Heroin Usage: Impact on Student Performance and Truancy amongst High School Students

This manuscript will provide an overview of Heroin, its short term and long-term consequences, as well as its prevalence in usage amongst high school students. The manuscript will also discuss the impact that Heroin has on students’ academic performance and truancy. Counseling interventions will be addressed in regards to treating adolescent heroin addiction, as well as ways to promote school engagement in order to reduce truancy and maximize students’ personal and academic potential.


Introduction
Between 2001 and 2009, the amount of drug and alcohol problems diagnosed by doctors in the United States had increased by 70% from 776,000 to 4.4 million, due to an increase in prescription opiate usage and abuse [1]. The total number of opiate prescriptions given by pharmacies in the United States has risen from 76 million in 1991 to 210 million in 2010 [2]. Based upon results from the 2013 National Survey on Drug Use and Health: Summary of National Findings [3], 52 million people, approximately 20% of those ages 12 and older, have taken nonprescription drugs at least once for non-medical reasons within their lifetime and more than half of non-medical users taking opiates obtained prescription drugs from a friend or relative for free. Heroin is a highly addictive opiate that causes harmful shortterm and long-term effects on its users. Heroin use has reached epidemic proportions in the United States amongst teenagers, who are experimenting with this drug due to its obtainability and affordability. Heroin users spend approximately $150 to $200 fueling their drug addiction [4].

Prevalence of Heroin Usage in the United States
Due to the fact that there are many Heroin related overdoses in the United States, there has been more emphasis placed on examining the relationship between prescription painkillers and Heroin usage. In 2013, there were 16,235 deaths involving prescription opioids nationwide and there were 8,257 Heroin related deaths in 2013, a 39% increase from 2012 [5]. In a study published in Drug and Alcohol Dependence, the researchers found a correlation between Heroin and prescription opioid usage amongst high school students and found that more than 75% of high school Heroin users began experimenting with opiates after initially being introduced to prescription painkillers [5]. Approximately 25% of students who reported using opioids more than 40 times also reported a lifetime of Heroin use [5]. According to surveys conducted during recent studies, nearly half of the adolescents who injected Heroin reported abusing prescription opioids before using Heroin [6].
The National Survey on Drug Use and Health (NSDUH) indicates that in 2013 approximately 669,000 Americans reported using Heroin in the past year. The trend in the rise in Heroin usage is driven largely by young adults age 18-25, but also by teenagers. Since 2012, the number of people who have used Heroin for the first time is approximately 156,000, which is almost double the approximately 90,000 individuals using Heroin in 2006 [7]. The impact of Heroin usage is felt all over the United States with Heroin being identified as one of the most important drug abuse issues affecting people, specifically the younger population [7]. Heroin can be mixed with water and injected intravenously or it can be smoked or snorted. When Heroin enters the brain it is converted back into morphine and it binds to molecules called opioid receptors. The short-term effects users experience may include a rush of euphoria or clouded thinking, sleepiness, and a sense of calmness. Regular Heroin users tend to foster tolerance, dependence, and addiction towards this drug due to its impactful side effects. Long-term effects of Heroin usage include a deterioration of brain capacity and mental functioning, tolerance and physical dependence, or having an inability to regulate behavior. Withdrawal from Heroin can be extremely painful and includes insomnia, severe chills, goose bumps, sweating, and leg movements, which can last for 24 to 48 hours [7]. Due to the extremely addictive nature of the drug, once a person becomes addicted, using Heroin becomes one of his/her primary purposes in life.
In 2011, more than 250,000 hospital emergency visits amongst teenagers involved Heroin. Heroin usage, especially when acute can cause severe itching, slowed breathing, increased risk to HIV, or becoming comatose. Many teens that are using Heroin experience a decline in their grade point average (GPA), peer relationships, physical appearance, and an increase in deviant behavior, illness, and personality changes. According to NIDA's Monitoring the Future Study, which measures trends in prevalence of Heroin usage amongst 8 th , 10 th and 12 th graders, over a lifetime 0.50% of 8 th graders, 0.70% of 10 th graders, and 0.80% of 12 th graders have used Heroin [8]. Thus, the results of the study indicate that Heroin usage is rampant amongst teens and heroin usage can accelerate, as they get older. Due to the sensitive nature of collecting data on drug usage, it is considered an underreported statistic. However, according to Murphey, Barry, Vaughn, Guzman, and Terzian [9], the researchers found that half of adolescents have used an illicit drug by the 12 th grade. The researchers also found that one in five 12 th graders reported having used a prescription drug without medical supervision, and one in nine teenagers in 8 th , 10 th and 12 th grades combined reported having access to household medications or substances to get high, which can also lead to an increase in Heroin usage. The researchers discovered that male adolescents are more likely than their female counterparts to utilize illicit drugs, specifically Heroin. It is also determined that Caucasian students are more likely than African American or Hispanic students to utilize illicit drugs [9]. Reports have shown that adolescents living in rural areas more so than urban areas, are more likely to use nonprescribed prescription drugs, especially if their health status was poor, they struggled with depression, or if they have used other drugs.

Effects of Heroin Usage on Adolescents' Academic Performance
Teenagers are vulnerable to drug usage for a myriad of reasons, including peer pressure, peer acceptance, self-exploration, identity, as well as the fact that their brains are still physically developing. Teenagers who engage in drug usage are more likely to also engage in risky sexual behavior or be involved in delinquency [9]. Many students who use drugs, particularly Heroin, display a decline in their academic performance, and have an increased likelihood of dropping out of school. In many instances adolescents who use illicit drugs have pre-existing problems at school, which also makes them more susceptible to taking drugs. Heroin usage amongst adolescents reports higher absenteeism and decreased productivity at work, an increased need for money, more secretive behavior, a change in friends or hobbies, as well as engaging in other risky behaviors [10]. A study of teens in 12 th grade who dropped out of school before graduating are more likely than their peers to use cigarettes, alcohol, and other illicit drugs. Illicit drug use including Heroin amongst dropouts (31.4%) was higher than for those students enrolled in school (18.2%) and one-third of school dropouts indicated that their use of illicit drugs was a significant factor in their decision to leave school [11]. According to data from the 2009 National Youth Risk Behavior Survey (YRBS), the findings indicate a negative and strong correlation between alcohol and other drug use and high school student academic achievement. Students with higher grades are less likely to engage in drug usage in comparison to their counterparts. The survey results indicated that 13% of students receiving A's have tried prescription drugs without a doctor's prescription (Percocet, Vicoden) while 41% of students receiving D's or F's have used prescription drugs without a doctor's prescription. Additionally, only 2% of students receiving A's have experimented with Heroin, while 10% of those receiving D's or F's have used Heroin. Thus, based upon survey findings the majority of students', who are using prescription drugs without a prescription, as well as Heroin, are also performing poorly academically [10].
In accordance with King, Meehan, Trim & Chassin [12], the researcher's synthesized literature on studies conducted regarding the impact of substance abuse on student academic performance. The researchers indicated that drug usage has a strong and direct correlation with truancy in that students who are utilizing drugs are more likely to suffer from chronic absenteeism, drop out of school, are exposed to negative peer influences, experience disengagement, poor self-control, lack of motivation, and do not possess the skills necessary to make constructive and healthy choices. Additionally, they noted that adolescent drug use is related to reduction in sustained engagement in their academic pursuits. Substance abuse impairs cognitive development, which negatively impacts academic progression. Additionally the researchers found that drug use, specifically Heroin usage, during adolescence leads to associations with antisocial peer groups, which also reduces school engagement and detracts from academic performance. The researchers indicated that outcomes such as grades, attendance, school completion, and dropout are also influenced by motivation and organizational skills, and behavioral skills [12].

Effects of Heroin Usage on Adolescents' Truancy
Students who have substance abuse issues, particularly Heroin, have low attendance or chronic absenteeism (truancy). In today's society truancy has become a major issue that negatively impacts the future of youth and is also very costly to tax payers. Education is pivotal to a student's success; however, each day there are thousands of students absent from school. Chronic absenteeism leads to increased dropout rates, drug usage, and delinquent behavior. Although to date there is not a national definition for truancy, many local jurisdictions report an increase in truancy rates correlating to increased crime and drug usage [13]. Students who miss school without a given reason are typically struggling with more serious personal or familial issues, which can be seen as a precursor to delinquency involvement [13]. In regards to substance usage, truancy is related to having increased odds of first time substance use, and if an adolescent has already experimented with substances, truancy is related to an increase in substance use. Additionally, truancy is a predictor of middle school drug use in that truant 8th graders were 4.5 times more likely than regular school attendees to start using marijuana or other substances [13]. Jurisdictions have also found relationships between truancy and an increase in daytime crimes including assaults and burglaries. Truancy has been linked to serious nonviolent and violent crimes amongst youth and the amount of truant youth held in juvenile detention centers is increasing [13]. Teen pregnancy and dropout rates are also major consequences associated with truant behaviors. Each year twenty percent of high school students drop out and nationally, one in five students who start high school do not receive their diploma [13].
DuPont et al. [11] indicated that high school truancy and the drop out phenomenon is a massive problem in our society and has dire long-term consequences. The researchers indicated that substance abuse tends to decrease student motivation to stay in school, since they are less engaged in academic pursuits. The researchers also stipulated that substance using students compared to non-substance abusing students are at a higher risk for academic failure, including dropping out and disengagement from school, as the substance usage becomes more frequent. Lastly, the researchers confirmed an association between substance use and other issues such as conduct problems, impulsivity and delinquency, which also have a deleterious impact on student academic performance [11].
Moreover, in a study conducted by Henry and Thornberry [14], the researchers examined the relationship between truancy (chronic absenteeism) and the escalation of substance use during adolescence. The researchers found that truancy is a robust predictor of onset of substance usage. Students who lack a school bond and are disengaged learners are more likely to engage in truant behaviors than those who feel a sense of connection to their school. Truancy had a greater impact on likelihood of substance usage than did school performance or commitment to school. The researchers also found that truancy escalated when peers spent risky time with friends [14].

Counseling Interventions and Treatment: Assisting Adolescents Struggling with Heroin Addiction
Adolescent substance usage is a problem impacting teenagers nationwide and the epidemic has many adverse and long-term consequences. There are several counseling interventions that can be utilized to help teenagers struggling with Heroin addiction to gain sobriety. Research has shown that intervening early on, in order to be proactive rather than reactive, elicits the most positive outcomes [15].

Brief Interventions
Brief interventions are shorter programs that can be used to help students reduce their substance usage. Their aim is to help prevent progression to more severe levels of usage [16]. Brief interventions provide suggestions, increase motivation to remain abstinent, and help to teach behavioral changes. Brief interventions typically last between one and five sessions and follow the FRAMES acronym. F represents feedback on behavior and its consequences for the student. R represents responsibility for change, A symbolizes advice for change, M indicates menu of options for change, E represents empathy, and S is representative of self-efficacy for change [15]. Many Brief Interventions integrate Motivational Interviewing or Brief Motivational Enhancement Therapy, which helps teens to enhance their readiness to change their destructive behaviors. Brief Interventions are Rogerian in nature in that they are client centered and emphasize unconditional acceptance, rather than using lecturing or confrontation. Motivation is seen as a state that can be altered rather than a trait that cannot be changed [15]. Brief interventions have been shown to reduce problematic substance usage amongst adolescents and can be extremely useful for students who have moderately risky patterns of substance usage.

SBIRT (Screening, Brief Intervention and Referral to Treatment)
The SBIRT method is used to help teens struggling with drug addiction, especially Heroin. A screening initially occurs to assess the severity of the addiction. Then a brief intervention is implemented which focuses on increasing insight and awareness, addressing the substance abuse issue, and works to enhance motivation towards behavioral change. Lastly, a referral to treatment is made which provides those identified as needing more extensive treatment to a facility that offers specialized care [17].

Group Therapy
Group therapy has been found to be effective when treating adolescents struggling with Heroin addiction as they have peer support, as well as positive social interactions with others who are struggling with the addition. Peer interaction helps to foster discussion regarding the importance of maintaining sobriety [7].

Adolescent Community Reinforcement Approach (A-CRA)
A-CRA is an intervention that helps teenagers to achieve and maintain abstinence from drugs by replacing influences in their lives that have reinforced substance use with healthier family, social, or educational relationships [2]. Teenagers learn effective problem solving, coping and communication skills that encourage them to engage in constructive social activities.

Cognitive Behavioral Therapy (CBT)
CBT strategies are based on the premise that learning plays a monumental role in the development of substance abuse behaviors. CBT helps to teach teenagers how to anticipate problems and helps to develop effective coping strategies. Using CBT helps teenagers to explore the positive and negative consequences of utilizing substances. Teenagers are encouraged to monitor their feelings and thoughts, as well as acknowledge how distorted thinking patterns can trigger substance usage. Teenagers are also encouraged to anticipate high-risk situations and are urged to apply self-control skills including emotion regulation, problem solving, and substance refusal [2].

Contingency Management (CM)
CM provides teenagers with a way to earn low cost incentives such as prizes in exchange for participating in drug treatment, achieving goals in treatment, and maintaining sobriety. The goal of CM is to weaken the influence of reinforcement obtained from using drugs and to substitute reinforcement with healthier activities and abstinence [7].

Motivational Enhancement Therapy (MET)
MET is a counseling approach that helps teenagers to resolve their ambivalence about engaging in treatment and ending their drug usage. This approach integrates Motivational Interviewing and assesses the teenager's level of motivation, as well as provides non-confrontational feedback in an empathic and directive manner. The adolescent is encouraged to say self-motivational statements in order to augment his/her motivation [7].

Twelve-Step Facilitation Therapy
This modality is designed to increase the likelihood that a teenager will become affiliated with a Twelve-step program. This program emphasizes the teenager's acceptance that life is unmanageable, that abstinence is needed, and that willpower alone may not help to overcome their addiction [2].

Narcotics Anonymous Twelve-Step Program
The Narcotics Anonymous Twelve-Step Program was founded in 1953 and is an addiction recovery organization created to help those combatting a narcotics addiction. It helps those struggling with an addiction to enhance their family relationships, overcome their addiction, increase social connectedness, identify hobbies and interests, encourages employment, as well as educational advancement. The Narcotics Anonymous Twelve-Step Program motivates members to draw on social supports in an alcohol and drug free setting in order to help promote and sustain a drug free life [2].

Brief Strategic Family Therapy (BSFT)
BSFT is a family system's approach, which demonstrates that one member's problem behaviors stem from unhealthy family interactions. During 12 to 16 sessions, the BSFT counselor builds rapport with each family member, observes how members behave, and helps the family to change negative interaction patterns [2].

Functional Family Therapy (FFT)
Involving family members is an integral part of helping to treat adolescents who are struggling with substance abuse issues, particularly Heroin. FFT combines a family systems view of family functioning, with behavioral techniques to help the family improve communication, resolve family problems, conflict resolution and parenting skills. The core techniques involve engaging families in the treatment process in order to enhance motivation for change, as well as to modify family members' behavior using Contingency Management techniques, behavioral contracts, and problem solving methods [7].

Multisystemic Therapy (MST)
MST is a comprehensive and intensive family and community based treatment that has been shown to be effective with teenagers struggling with severe substance abuse issues. In MST, the teenager's substance abuse is seen in terms of characteristics of the adolescent and his or her family, peers, school and neighborhood, including favorable attitudes towards drug usage, parenting, peers' attitudes towards drug usage, academic performance, or criminal subculture [2].

Buprenorphine and Methadone
Buprenorphine (Suboxone) and Methadone can be used in conjunction with counseling, in order to help teenagers gain sobriety, specifically from opioid addiction and Heroin. Buprenorphine helps to reduce opioid withdrawal symptoms, without producing dangerous side effects. It helps to activate and block opioid receptors in the brain. Methadone also helps to prevent withdrawal symptoms and helps to reduce cravings in opioid addicted individuals [7].

Assertive Continuing Care (ACC)
ACC is a home-based continuing care approach that uses positive and negative reinforcement to help shape behaviors, provide training in problem solving and communication skills, as well as assist teenagers in acquiring skills to engage in positive social activities [2].

Counseling Interventions and Treatment: Assisting Students Struggling with Truancy
Due to the fact that truancy can result in so many negative outcomes for youth, it is critical to address the issue of absenteeism in school before it evolves into truancy. The key to success is prevention and effective preventive strategies that keep youth engaged and connected to their school and community will help to prevent truancy and ultimately reduce the number of school dropouts.

Parental Involvement
Parents must be involved in the lives of their adolescents. The sooner that parents become involved in the process and in identifying the reasons behind their child's absenteeism, the greater the likelihood that truancy issues will be rectified. Schools and parents need to collaborate and work together in order to address issues of chronic absenteeism early on [13].

Coordinating Legal and School System Approaches
Having lawyers and judges coordinating preventative practices provide teenagers and their families a better understanding of the truancy process and emphasizes the importance of precourt involvement promotes rehabilitative rather than punitive measures. Contact between the courts, the adolescent, the family and the school fosters the importance of school attendance, as well as the consequences for truancy [13].

Mentorship/Case Management
Students who are struggling with truancy can greatly benefit from mentorship so that they have an opportunity to share their fears and struggles, as well as benefit from a strong support system. Having an advocate and mentor provides students with important resources, as well as offers them a sense of support and advocacy in order to increase their school connectedness and engagement [13].

Creating a Rigorous and Welcoming Environment for Students
Schools need to educate students about the importance of school attendance and the consequences of not earning a high school diploma. Schools also need to develop environments that celebrate students, help to stimulate intellectual curiosity, as well as foster an understanding and accepting atmosphere for all students in order for students to be engaged, challenged, and feel a sense of belonging [13].

Prevention Programs to Combat Truancy
Schools are encouraged to implement prevention programs to help students overcome truancy that include the elements of evaluation, communication/education, intervention and prevention recovery, and individualized assessments. Schools that can identify students who have absenteeism issues early on will be better able to help these students to improve their attendance and graduation rates [13].

Attendance Monitoring
Schools are encouraged to develop a monitoring system for attendance to identify the students who are missing school on a frequent basis. Effective monitoring helps educators to assist at-risk students from becoming chronically absent. Early-warning systems use routinely available data housed at the school that are good predictors of whether a student is likely to drop out of school [18]. Additionally, the National Center for School Engagement [19] indicates that attendance during the first 20 days of an academic period serves as an indicator for students who are likely to dropout or fail to graduate. They stipulate that students who miss 10% of instructional time in their first year of high school are more likely to dropout. Therefore, systems that track student attendance and indicate when students have missed a specific number of days affords pertinent information to administrators, teachers, counselors and parents that can be used to determine when to intervene in order to enhance student attendance.

Improving Student Mental Health
In order to reduce truancy, Kearney [20] proposed the use of clinical interventions. Many students who are struggling with truancy may also be struggling with anxiety or depression. Therefore, addressing mental health issues, referring students to seek outside counseling, educating parents and staff about mental health disorders, normalizing feelings and experiences for students, as well as discussing underlying reasons as to why students are reluctant to attend school, may also help to enhance their attendance rates [20].

Sanctions for Truancy
Schools need to reinforce to students and parents that there is a strict policy regarding absenteeism. Schools need to emphasize that if students miss a certain number of days, they will be in danger of failing a class or facing other consequences, as students need to be accountable for their choices and behaviors [21].

Suggestions for Future Research
There are several suggestions in regards to research that can be conducted in the future regarding Heroin addiction and its dire effects on students' lives. Longitudinal studies are needed to more closely examine which specific opiate leads to Heroin usage. In this regard, practitioners would be cognizant of educating adolescents regarding the dangers of particular opiates.
Moreover, research needs to be conducted on the school counseling strategies that have the most profound impact on enhancing engagement and student motivation, as these two variables are directly linked to substance usage and truancy. If school counselors recognize the evidence-based techniques that promote academic engagement, then they can implement these tactics in their school environment.
Continuing research to determine the underlying causes of truancy needs to be conducted. Many of the students who are chronically absent from school are experiencing mental health issues and may require a mental health screening and ultimately additional psychological services. Moreover, it would be advantageous to indicate the evidence-based practices that elicit the most positive outcomes for enhancing school attendance.
Lastly, conducting research as to the community based models for preventing and treating adolescents who are addicted to heroin would be beneficial to determine the systemic support that is needed.

Conclusion
Opiate addiction, specifically Heroin is rampant in today's society, due to its accessibility, affordability, and addictive nature. It is extremely harmful and results in lasting effects on students' academic performance, attendance rates, physical and mental health, and future endeavors. Research has shown that students who engage in substance use are less likely to achieve academic success, more likely to drop out, less likely to attend school, struggle with truancy and potentially engage in delinquent destructive behaviors.
In order to combat this epidemic, preventative and collaborative measures need to be implemented early on, to identify teenagers struggling with substance abuse and poor academic achievement. These students can benefit from developing healthy coping and communication skills rather than self-medicating to deal with their personal and familial challenges. School counselors are encouraged to utilize brief interventions that inspire, enlighten, and educate adolescents about the dangers of utilizing Heroin, as well as create collaborative school climates, that encourage parental involvement, monitor attendance, and offer mentorship programs to students who are struggling with addiction and truancy.
Developing a supportive, strength based, enlightening, and inclusive school environment is vital for helping students struggling with addiction or truancy issues. School counselors and other key stakeholders must educate students about the dangers of drug Evidence-based best practices need to be utilized in both school and mental health settings for the most effective techniques to be implemented with adolescents to combat their addiction. It is efficacious to take a holistic approach when working on preventing adolescents' Heroin usage from impeding upon their academic achievements and school attendance/connectedness, as this addiction can profoundly impact or ultimately destroy their lives.
On a broader scale, as a culture and society, we need to take an introspective look into the underlying reasons as to what is motivating adolescents to abuse substances, particularly Heroin. Adolescents may well be modeling the behaviors that many adults are displaying in our society, namely the use and abuse of illegal substances. It is of utmost significance that we address rather than minimize the catastrophic consequences of abusing legal and illegal substances.
usage, the consequences, as well as inspire students to achieve their potential by building upon their strengths and setting realistic goals that reflect their positive attributes. As educators, it is imminent to teach our youth about the importance of utilizing coping skills, communicating our concerns, understanding the concept of resilience, and working towards overcoming adversity, to strengthen self-discipline, integrity and character.
Family involvement is essential in that parents need to be educated and aware that their children's attendance, grades, peer affiliations, hobbies, physical health, and overall wellness are imperative, as these factors have a profound impact on the likelihood of drug usage, individual and academic success. Further, parents need to be cognizant of restricting their own medications and eliminating their children's access, particularly if they are opiates due to their alarming addictive nature.