have a past year MDE, some of

them could have needed mental health services during the

COVID-19 pandemic.

Figure 56. Perceived COVID-19 Pandemic Negative Effect on

Emotional or Mental Health: Among Youths Aged 12 to 17; by Past

Year Major Depressive Episode (MDE) Status, Quarter 4, 2020

30.8

10.5

9.6

35.1

50.8

40.8

35.1

52.2

18.3

48.7

55.3

12.7

0

10

20

30

40

50

60

70

Total Had MDE Had MDE with

Severe Impairment

Did Not Have MDE

Percent Perceiving Effect

Not at all A little or some Quite a bit or a lot

Note: The percentages do not add to 100percent due to rounding.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 51

Perceived Negative Effects on Mental Health Because of

the COVID-19 Pandemic among Adults Aged 18 or Older

Similar to adolescents, most adults aged 18 or older

in Quarter 4 of 2020 perceived a negative eﬀect of the

COVID-19 pandemic on their mental health. About 1 in 5

adults (18.3 percent or 45.2 million people) perceived that

the COVID-19 pandemic negatively aﬀected their mental

health “quite a bit or a lot,” and another 54.7 percent (or

135.2 million people) perceived “a little or some” negative

eﬀect on their mental health (Figure 57). However, slightly

more than 1 in 4 adults (27.0 percent or 66.8 million

people) perceived no negative eﬀect on their mental health

because of the COVID-19 pandemic. Because these data

were collected in Quarter 4, these estimates might not reﬂect

temporary negative eﬀects on mental health that occurred

early in the COVID-19 pandemic.

In Quarter 4 of 2020, adults aged 18 or older with AMI

or SMI in the past year were more likely than those who

did not have mental illness in the past year to perceive that

the COVID-19 pandemic negatively aﬀected their mental

health “quite a bit or a lot.” Among adults with AMI in the

past year, 45.2 percent (or 24.3 million people) perceived

the COVID-19 pandemic to have negatively aﬀected their

mental health “quite a bit or a lot,” as did more than half of

adults with SMI in the past year (54.9 percent or 7.9 million

people). In comparison, about 1 in 10 adults with no

mental illness in the past year (10.8 percent or 20.9 million

people) perceived the COVID-19 pandemic to have

negatively aﬀected their mental health “quite a bit or a lot.”

However, it is not known from these data whether adults

had pre-existing AMI or SMI that they perceived to have

worsened or whether they had AMI or SMI for the ﬁrst time

during the COVID-19 pandemic. Nevertheless, these data

indicate the need for adults with AMI and SMI to receive

mental health services during the COVID-19 pandemic.

Perceived Effects on Substance Use Because of the

COVID‑19 Pandemic

Stressors and feelings of social isolation during the

COVID-19 pandemic could have negatively aﬀected

Americans’ substance use. In many states, establishments

that sold alcohol for oﬀ-premises consumption (e.g., liquor

stores, grocery stores) remained open as “essential businesses”

during periods when stay-at-home orders were in eﬀect.

During the COVID-19 pandemic, some states also changed

laws to allow “to-go” drinks from bars and restaurants and

loosened restrictions on home delivery of alcohol.

124

Czeisler

and colleagues reported estimates from June 2020 showing

certain groups of adults started to use substances or increased

their substance use to cope with the COVID-19 pandemic.

21

Other studies conducted in May and June 2020 also showed

at least short-term increases in alcohol consumption,

especially among some population subgroups.

125,126

However, individuals also could have decreased their

substance use in the short or long term in response to the

COVID-19 pandemic. For example, data from Europe

indicated some temporary decreases in substance use during

the COVID-19 pandemic due to disruptions in illicit drug

markets, but these reductions began to disappear as social

distancing measures were eased.

127

Adolescents and college-

aged young adults living at home may have had fewer

opportunities to use substances regardless of their desire or

intent to use them. It does not appear that respondents in

the study by Czeisler and colleagues were asked whether

they reduced their substance use or stopped using speciﬁc

substances during the COVID-19 pandemic.

21

erefore,

a more complete picture of how people’s substance use

changed during the COVID-19 pandemic also would

include information on people who reduced their substance

use.

As mentioned previously, new questions in Quarter 4 of

the 2020 NSDUH asked respondents to rate how the

COVID-19 pandemic aﬀected their use of alcohol and other

drugs. Respondents who used alcohol or other drugs in the

past 12 months could report substance use ranging from

“much less” to “a lot more” than use before the COVID-19

Figure 57. Perceived COVID-19 Pandemic Negative Effect on

Emotional or Mental Health: Among Adults Aged 18 or Older; by

Past Year Mental Illness Status, Quarter 4, 2020

27.0

10.4

9.3

31.7

54.7

44.5

35.8

57.6

18.3

45.2

54.9

10.8

0

10

20

30

40

50

60

70

Total Any Mental Illness Serious Mental

Illness

No Mental Illness

Percent Perceiving Effect

Not at all A little or some Quite a bit or a lot

Note: The percentages do not add to 100percent due to rounding.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health52 | October 2021

pandemic. Respondents answered separate questions

about eﬀects of the COVID-19 pandemic on their alcohol

and other drug use. To facilitate analysis, responses were

collapsed into three categories: “a little less or much less,”

“about the same,” and “a little more or much more.”

128

Perceived Effects on Alcohol Use

Among people aged 12 or older in Quarter 4 of 2020 who

drank alcohol in the past year, most perceived that they

drank “about the same” amount as they did before the

COVID-19 pandemic began (59.4 percent or 100.0 million

people) (Figure 58). In addition, 25.2 percent of past year

alcohol users (or 42.5 million people) perceived that they

drank “a little less or much less” alcohol than they did

before the COVID-19 pandemic began, and 15.4 percent

(or 25.9 million people) perceived that they drank “a little

more or much more” than they did before. Because these

data were collected in Quarter 4, these estimates might not

reﬂect temporary increases in alcohol consumption early in

the COVID-19 pandemic that were followed by a return to

a pattern of alcohol use that was about the same as it was

before the COVID-19 pandemic began.

About 1 in 5 young adults aged 18 to 25 in Quarter 4 of

2020 who drank alcohol in the past year (18.2 percent

or 3.7 million people) perceived that they drank “a little

more or much more” than they did before the COVID-19

pandemic began. e percentage of young adult alcohol

users who perceived that they drank “a little more or much

more” than they did before the COVID-19 pandemic was

higher than the corresponding percentage among past year

alcohol users aged 26 or older (15.0 percent or 21.8 million

people). In addition, 14.5 percent of adolescents aged 12 to

17 who drank alcohol in the past year (or 491,000 people)

perceived that they drank “a little more or much more” than

they did before the COVID-19 pandemic began. People who

were drinking more than they did before the COVID-19

pandemic began might not return to their earlier patterns

of alcohol consumption, or their level of alcohol use could

decrease over time.

In Quarter 4 of 2020, 38.7 percent of adolescents aged 12 to

17 (or 1.3 million people) and 29.3 percent of young adults

aged 18 to 25 (or 5.9 million people) who drank alcohol in

the past year perceived that they were drinking “a little less

or much less” than they did before the COVID-19 pandemic

began. ese percentages were higher than the corresponding

percentage among adults aged 26 or older who used alcohol

in the past year (24.3 percent or 35.3 million people). It is

unknown whether people who were drinking less than they

did before the COVID-19 pandemic began will return to

their earlier patterns of alcohol consumption. For example,

college-age young adults who were living with their parents

during the COVID-19 pandemic could resume their earlier

patterns of alcohol consumption once they return to their

campus environment, and adolescents may increase their

drinking as opportunities increase for unsupervised social

activities.

Perceived Effects on the Use of Drugs Other than Alcohol

Among people aged 12 or older in Quarter 4 of 2020 who

used drugs other than alcohol in the past year,

128

about 1

in 3 (32.2 percent or 33.9 million people) perceived that

they used these drugs “a little less or much less” than they

did before the COVID-19 pandemic began, and more than

half (57.5 percent or 60.6 million people) perceived that

they used these drugs “about the same” as they did before

the COVID-19 pandemic began (Figure 59). An estimated

10.3 percent of past year users of drugs other than alcohol

(or 10.9 million people) perceived that they used these

drugs “a little more or much more” during the COVID-19

pandemic than they did before. It is not known, however,

whether people who reduced or increased their use of these

drugs will return to their earlier levels of use over time.

Figure 58. Perceived COVID-19 Pandemic Effect on Alcohol Use:

Among Past Year Alcohol Users Aged 12 or Older; Quarter 4, 2020

25.2

38.7

29.3

24.3

59.4

46.8

52.4

60.6

15.4

14.5

18.2

15.0

0

10

20

30

40

50

60

70

12 or Older 12 to 17 18 to 25 26 or Older

Percent Perceiving Effect

A little less or much less About the same A little more or much more

Note: The percentages do not add to 100percent due to rounding.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 53

In Quarter 4 of 2020, nearly half of adolescents aged 12

to 17 who used drugs other than alcohol in the past year

(46.4 percent or 2.0 million people) perceived that they used

these drugs “a little less or much less” than they did before

the COVID-19 pandemic began. is percentage among

adolescents was higher than the corresponding percentages

among young adults aged 18 to 25 (31.8 percent or

4.2 million people) and those aged 26 or older (31.5 percent

or 27.7 million people) who used these drugs. As previously

noted in relation to perceived reductions in alcohol use, these

adolescents could increase their use of other drugs as they have

more opportunities to engage in social activities with peers.

Adolescents and young adults in Quarter 4 of 2020

who used drugs other than alcohol in the past year were

more likely than their counterparts aged 26 or older to

perceive that they used these drugs “a little more or much

more” than they did before the COVID-19 pandemic.

Speciﬁcally, 15.2 percent of adolescents (or 665,000 people)

and 18.7 percent of young adults (or 2.5 million people)

perceived that they used these drugs “a little more or much

more” than they did before the COVID-19 pandemic began.

In comparison, 8.8 percent of adults aged 26 or older who

used drugs other than alcohol in the past year (or 7.7 million

people) perceived that they used these drugs “a little more or

much more” than they did before the COVID-19 pandemic

began. It is unknown, however, whether these will be

short- or long-term increases in other drug use that persist

beyond the COVID-19 pandemic. Further, because the data

were collected in Quarter 4 of 2020, there may have been

additional short-term increases in other drug use earlier in

2020 that are not reﬂected in these data.

Perceived Effects on Access to Services Because of

the COVID‑19 Pandemic

e COVID-19 pandemic could have aﬀected access to

substance use treatment, mental health services, and medical

care in diﬀerent ways. In response to the COVID-19

pandemic, for example, healthcare providers (including

behavioral healthcare providers) turned to virtual (i.e.,

telehealth) services (i.e., delivery of healthcare services over

the phone or Internet) as a means of delivering services

while also limiting in-person contact that could spread

COVID-19.

129

As discussed in the section Substance Use

Treatment in the Past Year, reimbursement for virtual

services was expanded during the COVID-19 pandemic,

including reimbursement for services delivered over the

phone (i.e., using only audio).

To assess the various eﬀects of the COVID-19 pandemic on

access to behavioral health and medical services, NSDUH

respondents in Quarter 4 were asked if they experienced

the following because of the COVID-19 pandemic:

(1) appointments moved from in-person to telehealth

format, (2) delays or cancellations in appointments, (3)

delays in getting prescriptions, and (4) inability to access

needed care resulting in moderate to severe impact on

health. Respondents were asked separately about each of

these situations in relation to their access to substance

use treatment, mental health treatment, and medical care

because of the COVID-19 pandemic.

Access to Substance Use Treatment

As noted previously, people were asked whether they

experienced the following in their access to substance

use treatment because of the COVID-19 pandemic: (1)

appointments moved from in-person to telehealth format,

(2) delays or cancellations in appointments, (3) delays in

getting prescriptions, and (4) inability to access needed care

resulting in moderate to severe impact on health. For people

in Quarter 4 of 2020 who received substance use treatment

in the past year, several estimates of perceived changes in

Figure 59. Perceived COVID-19 Pandemic Effect on Drug Use:

Among Past Year Users of Drugs Other than Alcohol Aged 12 or

Older; Quarter 4, 2020

32.2

46.4

31.8

31.5

57.5

38.4

49.5

59.7

10.3

15.2

18.7

8.8

0

10

20

30

40

50

60

70

12 or Older 12 to 17 18 to 25 26 or Older

Percent Perceiving Effect

A little less or much less About the same A little more or much more

Note: Use of drugs other than alcohol included the use of marijuana, cocaine (including crack), heroin,

hallucinogens, inhalants, or methamphetamine in the pastyear or any use (i.e., not necessarily

misuse) of prescription pain relievers, tranquilizers, stimulants, or sedatives in the pastyear. Drugs

other than alcohol did not include tobacco products or nicotine vaping.

Note: The percentages do not add to 100percent due to rounding.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health54 | October 2021

access to substance use treatment because of the COVID-19

pandemic could not be calculated with suﬃcient precision.

In addition, 97.5 percent of people aged 12 or older in 2020

with a past year SUD who did not receive substance use

treatment at a specialty facility in the past year did not think

that they needed substance use treatment. e COVID-19

pandemic’s eﬀect on access to substance use treatment would

not be relevant to people who did not feel that they needed

those services. For these reasons, this section of the report

does not present ﬁndings from Quarter 4 of 2020 on speciﬁc

eﬀects of the COVID-19 pandemic on people’s access to

substance use treatment.

Access to Mental Health Services

Among adults aged 18 or older in Quarter 4 of 2020 who

received mental health services in the past year, more than

half (58.3 percent or 26.6 million people) had appointments

moved from in person to telehealth, and 1 in 3 (38.7 percent

or 17.7 million people) experienced delays or cancellations in

appointments (Figure 60). e ﬁnding that more than half of

adults aged 18 or older who received mental health services

in the past year had appointments moved from in person to

telehealth likely reﬂects the use of virtual (i.e., telehealth)

services to continue delivering mental health services and the

expansion of reimbursement for virtual services.

In addition, about 1 in 6 adults aged 18 or older in 2020

who received mental health services in the past year

(16.0 percent or 7.3 million people) experienced delays

in getting prescriptions, and 1 in 10 (10.7 percent or

4.9 million people) were unable to access needed care

resulting in a perceived moderate to severe impact on health.

at 4.9 million adults perceived their health to have been

negatively aﬀected because they were unable to access needed

mental health services is an important indicator of adverse

impacts of changes in access to these services during the

COVID-19 pandemic.

ese patterns were consistent among adult age groups.

Among adults aged 18 or older in Quarter 4 of 2020 who

received mental health services in the past year, for example,

62.7 percent of young adults aged 18 to 25 (or 4.6 million

people) and 57.4 percent of adults aged 26 or older (or

22.0 million people) had appointments moved from in

person to telehealth. An estimated 9.7 percent of young

adults (or 715,000 people) and 10.9 percent of adults aged

26 or older (or 4.2 million people) who received mental

health services in the past year were unable to access needed

care resulting in a perceived moderate to severe impact on

health.

Access to Medical Services

Among people aged 12 or older in Quarter 4 of 2020,

nearly 1 in 3 (31.3 percent or 84.6 million people) had

medical appointments moved from in person to telehealth,

and more than 1 in 4 (29.4 percent or 79.4 million people)

experienced delays or cancellations in medical appointments

or preventive services (Figure 61). About 1 in 11 people

(8.9 percent or 23.9 million people) experienced delays

in getting prescriptions, and 1 in 20 (5.6 percent or

15.1 million people) were unable to access needed medical

care resulting in a perceived moderate to severe impact on

health. at 15.1 million people whose health was negatively

aﬀected because they were unable to access needed medical

care is particularly concerning. Issues discussed previously

regarding access to mental health services also would apply

if people’s in-person medical appointments were moved to

telehealth or if people experienced delays or cancellations

in their medical appointments during the COVID-19

pandemic.

Figure 60. Perceived COVID-19 Pandemic Effect on Mental Health

Services: Among Adults Aged 18 or Older Who Received Services;

Quarter 4, 2020

58.3

62.7

57.4

38.7

38.6

38.7

16.0

14.8

16.2

10.7

9.7

10.9

0

10

20

30

40

50

60

70

18 or Older 18 to 25 26 or Older

Percent Perceiving Effect

Appointments moved from in-person to telehealth

Delays or cancellations in appointments

Delays in getting prescriptions

Unable to access needed care resulting in moderate to severe impact on health

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 55

Figure 61. Perceived COVID-19 Pandemic Effect on Access to

Medical Care: Among People Aged 12 or Older; Quarter 4, 2020

31.3

15.1

24.4

34.2

29.4

19.3

20.2

32.0

8.9

5.4

7.8

9.4

5.6

1.4

5.3

6.1

0

10

20

30

40

12 or Older 12 to 17 18 to 25 26 or Older

Percent Perceiving Effect

Appointments moved from in-person to telehealth

Delays or cancellations in appointments

Delays in getting prescriptions

Unable to access needed care resulting in moderate to severe impact on health

Adults aged 26 or older in 2020 (regardless of quarter) were

more likely than adolescents and young adults to have had

two or more outpatient medical visits in the past year.

33

erefore, perceptions of whether the COVID-19 pandemic

aﬀected people’s access to medical care would be especially

relevant to adults aged 26 or older. Among adults aged 26

or older in Quarter 4 of 2020, 34.2 percent (or 72.9 million

people) had medical appointments moved from in person

to telehealth, 32.0 percent (or 68.2 million people)

experienced delays or cancellations in medical appointments

or preventive services, 9.4 percent (or 20.1 million people)

experienced delays in getting prescriptions, and 6.1 percent

(or 13.0 million people) were unable to access needed

medical care resulting in a perceived moderate to severe

impact on health.

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health56 | October 2021

Endnotes

1. Hasin, D. S., & Grant, B. F. (2015). e National Epidemiologic

Survey on Alcohol and Related Conditions (NESARC) Waves 1 and

2: Review and summary of ﬁndings. Social Psychiatry and Psychiatric

Epidemiology, 50, 1609-1640. https://doi.org/10.1007/s00127-015-

1088-0

2. World Health Organization. (2013). Mental health action plan 2013 –

2020. Retrieved from https://www.who.int/mental_health/publications/

action_plan/en/

3. Reeves, W. C., Strine, T. W., Pratt, L. A., ompson, W., Ahluwalia, I.,

Dhingra, S. S., McKnight-Eily, L. R., Harrison, L., D’Angelo, D. V.,

Williams, L., Morrow, B., Gould, D., & Safran, M. A. (2011). Mental

illness surveillance among adults in the United States. Morbidity and

Mortality Weekly Report CDC Surveillance Summaries, 60(Suppl. 3),

1-29. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/

su6003a1.htm

4. Murray, C. J. L., & Lopez, A. D. (2013). Measuring the global burden

of disease. New England Journal of Medicine, 369, 448-457. https://doi.

org/10.1056/nejmra1201534

5. is report occasionally presents estimated numbers of people with a

speciﬁc characteristic (e.g., estimated numbers of substance users). Some

of these estimated numbers are not included in ﬁgures or tables in the

report but may be found in the detailed tables for the 2020 NSDUH

available at https://www.samhsa.gov/data/.

6. Details about the sample design, weighting, and interviewing results

for the 2020 NSDUH are provided in Sections 2.1, 2.3.4, and

3.3.1 of CBHSQ (2021), including changes to the sample design

and weighting procedures because of the COVID-19 pandemic. In

particular, Tables 2.1 and 2.2 in CBHSQ (2021) provide sample design

information on the targeted numbers of completed interviews by state

and by age group, respectively. See the following reference: Center

for Behavioral Health Statistics and Quality. (2021). 2020 National

Survey on Drug Use and Health: Methodological summary and deﬁnitions.

Retrieved from https://www.samhsa.gov/data/

7. Overall response rates are not calculated for adolescents or adults

because the screening response rate is not speciﬁc to age groups.

8. Center for Systems Science and Engineering, Johns Hopkins University.

(2021). Coronavirus resource center: Global map: COVID-19 dashboard.

Retrieved from https://coronavirus.jhu.edu/map.html

9. Although the 2020 NSDUH sample size was smaller than the target

sample size of 67,500 completed interviews, relatively few estimates in

this report did not meet the criteria for publication due to low statistical

precision. Numbers of ﬁnal respondents in diﬀerent age groups also

were suﬃciently large to detect statistically signiﬁcant diﬀerences for

several estimates presented in this report. For discussion of the criteria

for suppressing (i.e., not publishing) unreliable estimates and for testing

for statistical signiﬁcance, see Sections 3.2.2 and 3.2.3 in the following

reference: Center for Behavioral Health Statistics and Quality. (2021).

2020 National Survey on Drug Use and Health: Methodological summary

and deﬁnitions. Retrieved from https://www.samhsa.gov/data/

10. Center for Behavioral Health Statistics and Quality. (2021). 2020

National Survey on Drug Use and Health: Methodological summary and

deﬁnitions. Retrieved from https://www.samhsa.gov/data/

11. For methodological reasons, the 2020 NSDUH estimates in this report

are not comparable with NSDUH data collected prior to 2002. For

more details, see Appendix C in the following report for the 2004

NSDUH: Oﬃce of Applied Studies. (2005). Results from the 2004

National Survey on Drug Use and Health: National ﬁndings (HHS

Publication No. SMA 05-4062, NSDUH Series H-28). Rockville, MD:

Substance Abuse and Mental Health Services Administration.

12. Estimates presented in this report have been weighted to reﬂect

characteristics of the civilian, noninstitutionalized population aged 12

or older in the United States. e calculation of NSDUH weights for

analysis includes a step that yields weights consistent with population

totals obtained from the U.S. Census Bureau based on the most recently

available decennial census.

13. For a discussion of the criteria for suppressing (i.e., not publishing)

unreliable estimates, see Section 3.2.2 in the following reference: Center

for Behavioral Health Statistics and Quality. (2021). 2020 National

Survey on Drug Use and Health: Methodological summary and deﬁnitions.

Retrieved from https://www.samhsa.gov/data/

14. Please refer to the 2020 NSDUH detailed tables (available at https://

www.samhsa.gov/data/) for population estimates cited in this report that

do not appear in the report ﬁgures, their accompanying data tables, or

the appendix tables.

15. Survey modes included data collection in person or through the web.

16. Chapters 3 and 6 of CBHSQ (2021) discuss data quality issues for

NSDUH in greater detail. See the following reference: Center for

Behavioral Health Statistics and Quality. (2021). 2020 National Survey

on Drug Use and Health: Methodological summary and deﬁnitions.

Retrieved from https://www.samhsa.gov/data/

17. American Psychiatric Association. (2013). Diagnostic and statistical

manual of mental disorders (DSM-5) (5th ed.). Arlington, VA: Author.

18. American Psychiatric Association. (1994). Diagnostic and statistical

manual of mental disorders (DSM-IV) (4th ed.). Washington, DC:

Author.

19. Hossain, M. M., Tasnim, S., Sultana, A., Faizah, F., Mazumder,

H., Zou, L., McKyer, E. L. J., Ahmed, H. U., & Ma, P. (2020).

Epidemiology of mental health problems in COVID-19: A

review. F1000 Research, 9, 636. https://doi.org/10.12688/

f1000research.24457.1

20. Torales, J., O’Higgins, M., Castaldelli-Maia, J. M., & Ventriglio, A.

(2020). e outbreak of COVID-19 coronavirus and its impact on

global mental health. International Journal of Social Psychiatry, 66(4),

317-320. https://doi.org/10.1177/0020764020915212

21. Czeisler, M. É., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A.,

Njai, R., Weaver, M. D., Robbins, R., Facer-Childs, E. R., Barger, L. K.,

Czeisler, C. A., Howard, M. E., & Rajaratnam, S. M. W. (2020). Mental

health, substance use, and suicidal ideation during the COVID-19

pandemic — United States, June 24-30, 2020. Morbidity and Mortality

Weekly Report, 69(32), 1049-1057. https://doi.org/10.15585/mmwr.

mm6932a1

22. For information on the statistical testing procedures for the 2020

NSDUH, see Section 3.2.3 in the following reference: Center for

Behavioral Health Statistics and Quality. (2021). 2020 National Survey

on Drug Use and Health: Methodological summary and deﬁnitions.

Retrieved from https://www.samhsa.gov/data/

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 57

23. Johnston, L. D., Miech, R. A., O’Malley, P. M., Bachman, J. G.,

Schulenberg, J. E., & Patrick, M. E. (2020). Monitoring the Future

national survey results on drug use 1975–2019: 2019 overview, key ﬁndings

on adolescent drug use. Ann Arbor, MI: University of Michigan, Institute

for Social Research. Retrieved from http://www.monitoringthefuture.

org/pubs/monographs/mtf-overview2019.pdf

24. U.S. Food and Drug Administration. (2020). 2019 National Youth

Tobacco Survey shows youth e-cigarette use at alarming levels. Retrieved

from https://www.fda.gov

25. Wang, T. W., Gentzke, A. S., Creamer, M. R., Cullen, K. A., Holder-

Hayes, E., Sawdey, M. D., Anic, G. M., Portnoy, D. B., Hu, S., Homa,

D. M., Jamal, A., & Neﬀ, L. J. (2019). Tobacco product use and

associated factors among middle and high school students — United

States, 2019. Morbidity and Mortality Weekly Report Surveillance

Summaries, 68(SS-12), 1-22. https://doi.org/10.15585/mmwr.

ss6812a1

26. Miech, R. A., Johnston, L. D., O’Malley, P. M., Bachman, J. G.,

Schulenberg, J. E., & Patrick, M. E. (2021). Monitoring the Future

national survey results on drug use, 1975–2020: Volume I, Secondary school

students. Ann Arbor, MI: University of Michigan, Institute for Social

Research. Retrieved from http://www.monitoringthefuture.org/pubs/

monographs/mtf-vol1_2020.pdf

27. Gentzke, A. S., Wang, T. W., Jamal, A., Park-Lee, E., Ren, C., Cullen,

K. A., & Neﬀ, L. (2020). Tobacco product use among middle and high

school students — United States, 2020. Morbidity and Mortality Weekly

Report, 69, 1882-1888. https://doi.org/10.15585/mmwr.mm6950a1

28. See the following reference: Center for Behavioral Health Statistics and

Quality. (2014). Results from the 2013 National Survey on Drug Use and

Health: Summary of national ﬁndings (HHS Publication No. SMA 14-4863,

NSDUH Series H-48). Retrieved from https://www.samhsa.gov/data/

29. U.S. Food and Drug Administration. (2021). Tobacco 21. Retrieved

from https://www.fda.gov/tobacco-products/retail-sales-tobacco-

products/tobacco-21

30. In the 2020 NSDUH, a “drink” was deﬁned as a can or bottle of beer,

a glass of wine or a wine cooler, a shot of liquor, or a mixed drink with

liquor in it. Times when respondents had only a sip or two from a drink

were not considered to be alcohol consumption.

31. e threshold for determining binge alcohol use for females was lowered

from ﬁve or more drinks on an occasion for the 2014 and earlier

NSDUHs to four or more drinks on an occasion for the 2015 NSDUH

to ensure consistency with federal deﬁnitions and other federal data

collection programs. e threshold for males in 2015 remained at ﬁve or

more drinks on an occasion. New baselines began in 2015 for estimates

of binge and heavy alcohol use for females and for binge and heavy

alcohol use for the overall population (both genders). Estimates from

2002 to 2020 for binge and heavy alcohol use among males are available

in the 2020 NSDUH detailed tables at https://www.samhsa.gov/data/.

32. e National Institute on Alcohol Abuse and Alcoholism (NIAAA)

deﬁnes binge drinking as a pattern of drinking that brings blood alcohol

concentration (BAC) levels to 0.08 grams per deciliter (g/dL). is

typically occurs after four drinks for women and ﬁve drinks for men in

about 2 hours. See the following two references:

National Institute on Alcohol Abuse and Alcoholism. (2004, Winter).

NIAAA council approves deﬁnition of binge drinking. NIAAA

Newsletter, 3, 3. Retrieved from https://pubs.niaaa.nih.gov/publications/

Newsletter/winter2004/Newsletter_Number3.pdf

National Institute on Alcohol Abuse and Alcoholism. (2019). Drinking

levels deﬁned. Retrieved from https://www.niaaa.nih.gov/alcohol-health/

overview-alcohol-consumption/moderate-binge-drinking

33. ese estimates were calculated from special analyses but are not

included in the appendix tables or in the 2020 detailed tables.

34. Alcohol Policy Information System, National Institute on Alcohol Abuse

and Alcoholism. (n.d.). Highlight on underage drinking. Retrieved from

https://alcoholpolicy.niaaa.nih.gov/underage-drinking

35. e 2020 NSDUH questionnaire included separate sections for

tranquilizer misuse and sedative misuse. Data from these sections

were combined to produce aggregate estimates for the misuse of any

tranquilizer or sedative.

36. e estimated numbers of current users of diﬀerent illicit drugs are not

mutually exclusive because people could have used more than one type

of illicit drug in the past month.

37. LSD = lysergic acid diethylamide; PCP = phencyclidine; MDMA =

methylenedioxy-methamphetamine; DMT = dimethyltryptamine;

AMT = alpha-methyltryptamine; Foxy = N, N-diisopropyl-5-

methoxytryptamine (5-MeO-DIPT). Deﬁnitions for these hallucinogens

also are included in Appendix A of the following reference: Center

for Behavioral Health Statistics and Quality. (2021). 2020 National

Survey on Drug Use and Health: Methodological summary and deﬁnitions.

Retrieved from https://www.samhsa.gov/data/

38. Desoxyn

®

was not mentioned in 2020 as some other stimulant and

has been mentioned only rarely in some years since 2015. Because

Desoxyn

®

is chemically similar to other prescription amphetamines (e.g.,

Adderall

®

), it was grouped with the other amphetamines.

39. For example, the product label for Xanax

®

, which is prescribed as

a tranquilizer, indicates the drug has an average half-life of 11.2

hours (i.e., the length of time for half of the dosage of the drug to be

metabolized), with a range of 6.3 to 26.9 hours in healthy adults. In

comparison, the product label for Halcion

®

, a benzodiazepine prescribed

as a sedative, has a short half-life in the range of 1.5 to 5.5 hours.

Product label information for these drugs is available on the U.S. Food

and Drug Administration’s Center for Drug Evaluation and Research

website at https://www.fda.gov/drugs/.

40. Examples of forms of fentanyl presented to NSDUH respondents are

available by prescription. NSDUH respondents were not asked about

the use of fentanyl illicitly manufactured in clandestine laboratories.

41. National Institute on Drug Abuse. (2021, April). DrugFacts: Cocaine.

Retrieved from https://www.drugabuse.gov/publications/ﬁnder/t/160/

drugfacts

42. National Institute on Drug Abuse. (2019, May). DrugFacts:

Methamphetamine. Retrieved from https://www.drugabuse.gov/

publications/ﬁnder/t/160/drugfacts

43. National Institute on Drug Abuse. (2018, June). DrugFacts: Prescription

stimulants. Retrieved from https://www.drugabuse.gov/publications/

ﬁnder/t/160/drugfacts

44. Drug Enforcement Administration. (2020). Drugs of abuse, a DEA

resource guide: 2020 edition. Retrieved from https://www.dea.gov/

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health58 | October 2021

45. Schedule I controlled substances have no currently accepted medical use

and have a high potential for abuse. See the following reference: Drug

Enforcement Administration. (2020). Drugs of abuse, a DEA resource

guide: 2020 edition. Retrieved from https://www.dea.gov/

46. U.S. National Library of Medicine. (2021). Diphenhydramine. Retrieved

from https://medlineplus.gov/druginformation.html

47. U.S. National Library of Medicine. (2021). Phenylephrine. Retrieved

from https://medlineplus.gov/druginformation.html

48. National Institute on Drug Abuse. (2019, April). DrugFacts: Kratom.

Retrieved from https://www.drugabuse.gov/publications/ﬁnder/t/160/

drugfacts

49. Although kratom is not scheduled nationally as a controlled substance,

the Drug Enforcement Administration includes kratom as a drug of

concern because it poses risks to people who use it. However, some

states may prohibit the possession and use of kratom. See the following

reference: Drug Enforcement Administration. (2020). Drugs of abuse, a

DEA resource guide: 2020 edition. Retrieved from https://www.dea.gov/

50. National Institute on Drug Abuse. (2020, June). DrugFacts: Synthetic

cannabinoids (K2/Spice). Retrieved from https://www.drugabuse.gov/

publications/ﬁnder/t/160/drugfacts

51. National Institute on Drug Abuse. (2020, July). DrugFacts: Synthetic

cathinones (bath salts). Retrieved from https://www.drugabuse.gov/

publications/ﬁnder/t/160/drugfacts

52. To measure initiation for most substances, NSDUH respondents who

reported they ever used a particular substance were asked to report

their age when they ﬁrst used it. To measure initiation of prescription

drug misuse (i.e., misuse of pain relievers, tranquilizers, stimulants, and

sedatives), NSDUH respondents who reported they misused a particular

prescription drug in the past 12 months were asked to report their

age when they ﬁrst misused it. Respondents who reported ﬁrst use (or

misuse in the case of prescription drugs) of a substance within a year

of their current age also were asked to report the year and month when

they ﬁrst used (or misused) it.

53. Estimates relating to the periods prior to the 12-month reference

period have not been considered here because of concerns about their

validity resulting from recall bias. See the following reference: Gfroerer,

J., Hughes, A., Chromy, J., Heller, D., & Packer, L. (2004, July).

Estimating trends in substance use based on reports of prior use in a

cross-sectional survey. In S. B. Cohen & J. M. Lepkowski (Eds.), Eighth

Conference on Health Survey Research Methods: Conference proceedings

[Peachtree City, GA] (HHS Publication No. PHS 04-1013, pp. 29-34).

Hyattsville, MD: U.S. Department of Health and Human Services,

Public Health Service, Centers for Disease Control and Prevention,

National Center for Health Statistics.

54. For substances other than prescription psychotherapeutic drugs,

respondents who had ever used the substance (e.g., marijuana) were

asked to report when they ﬁrst used the substance, and respondents who

reported ﬁrst use within a year of their current age were asked to report

the year and month when they ﬁrst used it. us, past year initiates of

the use of substances other than prescription psychotherapeutic drugs

reported their ﬁrst use within 12 months of the interview date.

55. Assessing whether respondents in the 2020 NSDUH had initiated

misuse of a prescription psychotherapeutic drug in the past 12 months

diﬀered from assessing whether respondents had initiated the use of

other substances in that period because the psychotherapeutic drug

categories (e.g., prescription pain relievers) include many diﬀerent types

of prescription drugs in a given category (e.g., pain relievers containing

hydrocodone, such as Vicodin

®

, Lortab

®

, Norco

®

, Zohydro

®

ER, or

generic hydrocodone). Respondents in 2020 were asked questions about

initiation of misuse only for the speciﬁc prescription drugs they misused

in the past 12 months, including their age when they ﬁrst misused a

drug and (if the ﬁrst misuse occurred within a year of the current age)

the year and month of ﬁrst misuse for that drug. Respondents who

reported they initiated misuse in the past 12 months for all of the

speciﬁc prescription drugs in a given category they misused in that

period were asked a follow-up question to establish whether they had

ever misused prescription drugs in that category more than 12 months

before being interviewed. Respondents who answered this follow-up

question as “no” were classiﬁed as being past year initiates of the misuse

of any prescription drug in the overall category. is answer meant

respondents had never misused any prescription drug in that category

more than 12 months prior to the interview date.

56. Section 3.4.2 in the following reference discusses the potential since

2015 for NSDUH respondents to underreport lifetime (but not past

year) misuse of prescription psychotherapeutic drugs: Center for

Behavioral Health Statistics and Quality. (2021). 2020 National Survey

on Drug Use and Health: Methodological summary and deﬁnitions.

Retrieved from https://www.samhsa.gov/data/

57. More information about the methods for measuring and estimating the

initiation of substance use and prescription drug misuse in NSDUH

can be found in Section 3.4.2 of the following reference: Center for

Behavioral Health Statistics and Quality. (2021). 2020 National Survey

on Drug Use and Health: Methodological summary and deﬁnitions.

Retrieved from https://www.samhsa.gov/data/

58. Numbers in Figure 21 refer to people who used a speciﬁc substance for

the ﬁrst time in the past year, regardless of whether the initiation of use

of other substances occurred prior to the past year.

59. Past year initiates of crack cocaine use are counted as past year initiates

of cocaine use only if they initiated any use of cocaine in the past year.

Likewise, past year initiates of LSD, PCP, or Ecstasy use are counted as

past year initiates of hallucinogen use only if respondents had previously

not used other hallucinogens.

60. Survey questions for the perceived risk from using diﬀerent substances

vary in terms of the frequency (e.g., use once or twice a week, use

nearly every day or daily) and quantity of use (e.g., having ﬁve or more

drinks of alcohol, any use of marijuana, cocaine, or heroin), making

comparisons diﬃcult for perceptions of risk from using diﬀerent

substances.

61. Compton, W. M., Han, B., Jones, C. M., Blanco, C., & Hughes, A.

(2016). Marijuana use and use disorders in adults in the USA, 2002-14:

Analysis of annual cross-sectional surveys. Lancet Psychiatry, 3, 954-964.

https://doi.org/10.1016/S2215-0366(16)30208-5

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 59

62. Because of the cross-sectional nature of NSDUH data (i.e., reports of

perceived risk and substance use made at a single point in time instead

of from the same individuals over multiple points in time), causal

connections cannot be made between perceptions of risk and substance

use.

63. Volkow, N. D., Baler, R. D., Compton, W. M., & Weiss, S. R. B. (2014).

Adverse health eﬀects of marijuana use. New England Journal of Medicine,

370, 2219-2227. https://doi.org/10.1056/NEJMra1402309

64. National Academies of Sciences, Engineering, and Medicine. (2017).

e health eﬀects of cannabis and cannabinoids: e current state of

evidence and recommendations for research. Washington, DC: e

National Academies Press. https://doi.org/10.17226/24625

65. For more information about the DSM-5 criteria for SUDs, see Section

3.4.3 and the deﬁnitions for abuse and dependence in Appendix A

of the following reference: Center for Behavioral Health Statistics

and Quality. (2021). 2020 National Survey on Drug Use and Health:

Methodological summary and deﬁnitions. Retrieved from https://www.

samhsa.gov/data/

66. e DSM-IV criteria for SUDs include separate criteria for dependence

or abuse. People who met the criteria for abuse for a given substance

(e.g., alcohol) did not meet the criteria for dependence for that

substance. For more information, see Section 3.4.3 and the deﬁnitions

for abuse and dependence in Appendix A of the following reference:

Center for Behavioral Health Statistics and Quality. (2020). 2019

National Survey on Drug Use and Health: Methodological summary and

deﬁnitions. Retrieved from https://www.samhsa.gov/data/

67. A Clinical Validation Study (CVS) was conducted in early 2020 to assess

NSDUH SUD questions that were revised to be consistent with the

DSM-5 criteria. For more information on the CVS, see Section 3.4.3.4

in the following reference: Center for Behavioral Health Statistics

and Quality. (2021). 2020 National Survey on Drug Use and Health:

Methodological summary and deﬁnitions. Retrieved from https://www.

samhsa.gov/data/

68. For alcohol, for example, withdrawal symptoms include (but are not

limited to) trouble sleeping, hands trembling, hallucinations (seeing,

feeling, or hearing things that were not really there), or feeling anxious.

69. Goldstein, R. B., Chou, S. P., Smith, S. M., Jung, J., Zhang, H., Saha,

T. D., Pickering, R. P., Ruan, W. J., Huang, B., & Grant, B. F. (2015).

Nosologic comparisons of DSM-IV and DSM-5 alcohol and drug use

disorders: Results from the National Epidemiologic Survey on Alcohol

and Related Conditions-III. Journal of Studies on Alcohol and Drugs,

76(3), 378-388. https://doi.org/10.15288/jsad.2015.76.378

70. Center for Behavioral Health Statistics and Quality. (2021). 2020

National Survey on Drug Use and Health: Detailed tables. Retrieved from

https://www.samhsa.gov/data/

71. Respondents who reported any use of prescription drugs in a given

prescription psychotherapeutic category in the past 12 months (e.g.,

prescription pain relievers) but did not report misuse of any drugs in

that category in the past 12 months were not asked the SUD questions

for that category.

72. Adolescents were ﬁrst asked whether they ever had a period in their

lifetime lasting several days or longer when any of the following was true

for most of the day: (a) feeling sad, empty, or depressed; (b) feeling very

discouraged or hopeless about how things were going in their lives; or

(c) losing interest and becoming bored with most things they usually

enjoy. Adolescents who reported any of these problems were asked

further questions about their experience with the nine symptoms of

MDE in their lifetime. Adolescents were classiﬁed as having an MDE

in their lifetime if they experienced at least ﬁve of the nine symptoms in

the same 2-week period in their lifetime; at least one of the symptoms

needed to be having a depressed mood or loss of interest or pleasure in

activities that had been enjoyable. Adolescents who reported gaining

weight without trying were asked if their weight gain occurred because

they were growing; this question was not asked of adult respondents.

Adolescent respondents who had a lifetime MDE were asked if they

had a period of 2 weeks or longer in the past 12 months when they felt

depressed or lost interest or pleasure in previously enjoyable activities,

and they reported having some of their other MDE symptoms. ese

adolescents were classiﬁed as having a past year MDE.

73. Adults were ﬁrst asked whether they ever had a period in their lifetime

lasting several days or longer when any of the following was true

for most of the day: (a) feeling sad, empty, or depressed; (b) feeling

discouraged about how things were going in their lives; or (c) losing

interest in most things they usually enjoy. Adults who reported any of

these problems were asked further questions about their experience with

the nine symptoms of MDE in their lifetime. Adults were classiﬁed

as having an MDE in their lifetime if they experienced at least ﬁve

of the nine symptoms in the same 2-week period in their lifetime; at

least one of the symptoms needed to be having a depressed mood or

loss of interest or pleasure in activities that had been enjoyable. Adult

respondents who had a lifetime MDE were asked if they had a period of

2 weeks or longer in the past 12 months when they felt depressed or lost

interest or pleasure in previously enjoyable activities, and they reported

having some of their other MDE symptoms. ese adults were classiﬁed

as having a past year MDE. Data on MDE in the past year for adults

have been available in NSDUH since 2005.

74. Questions measuring adolescents’ impairment in carrying out life

activities because of MDE were added to the survey in 2006.

75. Data on MDE with severe impairment for adults have been available

since 2009.

76. Details about the criteria for deﬁning a NSDUH interview as usable

are provided in Section 2.3.1 of CBHSQ (2021). See the following

reference: Center for Behavioral Health Statistics and Quality. (2021).

2020 National Survey on Drug Use and Health: Methodological summary

and deﬁnitions. Retrieved from https://www.samhsa.gov/data/

77. Bias refers to error in estimates that does not occur at random.

78. Details about the break-oﬀ analysis weights are provided in Sections

2.3.4, 3.4.7, and 6.2.2 of CBHSQ (2021). See the following reference:

Center for Behavioral Health Statistics and Quality. (2021). 2020

National Survey on Drug Use and Health: Methodological summary and

deﬁnitions. Retrieved from https://www.samhsa.gov/data/

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health60 | October 2021

79. Follow-up clinical interviews for classifying whether adults had a

mental, behavioral, or emotional disorder in the past year used the

Structured Clinical Interview for the DSM-IV-TR Axis I Disorders,

Research Version, Non-patient Edition (SCID-I/NP). See the following

reference: First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W.

(2002). Structured Clinical Interview for DSM-IV-TR Axis I Disorders,

Research Version, Non-patient Edition (SCID-I/NP). New York, NY: New

York State Psychiatric Institute, Biometrics Research.

80. Information on the deﬁnitions and estimation methods for the mental

illness estimates is provided in Section 3.4.7 and Appendix A of

CBHSQ (2021). See the following reference: Center for Behavioral

Health Statistics and Quality. (2021). 2020 National Survey on Drug

Use and Health: Methodological summary and deﬁnitions. Retrieved from

https://www.samhsa.gov/data/

81. Hedegaard, H., Curtin, S. C., & Warner, M. (2021, February). Suicide

mortality in the United States, 1999–2019 (NCHS Data Brief No. 398).

Retrieved from https://www.cdc.gov/nchs/products/databriefs.htm

82. Ahmad, F. B., & Anderson, R. N. (2021). e leading causes of death

in the US for 2020. JAMA, 325, 1829-1830. https://doi.org/10.1001/

jama.2021.5469

83. Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R., Yuan, K.,

Holland, K. M., Ivey-Stephenson, A. Z., & Crosby, A. E. (2018, June

8). Vital Signs: Trends in state suicide rates — United States, 1999-

2016 and circumstances contributing to suicide — 27 states, 2015.

Morbidity and Mortality Weekly Report, 67(22), 617-624. https://doi.

org/10.15585/mmwr.mm6722a1

84. Murphy, S. L., Xu, J., Kochanek, K. D., & Arias, E. (2018, November).

Mortality in the United States, 2017 (NCHS Data Brief No. 328).

Retrieved from https://www.cdc.gov/nchs/products/databriefs.htm

85. Xu, J., Murphy, S. L., Kochanek, K. D., & Arias, E. (2020, January).

Mortality in the United States, 2018 (NCHS Data Brief No. 355).

Retrieved from https://www.cdc.gov/nchs/products/databriefs.htm

86. Data are from the Centers for Disease Control and Prevention

WONDER (Wide-ranging ONline Data for Epidemiologic Research)

Multiple Cause of Death database, 2018-2019, as compiled from

data provided by the 57 vital statistics jurisdictions through the Vital

Statistics Cooperative Program. See the following reference: Centers for

Disease Control and Prevention, National Center for Health Statistics.

(2020). Underlying cause of death 2018-2019. Retrieved from https://

wonder.cdc.gov/ucd-icd10-expanded.html

87. Crosby, A. E., Han, B., Ortega, L. A. G., Parks, S. E., & Gfroerer, J.

(2011, October 21). Suicidal thoughts and behaviors among adults aged

≥18 years—United States, 2008-2009. Morbidity and Mortality Weekly

Report Surveillance Summaries, 60(SS13), 1-22. Retrieved from https://

www.cdc.gov/mmwr/preview/mmwrhtml/ss6013a1.htm

88. Han, B., Kott, P. S., Hughes, A., McKeon, R., Blanco, C., & Compton,

W. M. (2016). Estimating the rates of deaths by suicide among adults

who attempt suicide in the United States. Journal of Psychiatric Research,

77, 125-133. https://doi.org/10.1016/j.jpsychires.2016.03.002

89. Gunnell, D., Appleby, L., Arensman, E., Hawton, K., John, A., Kapur,

N., Khan, M., O’Connor, R. C., Pirkis, J., & COVID-19 Suicide

Prevention Research Collaboration. (2020). Suicide risk and prevention

during the COVID-19 pandemic. Lancet Psychiatry, 7, 468-471. https://

doi.org/10.1016/S2215-0366(20)30171-1

90. Wang, J., Sumner, S. A., Simon, T. R., Crosby, A. E., Annor, F.

B., Gaylor, E., Xu, L., & Holland, K. M. (2020). Trends in the

incidence and lethality of suicidal acts in the United States, 2006

to 2015. JAMA Psychiatry, 77, 684-693. https://doi.org/10.1001/

jamapsychiatry.2020.0596

91. Miron, O., Yu, K.-H., Wilf-Miron, R., & Kohane, I. S. (2019).

Suicide rates among adolescents and young adults in the United

States, 2000-2017. JAMA, 321, 2362-2364. https://doi.org/10.1001/

jama.2019.5054

92. Mojtabai, R., & Olfson, M. (2020). National trends in mental health

care for US adolescents. JAMA Psychiatry, 77, 703-714. https://doi.

org/10.1001/jamapsychiatry.2020.0279

93. Mojtabai, R., Olfson, M., & Han, B. (2016). National trends in the

prevalence and treatment of depression in adolescents and young adults.

Pediatrics, 138(6), e20161878. https://doi.org/10.1542/peds.2016-

1878

94. Examples of ACEs include abuse, neglect, and negative family

interactions. ACEs can occur anytime from birth to age 17.

95. ompson, M. P., Kingree, J. B., & Lamis, D. (2019). Associations

of adverse childhood experiences and suicidal behaviors in adulthood

in a US nationally representative sample. Child: Care, Health and

Development, 45(1), 121-128. https://doi.org/10.1111/cch.12617

96. Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D.

F., & Giles, W. H. (2001). Childhood abuse, household dysfunction,

and the risk of attempted suicide throughout the life span: Findings

from the Adverse Childhood Experiences Study. JAMA, 286(24), 3089-

3096. https://doi.org/10.1001/jama.286.24.3089

97. Yard, E., Radhakrishnan, L., Ballesteros, M. F., Sheppard, M., Gates,

A., Stein, Z., Hartnett, K., Kite-Powell, A., Rodgers, L., Adjemian,

J., Ehlman, D. C., Holland, K., Idaikkadar, N., Ivey-Stephenson, A.,

Martinez, P., Law, R., & Stone, D. M. (2021). Emergency department

visits for suspected suicide attempts among persons aged 12–25 years

before and during the COVID-19 pandemic — United States, January

2019–May 2021. Morbidity and Mortality Weekly Report, 70(24), 888-

894. https://doi.org/10.15585/mmwr.mm7024e1

98. Respondents were eligible to be asked the substance use treatment

questions if they reported lifetime use of alcohol, marijuana,

cocaine (including crack), heroin, hallucinogens, inhalants,

or methamphetamine, or the lifetime misuse of prescription

psychotherapeutic drugs (i.e., pain relievers, tranquilizers, stimulants, or

sedatives). Respondents who were lifetime users of tobacco products or

other substances (e.g., kratom) but who did not report lifetime use or

misuse of the substances mentioned in the previous sentence were not

asked the substance use treatment questions.

99. Substance Abuse and Mental Health Services Administration. (2020).

Opioid treatment program (OTP) guidance. Retrieved from https://www.

samhsa.gov/sites/default/ﬁles/otp-guidance-20200316.pdf

100. Drug Enforcement Administration. (2020). Use of telephone evaluations

to initiate buprenorphine prescribing. Retrieved on June 8, 2021, from

https://www.deadiversion.usdoj.gov/

101. U.S. Department of Health and Human Services. (2021). Best practice

guide: Telehealth for behavioral health care: Billing for telebehavioral

health. Retrieved on June 18, 2021, from https://telehealth.hhs.gov/

providers/telehealth-for-behavioral-health/billing-for-telebehavioral-

health/

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | 61

102. Lin, L., Casteel, D., Shigekawa, E., Weyrich, M. S., Roby, D. H.,

& McMenamin, S. B. (2019). Telemedicine-delivered treatment

interventions for substance use disorders: A systematic review. Journal

of Substance Abuse Treatment, 101, 38-49. https://doi.org/10.1016/j.

jsat.2019.03.007

103. Fiacco, L., Pearson, B. L., & Jordan, R. (2021). Telemedicine works

for treating substance use disorder: e STAR clinic experience during

COVID-19. Journal of Substance Abuse Treatment, 125. https://doi.

org/10.1016/j.jsat.2021.108312

104. Benavides-Vaello, S., Strode, A., & Sheeran, B. C. (2013). Using

technology in the delivery of mental health and substance abuse

treatment in rural communities: A review. Journal of Behavioral Health

Services & Research, 40, 111-120. https://doi.org/10.1007/s11414-012-

9299-6

105. Substance use treatment at a specialty facility refers to substance

use treatment at a hospital (only as an inpatient), a drug or alcohol

rehabilitation facility (as an inpatient or outpatient), or a mental

health center. is NSDUH deﬁnition historically has not considered

emergency rooms, private doctors’ oﬃces, prisons or jails, and self-

help groups to be specialty facilities for the receipt of substance use

treatment.

106. e NSDUH deﬁnition of the need for treatment does not explicitly

indicate the need for treatment at a specialty facility. People with an

SUD in the past year can be considered to need some form of assistance

for their problems with substance use. For more information about

the DSM-5 criteria for having an SUD, see Section 3.4.3 and the

deﬁnition for SUD in Appendix A of CBHSQ (2021). See the following

references:

American Psychiatric Association. (2013). Diagnostic and statistical

manual of mental disorders (DSM-5) (5th ed.). Arlington, VA: Author.

Center for Behavioral Health Statistics and Quality. (2021). 2020

National Survey on Drug Use and Health: Methodological summary and

deﬁnitions. Retrieved from https://www.samhsa.gov/data/

107. ere were 40.3 million people aged 12 or older in 2020 with an SUD

in the past year. Approximately 98 percent of the people in 2020 who

needed treatment for a substance use problem were classiﬁed as such

because they had an SUD in the past year, regardless of whether they

received substance use treatment at a specialty facility.

108. As per the deﬁnition of the need for substance use treatment, people

with an SUD were classiﬁed as needing substance use treatment.

109. Due to rounding, estimated numbers and percentages of people in

Figure 45 who made an eﬀort or did not make an eﬀort to get substance

use treatment do not sum to the total number of people who needed

substance use treatment, did not receive specialty treatment in the

past year, and perceived a need for treatment.

110. Respondents in Quarter 4 of 2020 who did not report receiving

substance use treatment in the past year were not asked if they received

telehealth services as substance use treatment. erefore, reasons for not

receiving treatment from Quarter 4 can include reasons for not receiving

telehealth services.

111. Reported estimates in this section may diﬀer slightly from corresponding

estimates in the 2020 detailed tables because the estimates in this section

used a special break-oﬀ analysis weight for adult respondents who did

not complete the interview. For more information about this break-oﬀ

analysis weight, see Section 2.3.4 in the following reference: Center

for Behavioral Health Statistics and Quality. (2021). 2020 National

Survey on Drug Use and Health: Methodological summary and deﬁnitions.

Retrieved from https://www.samhsa.gov/data/

112. Waugh, M., Voyles, D., & omas, M. R. (2015). Telepsychiatry:

Beneﬁts and costs in a changing health-care environment. International

Review of Psychiatry, 27, 558-568. https://doi.org/10.3109/09540261.20

15.1091291

113. Reay, R. E., Looi, J. C. L., & Keightley, P. (2020). Telehealth mental

health services during COVID-19: Summary of evidence and

clinical practice. Australasian Psychiatry, 28, 514-516. https://doi.

org/10.1177/1039856220943032

114. Health professionals include general practitioners or family doctors;

other medical doctors (e.g., cardiologist, gynecologist, urologist);

psychologists; psychiatrists or psychotherapists; social workers;

counselors; other mental health professionals (e.g., mental health nurse

or other therapist where type is not speciﬁed); and nurses, occupational

therapists, or other health professionals.

115. e specialty mental health setting includes services in outpatient or

inpatient settings. Outpatient services include those from (a) a private

therapist, psychologist, psychiatrist, social worker, or counselor; (b) a

mental health clinic or center; (c) a partial day hospital or day treatment

program; or (d) an in-home therapist, counselor, or family preservation

worker. Inpatient or residential specialty mental health services in which

adolescents stayed overnight or longer include services in a hospital or a

residential treatment center.

116. Due to questionnaire changes in 2009, estimates for the receipt of youth

mental health services in educational settings are not comparable with

estimates prior to 2009. Additionally, estimates for the receipt of youth

mental health services in juvenile justice settings were not available prior

to 2009.

117. Compton, W. M., omas, Y. F., Stinson, F. S., & Grant, B. F.

(2007). Prevalence, correlates, disability, and comorbidity of DSM-

IV drug abuse and dependence in the United States: Results from the

National Epidemiologic Survey on Alcohol and Related Conditions.

Archives of General Psychiatry, 64, 566-576. https://doi.org/10.1001/

archpsyc.64.5.566

118. Mojtabai, R., Chen, L.-Y., Kaufmann, C. N., & Crum, R. M. (2014).

Comparing barriers to mental health treatment and substance use

disorder treatment among individuals with comorbid major depression

and substance use disorders. Journal of Substance Abuse Treatment, 46,

268-273. https://doi.org/10.1016/j.jsat.2013.07.012

119. Hartz, S. M., Pato, C. N., Medeiros, H., Cavazos-Rehg, P.,

Sobell, J. L., Knowles, J. A., Bierut, L. J., & Pato, M. T. (2014).

Comorbidity of severe psychotic disorders with measures of substance

use. JAMA Psychiatry, 71, 248-254. https://doi.org/10.1001/

jamapsychiatry.2013.3726

120. Watkins, K. E., Hunter, S. B., Burnam, M. A., Pincus, H. A., &

Nicholson, G. (2005). Review of treatment recommendations for

persons with a co-occurring aﬀective or anxiety and substance use

disorder. Psychiatric Services, 56, 913-926. https://doi.org/10.1176/appi.

ps.56.8.913

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health62 | October 2021

121. Pettinati, H. M., O’Brien, C. P., & Dundon, W. D. (2013). Current

status of co-occurring mood and substance use disorders: A new

therapeutic target. American Journal of Psychiatry, 170, 23-30. https://

doi.org/10.1176/appi.ajp.2012.12010112

122. Han, B., Compton, W. M., Blanco, C., & Colpe, L. J. (2017).

Prevalence, treatment, and unmet treatment needs of US adults with

mental health and substance use disorders. Health Aﬀairs (Millwood),

36, 1739-1747. https://doi.org/10.1377/hlthaﬀ.2017.0584

123. Centers for Disease Control and Prevention. (n.d.). COVID Data

Tracker: Trends in number of COVID-19 cases and deaths in the US

reported to CDC, by state/territory. Retrieved on June 18, 2021, from

https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases

124. National Institute on Alcohol Abuse and Alcoholism. (2021, June 15).

State alcohol-related laws during the COVID-19 emergency for on-premises

and oﬀ-premises establishments as of June 15, 2021. Alcohol Policy

Information System (APIS). Retrieved from https://alcoholpolicy.niaaa.

nih.gov/resource/covid-19/98

125. Barbosa, C., Cowell, A. J., & Dowd, W. N. (2020). Alcohol

consumption in response to the COVID-19 pandemic in the United

States. Journal of Addiction Medicine. https://doi.org/10.1097/

ADM.0000000000000767

126. Pollard, M. S., Tucker, J. S., & Green, Jr., H. D. (2020). Changes in

adult alcohol use and consequences during the COVID-19 pandemic

in the US. JAMA Network Open, 3(9). https://doi.org/10.1001/

jamanetworkopen.2020.22942

127. European Monitoring Centre for Drugs and Drug Addiction. (2021).

European Drug Report 2021: Trends and developments. Luxembourg:

Publications Oﬃce of the European Union.

128. Use of drugs other than alcohol included the use of marijuana,

cocaine (including crack), heroin, hallucinogens, inhalants, or

methamphetamine in the past year or any use (i.e., not necessarily

misuse) of prescription pain relievers, tranquilizers, stimulants, or

sedatives in the past year. Drugs other than alcohol did not include

tobacco products or nicotine vaping.

129. U.S. Department of Health and Human Services. (2021, May). What is

telehealth? Retrieved on July 27, 2021, from https://telehealth.hhs.gov/

patients/understanding-telehealth/

Key Substance Use and Mental Health Indicators in the United States:

Results from the 2020 National Survey on Drug Use and Health October 2021 | A-1

AppendixA: Special Tables of Estimates for Substance Use and Mental Health Indicators

in the United States

A-2

Table A.1B Types of Illicit Drug, Tobacco Product, Alcohol, and Other Substance Use in the Past Month: Among People Aged 12 or Older; 2002-2020

Substance 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

GENERAL SUBSTANCE USE

Illicit Drugs, Tobacco Products, or Alcohol nc nc nc nc nc nc nc nc nc nc

Illicit Drugs or Alcohol nc nc nc nc nc nc nc nc nc nc

Tobacco Products or Alcohol 61.0 (0.40) 60.1 (0.38) 59.6 (0.40) 61.1 (0.39) 60.7 (0.39) 60.5 (0.37) 60.6 (0.38) 60.6 (0.36) 60.9 (0.39) 60.3 (0.38)

ILLICIT DRUGS nc nc nc nc nc nc nc nc nc nc

TOBACCO PRODUCTS OR NICOTINE

VAPING -- -- -- -- -- -- -- -- -- --

Tobacco Products 30.4 (0.35) 29.8 (0.34) 29.2 (0.33) 29.4 (0.35) 29.6 (0.35) 28.7 (0.34) 28.4 (0.35) 27.7 (0.33) 27.5 (0.34) 26.5 (0.33)

Cigarettes 26.0 (0.34) 25.4 (0.33) 24.9 (0.32) 24.9 (0.32) 25.0 (0.33) 24.3 (0.33) 24.0 (0.32) 23.3 (0.32) 23.0 (0.31) 22.1 (0.32)

Daily Cigarette Smoking

1

63.4 (0.66) 62.9 (0.67) 62.3 (0.63) 63.0 (0.62) 62.3 (0.59) 61.3 (0.65) 61.5 (0.70) 61.0 (0.68) 59.5 (0.71) 60.7 (0.71)

Smoked 1+ Packs of

Cigarettes per Day

2

53.1 (0.91) 53.5 (0.82) 54.0 (0.87) 51.4 (0.86) 50.6 (0.85) 50.9 (0.88) 49.2 (0.94) 45.9 (0.98) 45.1 (0.94) 43.8 (0.90)

Smokeless Tobacco nc nc nc nc nc nc nc nc nc nc

Cigars 5.4 (0.15) 5.4 (0.14) 5.7 (0.13) 5.6 (0.15) 5.6 (0.14) 5.4 (0.14) 5.3 (0.15) 5.3 (0.14) 5.2 (0.14) 5.0 (0.14)

Pipe Tobacco 0.8 (0.07) 0.7 (0.06) 0.8 (0.06) 0.9 (0.06) 0.9 (0.07) 0.8 (0.07) 0.8 (0.06) 0.8 (0.06) 0.8 (0.06) 0.8 (0.06)

Nicotine Vaping -- -- -- -- -- -- -- -- -- --

ALCOHOL 51.0 (0.42) 50.1 (0.39) 50.3 (0.40) 51.8 (0.40) 51.0 (0.39) 51.2 (0.41) 51.6 (0.39) 51.9 (0.38) 51.8 (0.39) 51.8 (0.39)

Binge Alcohol Use nc nc nc nc nc nc nc nc nc nc

Heavy Alcohol Use nc nc nc nc nc nc nc nc nc nc

OTHER SUBSTANCE USE

GHB -- -- -- -- 0.0 (0.01) 0.0 (0.00) 0.0 (0.01) 0.0 (0.00) 0.0 (0.01) 0.0 (0.01)

Nonprescription Cough or Cold Medicine -- -- -- -- 0.2 (0.02) 0.2 (0.02) 0.2 (0.02) 0.2 (0.02) 0.2 (0.03) 0.2 (0.02)

Kratom -- -- -- -- -- -- -- -- -- --

Synthetic Marijuana (Fake Weed, K2,

Spice) -- -- -- -- -- -- -- -- -- --

Synthetic Stimulants (“Bath Salts,” Flakka) -- -- -- -- -- -- -- -- -- --

NOTE: Footnotes and source information are shown at the end of the second half of this table.

A-3

Table A.1B Types of Illicit Drug, Tobacco Product, Alcohol, and Other Substance Use in the Past Month: Among People Aged 12 or Older; 2002-2020 (continued)

Substance 2012 2013 2014 2015 2016 2017 2018 2019 2020

GENERAL SUBSTANCE USE

Illicit Drugs, Tobacco Products, or Alcohol nc nc nc 60.9 (0.30) 60.2 (0.30) 60.7 (0.32) 60.2 (0.35) 60.1 (0.32) 58.7 (0.51)

Illicit Drugs or Alcohol nc nc nc 54.1 (0.31) 53.4 (0.32) 54.3 (0.33) 53.9 (0.36) 54.2 (0.34) 53.6 (0.52)

Tobacco Products or Alcohol 61.0 (0.37) 60.6 (0.39) 61.0 (0.31) 59.8 (0.30) 58.9 (0.30) 59.4 (0.32) 58.8 (0.35) 58.3 (0.33) 56.9 (0.51)

ILLICIT DRUGS nc nc nc 10.1 (0.17) 10.6 (0.18) 11.2 (0.19) 11.7 (0.21) 13.0 (0.20) 13.5 (0.32)

TOBACCO PRODUCTS OR NICOTINE

VAPING -- -- -- -- -- -- -- -- 20.7 (0.41)

Tobacco Products 26.7 (0.34) 25.5 (0.32) 25.2 (0.28) 23.9 (0.26) 23.5 (0.27) 22.4 (0.26) 21.5 (0.27) 21.1 (0.25) 18.7 (0.40)

Cigarettes 22.1 (0.32) 21.3 (0.30) 20.8 (0.26) 19.4 (0.25) 19.1 (0.25) 17.9 (0.25) 17.2 (0.25) 16.7 (0.23) 15.0 (0.38)

Daily Cigarette Smoking

1

60.7 (0.71) 59.6 (0.73) 58.8 (0.59) 58.1 (0.64) 57.9 (0.66) 57.1 (0.69) 58.2 (0.71) 58.4 (0.71) 60.1 (1.25)

Smoked 1+ Packs of

Cigarettes per Day

2

42.0 (0.94) 41.3 (1.00) 40.3 (0.83) 41.1 (0.87) 41.1 (0.89) 41.2 (0.92) 39.6 (0.94) 40.5 (0.95) 37.8 (1.78)

Smokeless Tobacco nc nc nc 3.4 (0.11) 3.3 (0.10) 3.2 (0.09) 2.9 (0.09) 3.1 (0.10) 2.5 (0.14)

Cigars 5.2 (0.15) 4.7 (0.14) 4.5 (0.11) 4.7 (0.12) 4.6 (0.11) 4.6 (0.11) 4.5 (0.12) 4.3 (0.11) 3.8 (0.19)

Pipe Tobacco 1.0 (0.07) 0.9 (0.06) 0.8 (0.05) 0.8 (0.05) 0.8 (0.05) 0.9 (0.05) 0.8 (0.04) 0.7 (0.04) 0.7 (0.08)

Nicotine Vaping -- -- -- -- -- -- -- -- 3.8 (0.15)

ALCOHOL 52.1 (0.39) 52.2 (0.41) 52.7 (0.33) 51.7 (0.32) 50.7 (0.31) 51.7 (0.33) 51.1 (0.37) 50.8 (0.34) 50.0 (0.52)

Binge Alcohol Use nc nc nc 24.9 (0.27) 24.2 (0.26) 24.5 (0.27) 24.5 (0.26) 23.9 (0.26) 22.2 (0.41)

Heavy Alcohol Use nc nc nc 6.5 (0.14) 6.0 (0.14) 6.1 (0.13) 6.1 (0.14) 5.8 (0.14) 6.4 (0.23)

OTHER SUBSTANCE USE

GHB 0.0 (0.01) 0.0 (0.01) 0.0 (0.01) 0.0 (0.01) 0.0 (0.00) * (*) 0.0 (0.00) 0.0 (0.01) 0.0 (0.01)

Nonprescription Cough or Cold Medicine 0.2 (0.03) 0.2 (0.03) 0.1 (0.02) 0.2 (0.02) 0.2 (0.02) 0.2 (0.03) 0.2 (0.03) 0.3 (0.04) 0.3 (0.05)

Kratom -- -- -- -- -- -- -- 0.3 (0.03) 0.4 (0.06)

Synthetic Marijuana (Fake Weed, K2,

Spice) -- -- -- -- -- -- -- -- 0.2 (0.03)

Synthetic Stimulants (“Bath Salts,” Flakka) -- -- -- -- -- -- -- -- 0.0 (0.01)

* = low precision; -- = not available; nc = not comparable due to methodological changes.

NOTE: Estimates shown are percentages with standard errors included in parentheses.

NOTE: Estimates in the 2020 column are italicized to indicate caution should be used when comparing estimates between 2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing between 2020 and prior years was

not performed. See the 2020 National Survey on Drug Use and Health: Methodological Summary and Definitions for details.

NOTE: Additional estimates may be found in the detailed tables for the 2020 NSDUH at https://www.samhsa.gov/data/

. Measures and terms are defined in Appendix A of the 2020 detailed tables.

NOTE: Estimates of 0.0 percent round to less than 0.1 percent when shown to the nearest tenth of a percent.

1

Percentages for daily cigarette smoking are among past month cigarette smokers.

2

Percentages for smoking one or more packs of cigarettes per day are among daily cigarette smokers in the past month. Respondents with missing data for the number of cigarettes smoked per day were excluded from the analysis.

Source:

SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2002-2019 and Quarters 1 and 4, 2020.

A-4

Table A.2B Types of Illicit Drug, Tobacco Product, Alcohol, and Other Substance Use in the Past Month: Among Adolescents Aged 12 to 17; 2002-2020

Substance 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

GENERAL SUBSTANCE USE

Illicit Drugs, Tobacco Products, or Alcohol nc nc nc nc nc nc nc nc nc nc

Illicit Drugs or Alcohol nc nc nc nc nc nc nc nc nc nc

Tobacco Products or Alcohol 24.0 (0.38) 23.6 (0.38) 23.4 (0.35) 22.0 (0.37) 21.8 (0.37) 21.1 (0.38) 19.7 (0.35) 19.7 (0.36) 18.2 (0.36) 17.5 (0.36)

ILLICIT DRUGS nc nc nc nc nc nc nc nc nc nc

TOBACCO PRODUCTS OR NICOTINE

VAPING -- -- -- -- -- -- -- -- -- --

Tobacco Products 15.2 (0.33) 14.4 (0.32) 14.4 (0.32) 13.1 (0.31) 12.9 (0.29) 12.4 (0.30) 11.5 (0.28) 11.8 (0.29) 10.7 (0.28) 10.0 (0.27)

Cigarettes 13.0 (0.30) 12.2 (0.29) 11.9 (0.30) 10.8 (0.28) 10.4 (0.26) 9.9 (0.27) 9.2 (0.25) 9.0 (0.26) 8.4 (0.26) 7.8 (0.24)

Daily Cigarette Smoking

1

31.8 (1.03) 29.7 (1.06) 27.6 (1.13) 25.8 (1.12) 26.5 (1.19) 26.4 (1.16) 22.3 (1.11) 23.0 (1.17) 22.5 (1.29) 22.7 (1.28)

Smoked 1+ Packs of

Cigarettes per Day

2

21.8 (1.61) 22.0 (1.68) 19.4 (1.80) 20.1 (1.87) 17.9 (1.94) 18.7 (2.14) 18.4 (2.08) 17.9 (2.12) 16.7 (2.24) 14.8 (1.97)

Smokeless Tobacco nc nc nc nc nc nc nc nc nc nc

Cigars 4.5 (0.19) 4.5 (0.17) 4.8 (0.18) 4.2 (0.18) 4.1 (0.16) 4.3 (0.18) 3.8 (0.16) 4.0 (0.16) 3.2 (0.15) 3.4 (0.16)

Pipe Tobacco 0.6 (0.06) 0.6 (0.07) 0.7 (0.08) 0.6 (0.07) 0.7 (0.07) 0.7 (0.08) 0.7 (0.07) 0.9 (0.09) 0.6 (0.07) 0.7 (0.07)

Nicotine Vaping -- -- -- -- -- -- -- -- -- --

ALCOHOL 17.6 (0.32) 17.7 (0.33) 17.6 (0.32) 16.5 (0.32) 16.7 (0.32) 16.0 (0.34) 14.7 (0.32) 14.8 (0.32) 13.6 (0.33) 13.3 (0.31)

Binge Alcohol Use nc nc nc nc nc nc nc nc nc nc

Heavy Alcohol Use nc nc nc nc nc nc nc nc nc nc

OTHER SUBSTANCE USE

GHB -- -- -- -- 0.0 (0.01) 0.0 (0.01) 0.0 (0.00) 0.0 (0.01) * (*) 0.0 (0.00)

Nonprescription Cough or Cold Medicine -- -- -- -- 0.5 (0.05) 0.5 (0.06) 0.4 (0.05) 0.4 (0.05) 0.4 (0.05) 0.3 (0.05)

Kratom -- -- -- -- -- -- -- -- -- --

Synthetic Marijuana (Fake Weed, K2,

Spice) -- -- -- -- -- -- -- -- -- --

Synthetic Stimulants (“Bath Salts,” Flakka) -- -- -- -- -- -- -- -- -- --

NOTE: Footnotes and source information are shown at the end of the second half of this table.

A-5

Table A.2B Types of Illicit Drug, Tobacco Product, Alcohol, and Other Substance Use in the Past Month: Among Adolescents Aged 12 to 17; 2002-2020 (continued)

Substance 2012 2013 2014 2015 2016 2017 2018 2019 2020

GENERAL SUBSTANCE USE

Illicit Drugs, Tobacco Products, or Alcohol nc nc nc 15.6 (0.37) 14.7 (0.36) 15.1 (0.37) 14.2 (0.34) 15.0 (0.34) 12.2 (0.68)

Illicit Drugs or Alcohol nc nc nc 14.2 (0.35) 13.2 (0.35) 13.8 (0.35) 13.2 (0.33) 14.1 (0.33) 11.5 (0.64)

Tobacco Products or Alcohol 16.5 (0.34) 15.1 (0.33) 14.6 (0.35) 12.4 (0.33) 11.8 (0.33) 12.0 (0.34) 11.0 (0.32) 11.2 (0.32) 9.4 (0.62)

ILLICIT DRUGS nc nc nc 8.8 (0.27) 7.9 (0.26) 7.9 (0.26) 8.0 (0.27) 8.7 (0.28) 6.7 (0.45)

TOBACCO PRODUCTS OR NICOTINE

VAPING -- -- -- -- -- -- -- -- 6.5 (0.49)

Tobacco Products 8.6 (0.25) 7.8 (0.24) 7.0 (0.25) 6.0 (0.23) 5.3 (0.21) 4.9 (0.21) 4.2 (0.19) 3.8 (0.19) 2.4 (0.29)

Cigarettes 6.6 (0.22) 5.6 (0.20) 4.9 (0.21) 4.2 (0.20) 3.4 (0.18) 3.2 (0.17) 2.7 (0.16) 2.3 (0.15) 1.4 (0.22)

Daily Cigarette Smoking

1

22.0 (1.33) 19.4 (1.35) 24.1 (1.89) 20.0 (1.84) 15.0 (1.64) 12.2 (1.64) 14.7 (2.04) 13.2 (2.04) * (*)

Smoked 1+ Packs of

Cigarettes per Day

2

10.8 (1.88) 11.9 (2.47) 11.9 (2.52) 7.8 (2.51) * (*) * (*) * (*) * (*) * (*)

Smokeless Tobacco nc nc nc 1.5 (0.10) 1.4 (0.11) 1.3 (0.10) 1.1 (0.10) 1.0 (0.10) 0.6 (0.11)

Cigars 2.6 (0.13) 2.3 (0.13) 2.1 (0.13) 2.1 (0.14) 1.8 (0.12) 1.9 (0.13) 1.7 (0.13) 1.4 (0.12) 0.8 (0.15)

Pipe Tobacco 0.7 (0.07) 0.6 (0.07) 0.7 (0.08) 0.3 (0.06) 0.5 (0.06) 0.4 (0.07) 0.3 (0.06) 0.3 (0.06) 0.3 (0.12)

Nicotine Vaping -- -- -- -- -- -- -- -- 5.1 (0.43)

ALCOHOL 12.9 (0.31) 11.6 (0.29) 11.5 (0.33) 9.6 (0.29) 9.2 (0.30) 9.9 (0.30) 9.0 (0.29) 9.4 (0.30) 8.2 (0.57)

Binge Alcohol Use nc nc nc 5.8 (0.23) 4.9 (0.22) 5.3 (0.22) 4.7 (0.22) 4.9 (0.22) 4.1 (0.42)

Heavy Alcohol Use nc nc nc 0.9 (0.10) 0.8 (0.09) 0.7 (0.08) 0.5 (0.07) 0.8 (0.10) 0.6 (0.15)

OTHER SUBSTANCE USE

GHB 0.0 (0.02) * (*) 0.0 (0.01) * (*) * (*) * (*) * (*) 0.0 (0.02) * (*)

Nonprescription Cough or Cold Medicine 0.4 (0.06) 0.3 (0.05) 0.2 (0.04) 0.3 (0.06) 0.3 (0.06) 0.3 (0.05) 0.3 (0.05) 0.2 (0.04) 0.1 (0.04)

Kratom -- -- -- -- -- -- -- 0.1 (0.03) 0.1 (0.08)

Synthetic Marijuana (Fake Weed, K2,

Spice) -- -- -- -- -- -- -- -- 0.5 (0.14)

Synthetic Stimulants (“Bath Salts,” Flakka) -- -- -- -- -- -- -- -- 0.0 (0.03)

* = low precision; -- = not available; nc = not comparable due to methodological changes.

NOTE: Estimates shown are percentages with standard errors included in parentheses.

NOTE: Estimates in the 2020 column are italicized to indicate caution should be used when comparing estimates between 2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing between 2020 and prior years was

not performed. See the 2020 National Survey on Drug Use and Health: Methodological Summary and Definitions for details.

NOTE: Additional estimates may be found in the detailed tables for the 2020 NSDUH at https://www.samhsa.gov/data/

. Measures and terms are defined in Appendix A of the 2020 detailed tables.

NOTE: Estimates of 0.0 percent round to less than 0.1 percent when shown to the nearest tenth of a percent.

1

Percentages for daily cigarette smoking are among past month cigarette smokers.

2

Percentages for smoking one or more packs of cigarettes per day are among daily cigarette smokers in the past month. Respondents with missing data for the number of cigarettes smoked per day were excluded from the analysis.

Source:

SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2002-2019 and Quarters 1 and 4, 2020.

A-6

Table A.3B Types of Illicit Drug, Tobacco Product, Alcohol, and Other Substance Use in the Past Month: Among Young Adults Aged 18 to 25; 2002-2020

Substance 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

GENERAL SUBSTANCE USE

Illicit Drugs, Tobacco Products, or Alcohol nc nc nc nc nc nc nc nc nc nc

Illicit Drugs or Alcohol nc nc nc nc nc nc nc nc nc nc

Tobacco Products or Alcohol 70.3 (0.48) 70.7 (0.46) 70.2 (0.48) 70.1 (0.49) 71.0 (0.47) 69.9 (0.47) 69.7 (0.47) 70.4 (0.49) 70.2 (0.46) 69.6 (0.48)

ILLICIT DRUGS nc nc nc nc nc nc nc nc nc nc

TOBACCO PRODUCTS OR NICOTINE

VAPING -- -- -- -- -- -- -- -- -- --

Tobacco Products 45.3 (0.48) 44.8 (0.48) 44.6 (0.50) 44.3 (0.48) 44.0 (0.49) 41.9 (0.50) 41.4 (0.47) 41.6 (0.50) 40.9 (0.49) 39.5 (0.49)

Cigarettes 40.8 (0.48) 40.2 (0.47) 39.5 (0.49) 39.0 (0.47) 38.5 (0.48) 36.2 (0.49) 35.7 (0.45) 35.8 (0.48) 34.3 (0.47) 33.5 (0.47)

Daily Cigarette Smoking

1

51.8 (0.72) 52.7 (0.69) 51.6 (0.72) 50.1 (0.73) 48.8 (0.77) 49.2 (0.76) 47.8 (0.81) 45.3 (0.80) 45.8 (0.80) 45.3 (0.86)

Smoked 1+ Packs of

Cigarettes per Day

2

39.1 (0.93) 37.1 (0.88) 34.9 (0.86) 36.9 (0.93) 34.4 (0.93) 32.9 (0.92) 31.6 (0.91) 29.5 (0.92) 27.3 (0.94) 26.1 (0.97)

Smokeless Tobacco nc nc nc nc nc nc nc nc nc nc

Cigars 11.0 (0.27) 11.4 (0.26) 12.7 (0.30) 12.0 (0.28) 12.1 (0.29) 11.9 (0.28) 11.4 (0.29) 11.5 (0.29) 11.3 (0.30) 10.9 (0.29)

Pipe Tobacco 1.1 (0.08) 0.9 (0.08) 1.2 (0.09) 1.5 (0.11) 1.3 (0.10) 1.2 (0.10) 1.4 (0.10) 1.8 (0.12) 1.8 (0.12) 1.9 (0.14)

Nicotine Vaping -- -- -- -- -- -- -- -- -- --

ALCOHOL 60.5 (0.53) 61.4 (0.50) 60.5 (0.51) 60.9 (0.51) 62.0 (0.51) 61.3 (0.52) 61.1 (0.49) 61.8 (0.52) 61.4 (0.50) 60.7 (0.54)

Binge Alcohol Use nc nc nc nc nc nc nc nc nc nc

Heavy Alcohol Use nc nc nc nc nc nc nc nc nc nc

OTHER SUBSTANCE USE

GHB -- -- -- -- 0.0 (0.01) 0.1 (0.03) 0.0 (0.01) 0.0 (0.01) 0.0 (0.01) 0.0 (0.01)

Nonprescription Cough or Cold Medicine -- -- -- -- 0.3 (0.05) 0.4 (0.06) 0.3 (0.05) 0.4 (0.05) 0.4 (0.06) 0.3 (0.04)

Kratom -- -- -- -- -- -- -- -- -- --

Synthetic Marijuana (Fake Weed, K2,

Spice) -- -- -- -- -- -- -- -- -- --

Synthetic Stimulants (“Bath Salts,” Flakka) -- -- -- -- -- -- -- -- -- --

NOTE: Footnotes and source information are shown at the end of the second half of this table.

A-7

Table A.3B Types of Illicit Drug, Tobacco Product, Alcohol, and Other Substance Use in the Past Month: Among Young Adults Aged 18 to 25; 2002-2020 (continued)

Substance 2012 2013 2014 2015 2016 2017 2018 2019 2020

GENERAL SUBSTANCE USE

Illicit Drugs, Tobacco Products, or Alcohol nc nc nc 67.9 (0.49) 66.8 (0.51) 65.8 (0.56) 64.4 (0.52) 64.0 (0.54) 59.7 (1.03)

Illicit Drugs or Alcohol nc nc nc 61.9 (0.52) 61.5 (0.53) 60.9 (0.59) 59.9 (0.55) 59.8 (0.56) 56.9 (1.05)

Tobacco Products or Alcohol 69.0 (0.46) 67.9 (0.49) 67.6 (0.53) 66.3 (0.49) 64.6 (0.52) 63.7 (0.56) 61.8 (0.53) 60.8 (0.56) 56.6 (1.02)

ILLICIT DRUGS nc nc nc 22.3 (0.42) 23.2 (0.43) 24.2 (0.47) 23.9 (0.48) 24.9 (0.45) 23.9 (0.84)

TOBACCO PRODUCTS OR NICOTINE

VAPING -- -- -- -- -- -- -- -- 25.1 (0.83)

Tobacco Products 38.1 (0.47) 37.0 (0.49) 35.0 (0.54) 33.0 (0.48) 30.0 (0.48) 29.1 (0.48) 25.8 (0.43) 24.3 (0.45) 19.2 (0.74)

Cigarettes 31.8 (0.47) 30.6 (0.46) 28.4 (0.53) 26.7 (0.46) 23.5 (0.47) 22.3 (0.44) 19.1 (0.39) 17.5 (0.40) 13.9 (0.64)

Daily Cigarette Smoking

1

45.1 (0.88) 43.1 (0.83) 43.0 (0.91) 42.0 (1.02) 39.9 (1.03) 38.4 (1.02) 37.4 (1.11) 35.4 (1.13) 33.1 (2.24)

Smoked 1+ Packs of

Cigarettes per Day

2

25.1 (0.90) 22.3 (0.90) 22.5 (1.16) 22.5 (1.11) 26.2 (1.42) 25.0 (1.45) 23.4 (1.49) 25.0 (1.60) 20.8 (3.03)

Smokeless Tobacco nc nc nc 5.4 (0.22) 5.2 (0.22) 4.8 (0.21) 4.4 (0.19) 4.9 (0.22) 3.9 (0.38)

Cigars 10.7 (0.27) 10.0 (0.29) 9.7 (0.30) 8.9 (0.27) 8.8 (0.27) 9.1 (0.29) 8.6 (0.27) 7.7 (0.26) 5.9 (0.46)

Pipe Tobacco 1.8 (0.11) 2.2 (0.14) 1.9 (0.13) 1.8 (0.13) 1.7 (0.12) 1.6 (0.14) 1.8 (0.14) 1.2 (0.11) 1.2 (0.18)

Nicotine Vaping -- -- -- -- -- -- -- -- 11.7 (0.57)

ALCOHOL 60.2 (0.49) 59.6 (0.53) 59.6 (0.56) 58.3 (0.53) 57.1 (0.55) 56.3 (0.60) 55.1 (0.57) 54.3 (0.58) 51.5 (1.04)

Binge Alcohol Use nc nc nc 39.0 (0.51) 38.4 (0.54) 36.9 (0.57) 34.9 (0.51) 34.3 (0.54) 31.4 (0.95)

Heavy Alcohol Use nc nc nc 10.9 (0.33) 10.1 (0.32) 9.6 (0.34) 9.0 (0.34) 8.4 (0.29) 8.6 (0.54)

OTHER SUBSTANCE USE

GHB 0.0 (0.02) 0.0 (0.01) * (*) 0.0 (0.01) 0.0 (0.02) * (*) * (*) 0.0 (0.02) * (*)

Nonprescription Cough or Cold Medicine 0.3 (0.07) 0.3 (0.05) 0.3 (0.06) 0.4 (0.06) 0.3 (0.06) 0.2 (0.04) 0.4 (0.07) 0.4 (0.07) 0.3 (0.10)

Kratom -- -- -- -- -- -- -- 0.5 (0.07) 0.2 (0.07)

Synthetic Marijuana (Fake Weed, K2,

Spice) -- -- -- -- -- -- -- -- 0.5 (0.17)

Synthetic Stimulants (“Bath Salts,” Flakka) -- -- -- -- -- -- -- -- 0.0 (0.02)

* = low precision; -- = not available; nc = not comparable due to methodological changes.

NOTE: Estimates shown are percentages with standard errors included in parentheses.

NOTE: Estimates in the 2020 column are italicized to indicate caution should be used when comparing estimates between 2020 and prior years because of methodological changes for 2020. Due to these changes, significance testing between 2020 and prior years was

not performed. See the 2020 National Survey on Drug Use and Health: Methodological Summary and Definitions for details.

NOTE: Additional estimates may be found in the detailed tables for the 2020 NSDUH at https://www.samhsa.gov/data/

. Measures and terms are defined in Appendix A of the 2020 detailed tables.

NOTE: Estimates of 0.0 percent round to less than 0.1 percent when shown to the nearest tenth of a percent.

1

Percentages for daily cigarette smoking are among past month cigarette smokers.

2

Percentages for smoking one or more packs of cigarettes per day are among daily cigarette smokers in the past month. Respondents with missing data for the number of cigarettes smoked per day were excluded from the analysis.

Source:

SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2002-2019 and Quarters 1 and 4, 2020.

A-8

Table A.4B Types of Illicit Drug, Tobacco Product, Alcohol, and Other Substance Use in the Past Month: Among Adults Aged 26 or Older; 2002-2020

Substance 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

GENERAL SUBSTANCE USE

Illicit Drugs, Tobacco Products, or Alcohol nc nc nc nc nc nc nc nc nc nc

Illicit Drugs or Alcohol nc nc nc nc nc nc nc nc nc nc

Tobacco Products or Alcohol 64.5 (0.51) 63.2 (0.47) 62.7 (0.51) 64.9 (0.49) 64.2 (0.48) 64.1 (0.47) 64.3 (0.48) 64.1 (0.45) 64.6 (0.48) 64.1 (0.48)

ILLICIT DRUGS nc nc nc nc nc nc nc nc nc nc

TOBACCO PRODUCTS OR NICOTINE

VAPING -- -- -- -- -- -- -- -- -- --

Tobacco Products 29.9 (0.44) 29.3 (0.41) 28.5 (0.41) 29.0 (0.43) 29.4 (0.43) 28.6 (0.42) 28.4 (0.44) 27.3 (0.40) 27.2 (0.42) 26.3 (0.41)

Cigarettes 25.2 (0.42) 24.7 (0.41) 24.1 (0.39) 24.3 (0.39) 24.7 (0.40) 24.1 (0.40) 23.8 (0.41) 23.0 (0.39) 22.8 (0.38) 21.9 (0.39)

Daily Cigarette Smoking

1

68.8 (0.87) 68.0 (0.86) 67.8 (0.80) 68.9 (0.79) 67.9 (0.74) 66.3 (0.83) 67.0 (0.86) 67.2 (0.84) 64.8 (0.86) 66.5 (0.88)

Smoked 1+ Packs of

Cigarettes per Day

2

57.1 (1.12) 58.0 (0.99) 59.2 (1.05) 55.1 (1.02) 54.5 (1.00) 55.1 (1.06) 53.0 (1.10) 49.4 (1.16) 48.8 (1.09) 47.4 (1.05)

Smokeless Tobacco nc nc nc nc nc nc nc nc nc nc

Cigars 4.6 (0.18) 4.5 (0.18) 4.6 (0.17) 4.7 (0.18) 4.6 (0.18) 4.4 (0.16) 4.4 (0.18) 4.4 (0.18) 4.4 (0.17) 4.2 (0.18)

Pipe Tobacco 0.8 (0.09) 0.6 (0.07) 0.7 (0.08) 0.8 (0.08) 0.9 (0.09) 0.8 (0.09) 0.6 (0.07) 0.7 (0.07) 0.7 (0.07) 0.7 (0.07)

Nicotine Vaping -- -- -- -- -- -- -- -- -- --

ALCOHOL 53.9 (0.53) 52.5 (0.49) 53.0 (0.51) 55.1 (0.51) 53.7 (0.49) 54.1 (0.52) 54.7 (0.50) 54.9 (0.48) 54.9 (0.48) 55.1 (0.49)

Binge Alcohol Use nc nc nc nc nc nc nc nc nc nc

Heavy Alcohol Use nc nc nc nc nc nc nc nc nc nc

OTHER SUBSTANCE USE

GHB -- -- -- -- 0.0 (0.01) * (*) 0.0 (0.01) * (*) 0.0 (0.01) 0.0 (0.01)

Nonprescription Cough or Cold Medicine -- -- -- -- 0.1 (0.02) 0.1 (0.02) 0.1 (0.03) 0.1 (0.03) 0.1 (0.03) 0.1 (0.03)

Kratom -- -- -- -- -- -- -- -- -- --

Synthetic Marijuana (Fake Weed, K2,

Spice) -- -- -- -- -- -- -- -- -- --

Synthetic Stimulants (“Bath Salts,” Flakka) -- -- -- -- -- -- -- -- -- --

NOTE: Footnotes and source information are shown at the end of the second half of this table.

A-9

Table A.4B Types of Illicit Drug, Tobacco Product, Alcohol, and Other Substance Use in the Past Month: Among Adults Aged 26 or Older; 2002-2020 (continued)

Substance 2012 2013 2014 2015 2016 2017 2018 2019 2020

GENERAL SUBSTANCE USE

Illicit Drugs, Tobacco Products, or Alcohol nc nc nc 65.2 (0.36) 64.5 (0.36) 65.3 (0.38) 64.9 (0.40) 64.6 (0.39) 63.8 (0.60)

Illicit Drugs or Alcohol nc nc nc 57.6 (0.37) 56.8 (0.39) 58.0 (0.39) 57.6 (0.43) 57.9 (0.40) 57.9 (0.61)

Tobacco Products or Alcohol 65.1 (0.45) 65.0 (0.47) 65.5 (0.36) 64.4 (0.36) 63.5 (0.36) 64.3 (0.38) 63.9 (0.40) 63.3 (0.39) 62.4 (0.60)

ILLICIT DRUGS nc nc nc 8.2 (0.19) 8.9 (0.21) 9.5 (0.22) 10.1 (0.24) 11.6 (0.23) 12.6 (0.37)

TOBACCO PRODUCTS OR NICOTINE

VAPING -- -- -- -- -- -- -- -- 21.6 (0.50)

Tobacco Products 27.0 (0.42) 25.7 (0.40) 25.8 (0.33) 24.5 (0.32) 24.6 (0.33) 23.4 (0.31) 22.8 (0.33) 22.6 (0.30) 20.4 (0.50)

Cigarettes 22.4 (0.40) 21.6 (0.38) 21.5 (0.32) 20.0 (0.31) 20.2 (0.31) 18.9 (0.30) 18.5 (0.30) 18.2 (0.28) 16.7 (0.47)

Daily Cigarette Smoking

1

66.0 (0.85) 64.9 (0.88) 63.3 (0.72) 62.7 (0.76) 62.2 (0.75) 61.5 (0.79) 62.3 (0.79) 62.5 (0.79) 64.1 (1.36)

Smoked 1+ Packs of

Cigarettes per Day

2

45.2 (1.09) 44.7 (1.15) 43.3 (0.93) 44.1 (0.98) 43.1 (1.00) 43.2 (1.02) 41.4 (1.03) 42.0 (1.01) 38.9 (1.86)

Smokeless Tobacco nc nc nc 3.2 (0.13) 3.1 (0.12) 3.1 (0.11) 2.9 (0.11) 3.1 (0.11) 2.5 (0.17)

Cigars 4.5 (0.19) 4.1 (0.17) 3.9 (0.12) 4.3 (0.14) 4.2 (0.13) 4.2 (0.13) 4.1 (0.14) 4.0 (0.14) 3.9 (0.23)

Pipe Tobacco 0.9 (0.09) 0.7 (0.07) 0.7 (0.06) 0.8 (0.06) 0.7 (0.06) 0.8 (0.06) 0.7 (0.05) 0.7 (0.05) 0.6 (0.09)

Nicotine Vaping -- -- -- -- -- -- -- -- 2.4 (0.15)

ALCOHOL 55.6 (0.48) 55.9 (0.50) 56.5 (0.39) 55.6 (0.38) 54.6 (0.38) 55.8 (0.40) 55.3 (0.43) 55.0 (0.41) 54.6 (0.62)

Binge Alcohol Use nc nc nc 24.8 (0.32) 24.2 (0.32) 24.7 (0.32) 25.1 (0.31) 24.5 (0.31) 22.9 (0.49)

Heavy Alcohol Use nc nc nc 6.4 (0.17) 6.0 (0.17) 6.2 (0.16) 6.2 (0.17) 6.0 (0.17) 6.7 (0.28)

OTHER SUBSTANCE USE

GHB 0.0 (0.01) 0.0 (0.01) 0.0 (0.01) 0.0 (0.01) * (*) 0.0 (0.00) 0.0 (0.01) 0.0 (0.01) 0.0 (0.02)

Nonprescription Cough or Cold Medicine 0.1 (0.03) 0.1 (0.04) 0.1 (0.02) 0.1 (0.02) 0.2 (0.03) 0.2 (0.04) 0.2 (0.03) 0.3 (0.04) 0.3 (0.06)

Kratom -- -- -- -- -- -- -- 0.3 (0.04) 0.4 (0.07)

Synthetic Marijuana (Fake Weed, K2,

Spice) -- -- -- -- -- -- -- -- 0.1 (0.02)