Research Report: The 2021 National Survey on Drug Use and Health

woman taking survey from another woman

Every year, the National Institutes of Health (NIH), in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA), conducts a nationwide survey called the National Survey on Drug Use and Health (NSDUH). Researchers survey close to 70,000 members of the civilian, non-institutionalized population on the following subjects:

  • Alcohol, tobacco, and drug use
  • Rates of substance use disorder (SUD), alcohol use disorder (SUD), and other drug use disorders
  • Rates of mental illness
  • Receipt of treatment for SUD, AUD, or other drug use disorder
  • Receipt of treatment for mental illness

In previous years, the NSDUH use one mode of data collection: surveys filled out in-person and submitted anonymously. For the 2021 NSDUH, however, researchers used a multi-modal approach: respondents completed surveys in-person and via the internet.

Therefore, the data in the 2021 NSDUH should not be compared to previous NSDUH surveys.

Although the figures are similar, and there are no large discrepancies between the previous surveys and the current survey, it’s important to understand that we should think of the 2021 NSDUH as a reset. We can use it for comparison moving forward, but – as the authors warn – comparing 2021 NSDUH data to earlier NSDUH data is not methodologically sound.

That’s why you’ll only see data for 2021 in the new report and in this article. In previous years, we would have included insights like “this figure represents a 20% increase over last year” which we will not include in this article.

Alongside the main NSDUH report, SAMHSA also published a shorter “Highlights” version of the yearly report. In this article, we summarize that version, and present the data in a way that’s both easy to read and understand.

We’ll also add our insights, and in some cases, explain why certain data sets can help us, as substance use disorder treatment providers, offer our patients the best possible support and care. Find a comfortable spot and get ready. There’s a lot of data I this article, but stick with us. We assure you that the information below is well worth the time it takes to read and understand.

The 2021 NSDUH: Highlights and Important Data

We’ll start with the overall, big picture data on substance use.

Substance Use in the Past Month, Age 12+

Individuals who reported use of substances in the past month meet criteria for current use.

  • Among people aged 12 or older in 2021, 57.8% used tobacco, alcohol, or an illicit drug in the past month
    • Alcohol: 47.5% (133.1 million)
    • Tobacco: 19.5% (54.7 million)
    • Illicit drug: 14.3% (or 40.0 million people)

Alcohol Use: Past Month, Heavy, and Binge Drinking, Age 12+

  • Current use: 133.1 million
  • Binge drinkers: 60.0 million (45.1%)
  • Among binge drinkers:
    • 18-25: 29.2% (9.8 million)
    • 26+: 22.4% (49.3 million)
    • 12-17: 3.8% (995,000)
  • Binge drinking among underage people: 8.3% (3.2 million)
  • Heavy alcohol use among underage people: 1.6% (613,000)

Illicit Drug Use

  • Marijuana use in past month (12+):
    • Total: 52.5 million (18.7%)
    • 18-25: 11.8 million (35.4%)
    • 26+: 37.9 million (17.2%)
    • 12-17: 2.7 million (10.5%)
  • Opioid Misuse in the past year:
    • Total: 9.2 million (3.3%)
    • 18-25:
    • 26+:
    • 12-17:
  • Opioid prescription misuse:
    • Total: 8.7 million
  • Heroin use:
    • Total: 1.1 million
  • Opioid prescription misuse + heroin use:
    • Total: 574,000

Substance Use Disorder

In the 2021 NSDUH, researchers use criteria established by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) to determine the presence of a substance use disorder (SUD) in the past year. The survey asked SUD-related questions for any alcohol or drugs they may have used in the 12 months before taking the survey.

The survey included questions about the following drugs:

  • Marijuana
  • Cocaine (including crack)
  • Heroin
  • Hallucinogens
  • Inhalants
  • Methamphetamine
  • Prescription stimulants, tranquilizers/sedatives, and pain relievers

Here are the overall figures for SUD among people in the U.S. in 2021.

SUD in 2021

  • Total: 46.3 million (16.5%)
  • 18-25: 8.6 million (25.6%)
  • 26+: 35.5 million (16.1%)
  • 12-17: 2.2 million (8.5%)

Here’s the SUD data listed by substance:

SUD by Substance in 2021

  • Alcohol use disorder: 29.5 million
  • Illicit drug use disorder: 24.0 million
  • Marijuana use disorder: 16.3 million
  • Pain reliever use disorder: 5.0 million
  • Methamphetamine use disorder: 1.6 million
  • Stimulant use disorder: 1.5 million
  • Cocaine use disorder: 1.4 million
  • Heroin use disorder: 1.0 million

Here’s the data on SUD, AUD, and any illicit drug use disorder, listed by age group:

SUD, AUD, and Illicit Drug Use Disorder by Age Group

  • SUD
    • 12 + total: 16.5%
    • 12-17: 8.5%
    • 18-25: 25.6%
    • 26+: 16.1%
  • AUD:
    • 12 + total: 10.6%
    • 12-17: 3.4%
    • 18-25: 15.0%
    • 26+: 10.7%
  • DUD:
    • 12 + total: 8.6%
    • 12-17: 6.8%
    • 18-25: 16.3%
    • 26+: 7.6%

Substance Use Treatment: Needed Treatment and Received Treatment

The NSDUH team defined the term needed SUD treatment in the past year as anyone diagnosed with an alcohol or substance use disorder, or anyone who received substance used treatment at a specialized facility in the past year.

Needed SUD Treatment in The Past Year

  • 12+: 15.6% (43.7 million)
  • 12-17: 7.6% (2.0 million)
  • 18-25: 25.1% (8.4 million)
  • 26+: 15.1% (33.3 million)

Received Any SUD Treatment in The Past Year

  • 12+: 1.5% (4.1 million)
  • 12-17: 0.3% (82,000)
  • 18-25: 1.3% (438,000)
  • 26+: 1.6% (3.6 million)

Those two sets of bullet points reveal something we often discuss in our articles: the treatment gap. The treatment gap is the difference between the number of people who need SUD treatment and the number of people who receive SUD treatment. Here’s what this data tells us about the treatment gap in 2021.

The Treatment Gap: 2021

  • Overall, 12+: 90% of people 12+ who needed treatment did not get the treatment they needed
  • 12-17: 96% of people 12-17 who needed treatment did not get the treatment they needed
  • 18-25: 95% of people 18-25 who needed treatment did not get the treatment they needed
  • 26+: 89% of people 26+ who needed treatment did not get the treatment they needed

Those gaps are far too large. This data – like the data for adults with mental illness – tells us we need to increase our overall efforts in the following areas: awareness, education, advocacy, and access. In order to close the treatment gap, we need to inform people about the need for treatment, teach them what treatment is and what it entails, encourage them to seek help when needed, and work to reduce barriers to care for people who want and need professional support for SUD.

Now let’s look at how the people who did receive treatment received their treatment.

How People Received SUD Treatment in The Past Year

  • Self-help group like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA): 2.0 million
  • Virtual support: 1.9 million
  • Outpatient SUD center: 1.8 million
  • Outpatient mental health center: 1.5 million
  • Inpatient SUD center: 1.3 million
  • Hospital inpatient: 1.1 million
  • Emergency room: 571,000
  • While incarcerated: 354,000

Now let’s narrow the focus on treatment for SUD, and examine the data on people who received medication-assisted treatment for opioid misuse or opioid use disorder (OUD).

Medication-Assisted Treatment for OUD

  • A total of 5.6 million people had OUD, including people with:
    • Heroin use disorder
    • Prescription opioid use disorder
    • Other opioid-related SUDs
  • 1.2 million people with OUD received treatment for OUD
  • 533,000 people with OUD received MAT for OUD
  • 1.1 million people received MAT for opioid use, with or without OUD diagnosis
  • 887,000 who reported misusing opioids received MAT for OUD

Those figures reveal another treatment gap: 90 percent of people diagnosed with OUD did not receive the gold-standard treatment for OUD, which is medication-assisted treatment (MAT). That’s another serious issue we can address by increasing our efforts around awareness, education, advocacy, and reducing barriers to care.

We have one more set of bullet points to share. In the 2021 NSDUH, the survey asked people diagnosed with AUD or SUD who didn’t receive treatment why they didn’t receive treatment. These individuals said they were:

  • Not ready to stop: 36.7%
  • No insurance/can’t afford treatment: 24.9%
  • Unsure where to seek treatment: 17.9%
  • Unable to find the kind of treatment they wanted: 15.8%
  • Able to handle their disorder without treatment: 15.0%
  • Worried getting treatment might have a negative effect on their job: 14.7%

We’ll leave that data right there, with only this comment: data shows that the sooner people with a clinical diagnosis for AUD or SUD get treatment, the better the overall outcome.

That’s all the data we have on SUD and SUD treatment.

Now it’s time to switch gears and look at another set of data that has a direct impact on the work we do with people diagnosed with substance use disorder: the latest statistics on mental health, mental health disorders, and mental health treatment.

Mental Health in 2021

Three things drive the fourth wave of the overdose/opioid epidemic: the presence of fentanyl in opioids and other drugs of misuse/disordered use, polysubstance misuse, and an increase in the presence of co-occurring disorder, or when a person has a substance use disorder and a mental health disorder at the same time.

That’s why the data on mental health from 2021 matters to us. In the integrated model of care, we address the whole person, including any mental health disorder they have in addition to their primary substance use disorder. The more we know about the current state of mental health among people in the U.S., the better we can prepare to offer comprehensive support to any and every patient we admit to one of our programs.

Mental Health Among Adolescents 12-17

Although we don’t treat adolescents in our SUD treatment centers, this data is important to us for a simple reason: we need to know what to expect over the next several years. By today, many of the teens in this survey have become adults, and therefore, may need our support.

Major depressive disorder:

  • Major depressive episode (MDE) in past year: 20.1% (5.0 million)
  • MDE with severe impairment: 14.7% (3.7 million)

This year, the NSDUH included questions to determine the number of adolescents with MDE who also used illicit drugs. Here’s what they report:

  • Among adolescents with MDE: 27.7% used illicit drugs in the past year
  • Among adolescents without MDE: 10.7% used illicit drugs in the past year

That’s a clear example of why this data matters: rates of illicit drug use are almost three times higher among adolescents with a past year MDE, compared to adolescents without a past year MDE.

Now let’s let look at the data on adult mental health for 2021.

Mental Health Among Adults

We’ll start this section with the two broad categories the NSDUH uses for adults: any mental illness (AMI) and serious mental illness (SMI). Keep in mind that AMI and SMI can mean a clinical diagnosis of a depressive disorder, an anxiety disorder, a personality disorder, bipolar disorder, schizophrenia, or any type of psychotic disorder. Serious mental illness refers to the level of disruption the mental illness causes: if it prevents a person from engaging in typical daily activity, it’s considered serious.

Any Mental Illness (AMI):

  • Adults 18+: 22.8% (57.8 million)
  • 18-25: 33.7% (11.3 million)
  • 26-49: 28.1% (28.8 million)
  • 50+: 15.0% (17.7 million)

Serious Mental Illness (SMI):

  • Adults 18+: 5.5% (14.1million)
  • 18-25: 11.4% (3.8 million)
  • 26-49: 7.1% (7.3 million)
  • 50+: 2.5% (3.0 million)

This year, the NSDUH included questions to determine the number of adults who had either SUD or AMI. Here’s what they report:

  • Adults 18 to 25: 45.8% (15.3 million) had either SUD or AMI
  • Among adults 26-49: 39.5% (40.4 million) had either SUD or AMI
  • Adults 50+: 22.6% (26.7 million) had either SUD or AMI

They also collected data on adults with past year AMI or SMI who used illicit drugs in the past year. Here’s what they report:

  • Adults 18+ with AMI or SMI: 2% used illicit drugs in the past year
  • Adults 18+ without AMI or SMI: 17.7% used illicit drugs in the past year

Like the data on adolescents, this data helps us better understand the default circumstances among adults in the U.S. We can see clear evidence here that rates of illicit drug use are almost three times as high among people with AMI or SMI compared to people without AMI or SMI. This data helps us calibrate efforts across all our areas of work: advocacy, education, treatment, and support.

A Note on the Perceived Impact of COVID-19 on Mental Health

We’ll end this section with a brief note on how the COVID-19 pandemic affected mental health. Among adolescents 12-17 with MDE, 45 percent (2.2 million) said the pandemic negatively affected their mental health “quite a bit or a lot,” while 12.4 percent of adolescents 12-17 without MDE said the pandemic affected their mental health “quite a bit or a lot.” With regards to adults, among those with SMI, 48.9 percent (6.8 million) said COVID-19 had a negative impact on their mental health.

Mental Health Treatment: Service Use

Next, we’ll look at rates of treatment for people with mental health disorders. We’ll focus on treatment services utilized by people with mental health disorders, as well as treatment services utilized by people with co-occurring mental health and substance use/alcohol use disorders.

We’ll start with the data on people who reported at least one major depressive episode (MDE) in the past year.

  • Adolescents 12-17 with MDE:
    • 10.6% (2.0 million) received treatment for depression
  • Adolescents 12-17 with MDE with severe impairment:
    • 55.8% (1.6 million) received treatment for depression
  • Adults 18+ with MDE:
    • 61.0% (12.6 million) received treatment for depression
  • Adults 18+ with MDE with severe impairment:
    • 8% received treatment
    • 18-25: 56.7% received treatment
    • 26-49: 66.6% received treatment
    • 50+: 71.8% received treatment

Next, we’ll offer the data on adults with any mental illness (AMI) and serious mental illness (SMI).

  • Adults 18+ with AMI: 47.2% (26.5 million) received treatment
  • Adults with SMI: 65.4% (9.1 million) received treatment
  • Received treatment means they participated in or received at least one of the following modes of support:
    • Inpatient mental health treatment
    • Outpatient mental health treatment
    • Prescription medication for a mental health issue/disorder
    • Virtual support, i.e., telehealth or video consultations
  • Among adults with SMI: 51.5% (7.2 million) said they perceived an “unmet need for mental health treatment/services” in the past year

Now we’ll move to a set of statistics that’s more important than ever: the data on co-occurring mental health and substance use/alcohol use disorders. As we mention above, the fourth wave of the opioid and overdose crisis in the U.S. involves an increasing number of people with SUD/AUD and mental illness. As a reminder, that’s what co-occurring disorders means: when a person has AUD/SUD and a mental health disorder at the same time.

Co-Occurring Mental Health Disorder and AUD/SUD: Service Use

As above, we’ll start with the data on adolescents.

  • Adolescents 12-17 with MDE and SUD/AUD:
    • 842,000 total
    • 156.% (471,000) received either SUD treatment or mental health treatment
    • 93.5% received on mental health treatment
    • 7.5% received treatment for both
  • Treatment setting, Adolescents 12-17:
    • Outpatient: 17.5%
    • Inpatient/residential: 2.5%
    • School: 11.9%
    • General medical office: 3.8%
    • Child welfare facility: 0.4%
    • Juvenile justice facility: 0.1%
    • Virtual care: 10.6%

Now for the data on adults.

  • Adults 18+ with AMI and a mental health disorder:
    • 17. 9 million total
    • 52.5% (9.0 million) received either SUD treatment or mental health treatment
    • 84% received only mental health treatment
    • 16% received treatment for both
  • Adults 18+ with SMI and a mental health disorder:
    • 5.8 million total
    • 66.9% (3.9 million) received either SUD treatment or mental health treatment
    • 81.5% received only mental health treatment
    • 18.5% received treatment for both

You made it!

That’s all the data we have to share – for now.

That last set of statistics is an instructive place to stop. It tells us that there’s a serious treatment gap for people with co-occurring disorders. In light of the dynamics driving the current phase of the opioid and overdose crisis – which we mention above – we’re reminded again of the core mantra of integrated, whole-person treatment: when a person a substance use disorder and a mental health disorder, treating one and not the other typically leads to attenuated and unsatisfactory outcomes for both.

Valuable Data For 2023 and Beyond

It takes time to collect and verify data in order to make it useful.

That’s why the 2021 gets published now, in 2023: it took that long to analyze the data and prepare it for publication. While it takes time, the service is invaluable. Here’s how SAMHSA describes the contents of these yearly reports:

“NSDUH estimates allow researchers, clinicians, policymakers, and the general public to better understand and improve the nation’s behavioral health.”

That’s what it does: it helps us understand what’s happening in the U.S. with regards to drug use and mental health with concrete data and statistical analysis. That’s why we read it every year, and that’s why we share this data with you, now. Our mission is to offer the best SUD and mental health treatment available, and we can only do that with the best and latest knowledge – which you now have access to as well, in the form of this article, and the links we provide throughout.