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(see Figure to left).23 This trajectory speaks to the need to understand what drives youth drug use, identify current and emerging trends, and match programs and policies with local conditions so as to effectively reduce youth substance use. There are simultaneous conditions that converge to create a particularly dangerous circumstance for adolescents – drug use increases during a period of time when the brain is especially vulnerable to damage from drug use.24 During adolescence there is a significant reorganization of brain regions necessary for intellectual function, memory, emotional regulation, and decisionmaking.25,26 Drug use often disrupts normal brain development and can result in long-lasting negative consequences, including reduced academic achievement and increased risk of depression, anxiety, suicide, and substance use disorder (SUD) later in life. 27,28,29,30,31 Adolescent drug use can also cause persistent changes in brain32 structure and function. 33 A range of factors influence mental, emotional, and behavioral development in children and adolescents.34 These include societal, environmental, familial, and genetic dynamics. Social determinants of health (SDOH) play a critical role in overall health status35 and substance use, including opioid use.36 The Department of Health and Human Services (HHS) describes SDOH as the conditions in which people are born, grow, live, work and age, all of which affect a wide range of health risks and outcomes.37 Prevention initiatives, couples with social needs interventions, can be impactful across the lifespan, including and in particular for the prenatal period and throughout adulthood. More generally, social determinants include factors such as food and housing security, access to services and supports, income, lack of transporation, stable employment, education, and social inclusion. Studies suggest that roughly 30-percent to 55-percent of health outcomes are driven by SDOH, 38 and experiencing these social factors may increase levels of stress experienced which can elevate the risk of substance use.39 Peers are often identified as an influence to youth substance use, but SDOH also contribute to youth substance use trends and negative health outcomes associated with substance use. Parental influence can deter youth use or unintentionally enable youth use. For example, strong parental monitoring, and communicating « « « « « « 18 NATIONAL DRUG CONTROL STRATEGY clear expectations about risk and positive role modeling, can reduce use in youth. Conversely, parents can unintentionally enable underage alcohol use and/or youth drug use by not securing alcohol and prescription drugs.40,41 Unstable housing is associated with higher rates of substance use among youth, while some families and caregivers who receive income supplements see a significant decrease in adolescent substance use.42,43,44 Addressing SDOH is necessary to help improve health and reduce inequities in health outcomes—including in youth substance use, and this effort will require all sectors of Government and society to identify and improve factors that influence health outcomes. Another factor to consider in understanding the origins of substance use among youth is the impact of adverse childhood experiences (ACEs), their connection to SDOH, and equity. ACEs are potentially traumatic events that occur during childhood and adolescence (between the ages of 0-17 years). Large scale population based studies have shown that individuals with more ACEs are likely to have health problems later in life. Types of ACEs include abuse and neglect, experiencing or witnessing violence, experiencing divorce of parents, a family member in jail, parental mental health or SUD, having a family member or caregiver attempt or die by suicide, and chronic poverty.45,46,47Recently, researchers have included experiences with racism, bullying, and community violence as traumatic experiences that can impact health and wellbeing.48 While nearly 61 percent of adults surveyed report they experienced at least one type of ACE, women and most racial minority groups were more likely to have experienced four or more ACEs. The link between ACEs and illicit substance use has been identified in a number of studies.49,50 The more ACEs a child experiences, the more likely the child is to d develop a chronic disease, poor academic achievement, and/or illicit substance use.51 Compared with people with no ACEs, individuals with more than five ACEs were seven to ten times more likely to report problems with illicit drug use.52,53 It is possible to prevent youth exposure to ACEs, and to reduce the harms associated with ACEs among individuals who have already experienced them.54 A coordinated effort to address SDOH will improve individual and population health, advance health equity, and decrease youth exposure to ACEs. The goal of substance use prevention efforts is to prevent and/or delay the first use of substances. Research shows that early age of onset is an important predictor for the development of SUD later in life.55,56 Research also indicates that the majority of individuals who have SUD started using substances before age 18 and are relatively more likely to have developed SUD by age 20.57 The age of onset is therefore an important predictor for the development of SUDlater in life.58,59,60 Youth 

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