Alcohol as a gateway drug: a study of US 12th graders

Do traumatic events and substance use co-occur during adolescence? Testing three causal etiologic hypotheses

BACKGROUND

Why do potentially traumatic events (PTEs) and substance use (SU) so commonly co-occur during adolescence? Causal hypotheses developed from the study of posttraumatic stress disorder (PTSD) and substance use disorder (SUD) among adults have not yet been subject to rigorous theoretical analysis or empirical tests among adolescents with the precursors to these disorders: PTEs and SU. Establishing causality demands accounting for various factors (e.g. genetics, parent education, race/ethnicity) that distinguish youth endorsing PTEs and SU from those who do not, a step often overlooked in previous research.

METHODS

We leveraged nationwide data from a sociodemographically diverse sample of youth (N = 11,468) in the Adolescent Brain and Cognitive Development Study. PTEs and substance use prevalence were assessed annually. To account for the many pre-existing differences between youth with and without PTE/SU (i.e. confounding bias) and provide rigorous tests of causal hypotheses, we linked within-person changes in PTEs and SU (alcohol, cannabis, nicotine) across repeated measurements and adjusted for time-varying factors (e.g. age, internalizing symptoms, externalizing symptoms, and friends' use of substances).

RESULTS

Before adjusting for confounding using within-person modeling, PTEs and SU exhibited significant concurrent associations (βs = .46-1.26, ps < .05) and PTEs prospectively predicted greater SU (βs = .55-1.43, ps < .05) but not vice versa. After adjustment for confounding, the PTEs exhibited significant concurrent associations for alcohol (βs = .14-.23, ps < .05) and nicotine (βs = .16, ps < .05) but not cannabis (βs = -.01, ps > .05) and PTEs prospectively predicted greater SU (βs = .28-.55, ps > .05) but not vice versa.

CONCLUSIONS

When tested rigorously in a nationwide sample of adolescents, we find support for a model in which PTEs are followed by SU but not for a model in which SU is followed by PTEs. Explanations for why PTSD and SUD co-occur in adults may need further theoretical analysis and adaptation before extension to adolescents.

Nicotine and Alcohol Use as Predictors of Recreational Cannabis Use in Adolescence: A Systematic Review and Narrative Synthesis

Background: The prevalence of recreational cannabis use among adolescents is a growing public health concern due to its link to short- and long-term adverse effects on adolescents' wellbeing, physical health, mental health, and interpersonal behaviors. Method: Five databases were searched from inception to March 17, 2023, for exposure (nicotine product, alcohol) and outcome (recreational cannabis) in adolescents (persons aged 10-19 years). The studies were screened independently by two reviewers, and the quality of the studies was assessed with Newcastle Ottawa and AXIS tool. PRISMA guidelines were employed in this review. Result: Twenty-one (21) studies involving 2,778,406 adolescents were included in the appraisal and heterogeneity was found among these studies. Ascertainment bias was commonly detected in thirteen (13) of the included studies. Among the substances examined as potential exposures, nicotine-product use emerged as a significant factor associated with future cannabis use among adolescents, particularly in mid-adolescence and in places where recreational cannabis use has been legalized. Conclusion: Current evidence suggests an association between nicotine-product use and subsequent recreational cannabis use among adolescents. However, further research is needed to establish causality between exposure to nicotine substances and the use of recreational cannabis within this age demographic. Additionally, there is a need for the development of prevention programs and targeted policies that continuously inform and update this vulnerable sub-population about the risks associated with cannabis use for leisure.

[Binge drinking in early adolescence : Results of the "Präventionsradar" from 2016 to 2023]

INTRODUCTION

In Germany, no other psychotropic substance is consumed as often and in such large quantities during adolescence as alcohol. This work aims to examine trends in binge drinking in early adolescence from 2016 to 2023.

METHOD

Based on seven waves of the "Präventionsradar," which is a school-based epidemiological study in lower secondary education, the lifetime as well as the 30-day prevalence of binge drinking (for girls 4, for boys 5 alcoholic drinks on one occasion) were determined for the period from 2016 to 2023 for 12- to 15-year-olds.

RESULTS

The analyses were based on 44,713 questionnaires. The sex ratio was balanced (50% female), and the mean age was 13.8 years (SD = 1.02). From 2016 to 2023, lifetime prevalence of binge drinking increased significantly by 3.6 percentage points to 25.3% (95% confidence interval 24.1-26.5). The 30-day prevalence did not change statistically during the observation period and was 15.9% (95% CI 14.9-16.9) in 2023. Compared to the previous year, both lifetime prevalence (-2.5 percentage points) and 30-day prevalence of binge drinking (-3.5 percentage points) decreased significantly in the first year of the COVID-19 pandemic (2020/2021) and increased again in subsequent years. Systematic differences between the genders could not be found.

DISCUSSION

The German Youth Protection Act does not allow legal access to alcohol for the age group under study. Against this background, it is worrying that every fourth adolescent already reports experiences of binge drinking. Consistent structural and behavioral prevention measures are necessary to curb the high prevalence of binge drinking in childhood and adolescence.

Alcohol and cannabis use among rural university students: A quantitative analysis of barriers to care, student resilience, and school climate

Objective: This article examines impacts of student resilience, school climate, and barriers to mental health care on problematic drinking behavior and cannabis use among rural university students. Participants: A total of 948 students from a public university in a southeastern state that completed the 2019-2020 Healthy Minds Study. Methods: Cross-tabulations and multivariate logistic regression analyses were employed to test study hypotheses. Results: Students who binge drink are more likely to engage in problematic drinking behaviors than students who do not binge drink; students who engage in problematic drinking are more likely to use cannabis than those who do not engage in problematic drinking. As students face more barriers to mental health care, they are more likely to engage in problematic drinking and cannabis use; students who are more resilient are less likely to engage in problematic drinking. Conclusions: To promote health and wellbeing, universities must understand factors that impact substance use among students.

"She gives it to her child who doesn't even talk": a qualitative exploration of alcohol and drug use among primary school-age children in Uganda

BACKGROUND

There is little research on alcohol and other drugs (AOD) use by school-age children in low-resource settings like Uganda. Including the voices of children in research can inform prevention and early intervention efforts for those at risk of AOD use. The aim of this study was to understand the perspectives of children aged 6 to 13 years regarding AOD in Uganda.

METHODS

This qualitative study was conducted in Mbale district, Uganda from February to March 2020. Eight focus group discussions (FGDs) were conducted with 56 primary school-age children, stratified by age (6-9 and 10-13 years), sex (male and female), and school status (in school and out of school). All FGDs were conducted in either Lumasaaba or Luganda. The FGDs were audio-recorded, transcribed verbatim, and translated into English. Data were coded, and overarching themes were identified using thematic framework analysis.

RESULTS

Two themes identified were (1) Children's perceptions and experiences with AODs. The participants understood alcohol by its consistency, colour, odour, and by brand/logo. They described the types and quantities of AOD consumed by school-age children, brewing processes for homemade alcoholic drinks, and short and long-term consequences of the use of alcohol. (2) Contributing factors to childhood drinking included: Stress relief for children who experienced multiple adversities (orphaned, poverty-stricken, and hailing from broken homes), fitting in with friends, influence from families, and media exposure that made alcohol look cool. Children would start drinking at an early age) or were given alcohol by their parents, sometimes before they could start talking. In the community, alcohol and other drugs were cheap and available and children could drink from anywhere, including in the classroom.

CONCLUSIONS

Children eligible for primary education in Uganda can easily access and use AOD. Several factors were identified as contributing to alcohol and other drug use among children, including availability and accessibility, advertising, lack of parental awareness and supervision, peer influence, adverse childhood experiences, socioeconomic factors, and cultural norms. There is a need for multi-sectoral action for awareness of childhood AOD use and deliberate consideration of children in the planning, design, and implementation of research, policies, and programs for prevention and early intervention.

Prevalence and correlates of substance use among school-going adolescents (11-18years) in eight Sub-Saharan Africa countries

BACKGROUND

Substance use constitutes a major public health issue especially among adolescents as it has associated adverse behavioural, health, social and economic outcomes. However, there is a paucity of comprehensive evidence on the prevalence and associated factors of substance use (alcohol, marijuana and amphetamine) among school-going adolescents in sub-Saharan Africa (SSA). This study examined the magnitude of substance use and its associated factors among school-going adolescents in eight eligible sub-Saharan Africa countries.

METHODS

Data for the study were obtained from the Global School-based Health Survey (2012-2017) of 8 countries in SSA (N = 16,318).

RESULTS

Findings showed overall prevalence rates of 11.3% (95%CI = 10.8 - 11.8%), 2% (95%CI = 1.8 - 2.2%) and 2.6% (95%CI = 2.3 - 2.9%) for current alcohol use, current marijuana use and lifetime amphetamine use, respectively between 2012 and 2017. Late adolescence (15-18 years), being male, anxiety, bullying, fighting, truancy, having close friends, current cigarette smoking and tobacco use are significant risk factors for alcohol use. Anxiety, truancy, current cigarette smoking, tobacco use and suicidal attempt are significant risk factors for marijuana use. Anxiety, bullying, truancy, current cigarette smoking, tobacco use and suicidal attempt are significant risk factors for amphetamine use. Parental knowledge of activity, supervision and respect of privacy are significant protective factors of substance use.

CONCLUSION

There is the need for comprehensive public health policies beyond school-based psycho-behavioural interventions targeting the significant risk factors of substance use among school-going adolescents in SSA.

Socioeconomic Inequalities in Alcohol and Tobacco Consumption: A National Ecological Study in Mexican Adolescents

Alcohol and cigarettes are the psychoactive substances that adolescents use most frequently. When both addictions are combined, they carry the worst burden of disease globally. The objective of this study was to identify whether socioeconomic factors correlate with alcohol and tobacco consumption in Mexican adolescents aged 10 years or more and to establish the relationship in the consumption between the two substances. This ecological study utilized data describing alcohol and tobacco consumption among adolescents aged 10-16 years (n = 48,837 ≈ N = 11,621,100). Having ever consumed any alcohol-containing beverage constituted alcohol consumption. Smoking a cigarette within 30 days constituted cigarette consumption. For both variables, the state-level percentages reported in the survey were used. Diverse socioeconomic variables were collected from official sources. Data on the prevalence of tobacco use and alcohol consumption were entered into an Excel database estimated for each of the states of the Mexican Republic, as well as the socioeconomic variables. We performed the analysis using Stata 14. Consumption prevalence was 15.0% for alcohol and 4.2% for tobacco. Alcohol consumption was not correlated with any studied socioeconomic variable (p > 0.05). The prevalence of tobacco consumption among elementary school students correlated (p < 0.05) with the portion of the population living in private dwellings without sewage, drainage, or sanitation (r = 0.3853). The prevalence of tobacco consumption among middle-school adolescents correlated with the portion of the employed population that earned up to two minimum wages (r = 0.3960), the percentage in poverty by income 2008 (r = 0.4754) and 2010 (r = 0.4531), and the percentage in extreme poverty by income 2008 (r = 0.4612) and 2010 (r = 0.4291). Positive correlations were found between tobacco consumption and alcohol consumption among both elementary (r = 0.5762, p=0.0006) and middle-school children (r = 0.7016, p=0.0000). These results suggest that certain socioeconomic factors correlate with tobacco consumption but not alcohol consumption. A correlation between alcohol consumption and tobacco consumption was observed. The results can be used for developing interventions in adolescents.

First use of cannabis compared to first use of alcohol and tobacco: Associations with single and poly-substance use behavior

INTRODUCTION

Young adults report high rates of current cannabis use. The proliferation of legalized cannabis in the US has led to greater access and availability, causing cannabis to become the new "gateway" drug. This study examined the prevalence of trying cannabis before alcohol or tobacco and the association of initiation with cannabis first with single and poly-substance use in young adults.

METHODS

METHODS: Data were analyzed from young adults (n=8062) in Waves 1 through 5 (2013-2019) of the Population Assessment of Tobacco and Health study who had ever tried alcohol, cannabis, or tobacco and provided age at first use of these substances. Weighted multivariable models examined associations between cannabis initiation before, at the same age, or after initiating alcohol or tobacco use with past 30-day substance use (alcohol, cannabis, tobacco, poly-substance use) in a subsequent wave (Waves 2-5).

RESULTS

Initiating cannabis before alcohol and tobacco (6%) was rare. In adjusted regression models, initiating cannabis before alcohol and tobacco was associated with increased odds of past 30-day cannabis use, past 30-day tobacco use, and past 30-day polysubstance use and decreased odds of past 30-day alcohol use. Initiating cannabis at the same age as either alcohol or tobacco, or trying cannabis after these substances was associated with increased odds of all substance use outcomes.

CONCLUSIONS

Cannabis initiation before alcohol and tobacco is uncommon and may even protect against future alcohol use. Deterring cannabis initiation with multiple substances could have public health benefits.

Early-onset prescription drug misuse in Indiana youth

BACKGROUND

Based on 2018 national estimates, approximately 5-10% of youth between the ages of 12-17 report past year prescription drug misuse (PDM) in the United States. PDM among adolescents is associated with negative health outcomes and risk behaviors. The current study examined both the prevalence of PDM among diverse groups of adolescents and the association of alcohol and cigarette use with early PDM.

METHODS

Data came from the cross-sectional state-based 2018 Indiana Youth Survey of students from grades 6-12, ranging in age from 10 to 17 years (n = 80,926). Lifetime PDM, alcohol, and cigarettes were assessed by self-report, including ages at first use. A series of analyses were conducted separately for non-Hispanic Black, non-Hispanic White, and Hispanic students. We estimated the prevalence of PDM. Likelihood of PDM was estimated using the Kaplan-Meier survivor function. Cox proportional hazards regression models estimated age at first PDM from ages at first use of alcohol and cigarettes.

RESULTS

Three percent of non-Hispanic Black, 4% of non-Hispanic White, and 5% of Hispanic students reported PDM. Onset of smoking was associated with first PDM across adolescence for all groups. Onset of drinking was associated with first PDM among Hispanic students across adolescence. For Non-Hispanic Black and Non-Hispanic White students, likelihood of PDM was most pronounced during very early adolescence.

CONCLUSIONS

Onset of alcohol and cigarette use were associated with of PDM among Indiana youth, suggesting that interventions aimed at preventing early smoking and drinking may also reduce PDM among youth.

Longitudinal associations between adolescent out-of-school time and adult substance use

INTRODUCTION

Based on Bronfenbrenner's bioecological theory and Bornstein's specificity principle, the purpose of this study was to examine adolescents' time in out-of-school settings as a precursor of three types of problematic substance use in adulthood (i.e., binge drinking, regular marijuana use, and use of illicit drugs).

METHOD

Adolescents (N = 978) reported the time they spent in four common out-of-school settings at ages 15 and 18: unsupervised time with peers, organized sports, other organized activities, and paid employment. At age 26, participants reported binge drinking, marijuana use, and illicit drug use.

RESULTS AND CONCLUSIONS

Adolescents' time in out-of-school settings during high school predicted age 26 substance use over and above family and adolescent factors, including adolescents' substance use during high school. Adolescents' unsupervised time with peers increased the odds and frequency of binge drinking and regular marijuana use at age 26. Time in high school organized sports increased the odds of binge drinking at age 26, but not marijuana or illicit drug use. Time spent in other organized activities, such as community service and the arts, lowered the odds of illicit drug use whereas paid employment in high school was not related to age 26 substance use. Aligned with Bornstein's specificity principle, time spent in specific out-of-school settings during adolescence were differentially related to substance use problems in early adulthood, with some activities serving as a risk factor and other activities serving as a protective factor for young adults.

Parenting style and its effect on eating disorders and substance abuse across the young population

This article attempts to examine the occurrence of two behavioural changes, namely, substance abuse and eating disorders in order of onset mediated by ineffective parenting styles during young age. The four parenting styles and their consequential behavioural adverse effects are taken as the focal point of this study and are synthesized to provide an outlook on the status of ineffective parenting and deviant offspring behaviours. A review of literature was primarily undertaken to examine the characteristic features of ineffective parenting. A causal relationship was then drawn between the onset of behavioural disorders with an emphasis on substance abuse and eating disorders, along the parenting spectrum. We probed into the order and directionality of the offspring behavioural changes against ineffective parenting. The current available data shows the superimposition of the parenting style spectrum on a bell-shaped distribution of behavioural outcomes as exemplified by authoritarian, permissive and neglectful parenting as a prime determinant of several disorders among the young age; parenting styles being at the extremities of the parenting spectrum. The sweet spot of parenting, mainly associated to the authoritative approach, bears the most positive effect on the growing child. The extreme ends of parenting as per the varying degree of responsiveness and demandingness, generally observed in authoritarian and neglectful parenting precipitate concomitant deviant behaviours cascading from one another; intricately linking substance abuse and eating disorders. A number of studies describe the isolated effects of ineffective parenting on the development of substance abuse and eating disorders during the adolescent period. However, the relationship between both eating disorders and substance abuse is underplayed and need to be stressed upon to tailor behaviour-specific targeted therapies and restore the normalcy of these altered behaviours.

How the parenting style adopted can lead to a concurrent amalgam of disordered eating patterns and substance abuse.

How disordered eating behaviours and substance abuse are initiated as coping strategies to deal with the consequences of poor parenting.

Isolation of specific risk factors to deter the development of those deviant behaviours in addition to improvement of parenting methods.

Analysis of related factors for adolescents' intention to use alcohol in Korea

The harmful effects of alcohol consumption by adolescents have been increasingly emphasized. Thus, it is necessary to identify individual and environmental factors that encourage drinking. This study investigated factors associated with the sustainable use of alcohol (SUA) in adolescents who consume alcohol, and the possibility of future drinking (PFD) in non-drinking adolescents. Data from "The Adolescents Awareness Survey of Alcohol Encouraging Environment" by the Ministry of Health and Welfare and the Korea Health Promotion Institute (2017) were used. The survey was completed by 1,038 participant, selected through a proportional allocation extraction method, who were aged 13-18 years and lived in five cities with a population of over 1 million. The factors associated with SUA included gender (β = 0.634, p = 0.004), grade (8th β = 1.591, p<0.001, 9th β = 1.674, p<0.001, 10th β = 1.497, p = 0.001, 11th β = 1.041, p = 0.004, 12th β = 2.610, p<0.001), drinking alone (β = -2.147, p = 0.002), liquor commercial (β = 1.644, p<0.001), ease of alcohol purchase (β = 1.541, p = 0.025), parent's recommendation for drinking (β = 1.084, p<0.001), not knowing the mother's education level (β = -0.685, p = 0.045), positive expectancy of drinking (β = 0.141, p<0.001), number of pubs (β = 0.303, p = 0.002), internet game cafes (β = 0.456, p = 0.019), and karaokes (β = -0.098, p = 0.023) in the community. The factors associated with the PFD in non-drinkers were grade (8th β = 0.531, p = 0.024, 10th β = 0.717, p = 0.035, 12th β = 1.882, p = 0.001), liquor commercial (β = -1.355, p<0.001), parent's recommendation for drinking (β = 0.783, p = 0.020), positive expectancy of drinking (β = 0.139, p<0.001), and relationship with the father (β = 0.072, p = 0.033). Multidimensional interventions, including those by individuals, parents, peers, and local communities, are needed to prevent SUA and the PFD in adolescents.

College students mandated to substance use courses: Age-of-onset as a predictor of contemporary polysubstance use

Objective: College campuses report alcohol and other drug policy violations as the most frequent reason students receive disciplinary referrals and, thus, are mandated to programming. This study sought to determine predictors of mandated students' alcohol use frequency, and the likelihood of early-onset alcohol using college students enrolled in mandated programming engaging in current polysubstance use. Methods and participants: Employing a purposive sampling method, n = 822 participants were recruited from a pool of students who violated their university's alcohol policy between October 2019 and July 2021. Results: Data analysis revealed early-onset alcohol use (p < .001), gender ID (p < .01), Greek Affiliation (p < .001), ethnicity (p < .05), and perceived norms (p < .001) significantly predicted alcohol frequency. Analysis also revealed engaging in early-onset alcohol use significantly predicted current participation in polysubstance use (p < 0.01), outside of controls. Conclusions: University programs should consider exploring polysubstance use targeted interventions to mitigate these harmful behaviors and associated negative consequences.

Loot boxes and problem gambling: Investigating the "gateway hypothesis"

Loot boxes are purchasable items in video games with a chance-based outcome. They have attracted substantial attention from academics and legislators over recent years, partly because of associations between loot box engagement and problem gambling. Some researchers have suggested that loot boxes may act as a gateway into subsequent gambling and/or problem gambling. However, such "gateway effects" have not been formally investigated. Using a survey of 1102 individuals who both purchase loot boxes and gamble, we found that 19.87% of the sample self-reported either "gateway effects" (loot boxes causally influencing subsequent gambling) or "reverse gateway effects" (gambling causally influencing subsequent loot box engagement). Both subsets of participants had higher scores for problem gambling, problem video gaming, gambling-related cognitions, risky loot boxes engagement, and impulsivity. These individuals also had a tendency for higher loot box and gambling spend; suggesting that potential gateway effects are related to measurable risks and harms. Moreover, the majority of participants reporting gateway effects were under 18 when they first purchased loot boxes. Content analysis of free text responses revealed several reasons for self-reported gateway effects, the most frequent of which were sensation-seeking, normalisation of gambling-like behaviours, and the addictive nature of both activities. Whilst the cross-sectional nature of our findings cannot conclusively establish directions of causality, thus highlighting the need for longitudinal research, we conclude that there is a case for legislation on loot boxes for harm minimisation purposes.

Magnitude of Substance Use and Its Associated Factors Among the Medical Students in India and Implications for Medical Education: A Narrative Review

BACKGROUND

Medical students are at an increased risk of developing substance use and related problems (SURP) because of the inherent stress associated with the professional medical course apart from the developmental risk factors. However, this is under-researched. Moreover, a comprehensive review on the prevalence of SURP among the medical undergraduates (UGs) and associated factors is lacking from India. To fill this gap, the current research work is aimed to review the existing literature on the magnitude of the SURP among UGs of India and its determinants.

METHODS

PubMed, Medline, and Google Scholar databases were searched for the original articles studying the prevalence of SURP among medical UGs of India, published from inception till date. Non-original articles, studies on behavioral addictions, and those not directly assessing the prevalence of SURP among the medical UGs were excluded.

RESULTS

A total of 39 studies were found eligible for the review. Alcohol (current use: 3.2%-43.8%), followed by tobacco (3.7%-28.8%) and cannabis (1.6%-15%), were the common substances used by the medical students. Among the females, an increasing trend of substance use, particularly of nonprescription sedatives (even higher than males), alcohol, and smoking, was seen. Family history, peer pressure, transition from school to college life, and progression in the medical course were important associated factors.

CONCLUSION

Sensitizing medical students and college authorities, increasing the duration of training on SURP in medical curricula, and providing psychological support for the students with SURP could address this issue.

Attention deficit hyperactivity disorder symptoms and cannabis use after one year among students of the i-Share cohort

Background

Cannabis use in university students is associated with academic achievement failure and health issues. The objective of the study was to evaluate the association between attention deficit hyperactivity disorder (ADHD) symptoms and cannabis use after 1 year among students according to previous cannabis use.

Methods

Students in France were recruited from February 2013 to July 2020 in the i-Share cohort. 4,270 participants were included (2,135 who never used cannabis at inclusion and 2,135 who did). The Adult ADHD Self-Report Scale (ASRS) was used to assess ADHD symptoms at inclusion. Cannabis use frequency was evaluated 1 year after inclusion. Multinomial regressions were conducted to assess the association between inclusion ADHD symptoms and cannabis use after 1 year.

Results

Increase in ASRS scores was linked with a greater probability to use cannabis after 1 year and to have a higher cannabis use frequency (once a year—once a month adjusted odds ratio [OR]: 1.24 (1.15–1.34), more than once a month adjusted OR: 1.43 (1.27–1.61)). Among participants who never used cannabis at inclusion, this association disappeared (once a year—once a month adjusted OR: 1.15 (0.95–1.39), more than once a month adjusted OR: 1.16 (0.67–2)) but remained in participants who ever used cannabis at inclusion (once a year—once a month adjusted OR: 1.17 (1.06–1.29), more than once a month adjusted OR: 1.35 (1.18–1.55)).

Conclusions

High levels of ADHD symptoms in students could lead to continued cannabis use rather than new initiations.

Using Mendelian randomization to explore the gateway hypothesis: possible causal effects of smoking initiation and alcohol consumption on substance use outcomes

BACKGROUND AND AIMS

Initial use of drugs such as tobacco and alcohol may lead to subsequent more problematic drug use-the 'gateway' hypothesis. However, observed associations may be due to a shared underlying risk factor, such as trait impulsivity. We used bidirectional Mendelian randomization (MR) to test the gateway hypothesis.

DESIGN

Our main method was inverse-variance weighted (IVW) MR, with other methods included as sensitivity analyses (where consistent results across methods would raise confidence in our primary results). MR is a genetic instrumental variable approach used to support stronger causal inference in observational studies.

SETTING AND PARTICIPANTS

Genome-wide association summary data among European ancestry individuals for smoking initiation, alcoholic drinks per week, cannabis use and dependence, cocaine and opioid dependence (n = 1749-1 232 091).

MEASUREMENTS

Genetic variants for exposure.

FINDINGS

We found evidence of causal effects from smoking initiation to increased drinks per week [(IVW): β = 0.06; 95% confidence interval (CI) = 0.03-0.09; P = 9.44 × 10-06 ], cannabis use [IVW: odds ratio (OR) = 1.34; 95% CI = 1.24-1.44; P = 1.95 × 10-14 ] and cannabis dependence (IVW: OR = 1.68; 95% CI = 1.12-2.51; P = 0.01). We also found evidence of an effect of cannabis use on the increased likelihood of smoking initiation (IVW: OR = 1.39; 95% CI = 1.08-1.80; P = 0.01). We did not find evidence of an effect of drinks per week on other substance use outcomes, except weak evidence of an effect on cannabis use (IVW: OR = 0.55; 95% CI = 0.16-1.93; P-value = 0.35). We found weak evidence of an effect of opioid dependence on increased drinks per week (IVW: β = 0.002; 95% CI = 0.0005-0.003; P = 8.61 × 10-03 ).

CONCLUSIONS

Bidirectional Mendelian randomization testing of the gateway hypothesis reveals that smoking initiation may lead to increased alcohol consumption, cannabis use and cannabis dependence. Cannabis use may also lead to smoking initiation and opioid dependence to alcohol consumption. However, given that tobacco and alcohol use typically begin before other drug use, these results may reflect a shared risk factor or a bidirectional effect for cannabis use and opioid dependence.

Risky Alcohol Use and Comorbidity in a Swedish Adolescent Emergency Psychiatric Inpatient Population

INTRODUCTION

Underage drinking is associated with poor mental health. Early detection for risky alcohol use is recommended, although less implemented in adolescent care. The objective of this study was to investigate the prevalence of risky alcohol use and psychiatric comorbidity.

METHODS

Over a nine-month period, 145 eligible adolescents admitted to the child and adolescent emergency unit in Malmö, Sweden, were offered computerized screening with Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) and Drug Use Disorders Identification Test (DUDIT).

RESULTS

Ninety-six patients (73 girls and 23 boys) agreed to participate. The most common diagnoses were affective disorder (41%) and anxiety disorder (27%). Risky alcohol use was found among 33% of the girls and 22% of the boys (p=0.45) and did not differ between diagnostic categories. There was a positive correlation between AUDIT-C and DUDIT scores (p=0.019). Among adolescents with risky alcohol use, 33% of the girls and 60% of the boys also had a risky drug use. Conversely, 47% of the girls and 60% of the boys with risky drug use also had a risky alcohol use.

CONCLUSION

In view of the poor prognosis of risky alcohol use in adolescents, alcohol and drug habits should be assessed when adolescents seek psychiatric emergency care.

Illicit Drug Use Pattern, Health-Risk Behaviors, and Social Contexts Among Indonesian Students

Health-risk behaviors (smoking, alcohol consumption, and premarital sex) among Indonesian students are important issues. Understanding the association of these health-risk behaviors and adolescents’ social contexts (family, peers, and neighborhood characteristics) to illicit drug use is required to develop strategies in preventing illicit drug use in Indonesia. The study used a multi-stage cluster random sampling method to collect data from the 2016 National Narcotics Survey of Indonesian students. The sample included 31,439 students. The result shows that the illicit drug use pattern was different from previous studies: the most prevalent was at the senior high school level. Multiple logistic regression analyses showed that smoking, alcohol consumption, premarital sex, peers, sex, family, and neighborhood were associated with illicit drug use. The study highlighted the importance of health-risk behaviors, social contexts of adolescents, and the illicit drug use pattern as considering factors in developing strategies to reduce illicit drug use prevalence.

Chronic alcohol exposure during critical developmental periods differentially impacts persistence of deficits in cognitive flexibility and related circuitry

Cognitive flexibility in decision making depends on prefrontal cortical function and is used by individuals to adapt to environmental changes in circumstances. Cognitive flexibility can be measured in the laboratory using a variety of discrete, translational tasks, including those that involve reversal learning and/or set-shifting ability. Distinct components of flexible behavior rely upon overlapping brain circuits, including different prefrontal substructures that have separable impacts on decision making. Cognitive flexibility is impaired after chronic alcohol exposure, particularly during development when the brain undergoes rapid maturation. This review examines how cognitive flexibility, as indexed by reversal and set-shifting tasks, is impacted by chronic alcohol exposure in adulthood, adolescent, and prenatal periods in humans and animal models. We also discuss areas for future study, including mechanisms that may contribute to the persistence of cognitive deficits after developmental alcohol exposure and the compacting consequences from exposure across multiple critical periods.

Acceptance of Drug Use Mediates Future Hard Drug Use Among At-Risk Adolescent Marijuana, Tobacco, and Alcohol Users

Alternative high school (AHS) students typically report higher levels of alcohol and other drug use compared to students attending traditional high schools. Greater use of such drugs as heroin, methamphetamines, and cocaine in this at-risk population may be driven, in part, by a greater latitude of acceptance toward substance use in general, which may accelerate the transition from gateway drugs to hard drugs. Seven hundred seventy-seven adolescents (mean age 16.6; 56% female) were recruited from alternative high schools throughout Southern California. To understand the factors that may lead AHS students to use hard drugs, a model was tested in order to determine if AHS students' latitude of acceptance toward substance use was a mediator between the relationship of past use of gateway drugs and future use of hard drugs. Latitude of acceptance was found to be a statistically significant mediator of future hard drug use (b = 0.03, 95% confidence intervals = 0.01 to 0.05) among gateway drug users. An individual's latitude of acceptance to various drug use behaviors may be consistent with societal norms. However, after exposure to, or use of, gateway drugs, attitudes that are more permissive toward hard drug use may be encountered, the acceptance of hard drugs may expand, and the use of hard drugs may escalate. Interventions designed to reduce the use of hard drugs among at-risk youth may be more persuasive by crafting messages that are within the latitude of acceptance of the target population and prevent the acceptance of hard drug use.

Plausibility of patient-centred care in high-intensity methadone treatment: reflections of providers and patients

Background

Patients with opioid use disorder (OUD) often have complex health care needs. Methadone is one of the medications for opioid use disorder (MOUD) used in the management of OUDs. Highly restrictive methadone treatment—which requires patient compliance with many rules of care—often results in low retention, especially if there is inadequate support from healthcare providers (HCPs). Nevertheless, HCPs should strive to offer patient-centred care (PCC) as it is deemed the gold standard to care. Such an approach can encourage patients to be actively involved in their care, ultimately increasing retention and yielding positive treatment outcomes.

Methods

In this secondary analysis, we aimed to explore how HCPs were applying the principles of PCC when caring for patients with OUD in a highly restrictive, biomedical and paternalistic setting. We applied Mead and Bower’s PCC framework in the secondary analysis of 40 in-depth, semi-structured interviews with both HCPs and patients.

Results

We present how PCC's concepts of; (a) biopsychosocial perspective; (b) patient as a person; (c) sharing power and responsibility; (d) therapeutic alliance and (e) doctor as a person—are applied in a methadone treatment program. We identified both opportunities and barriers to providing PCC in these settings.

Conclusion

In a highly restrictive methadone treatment program, full implementation of PCC is not possible. However, implementation of some aspects of PCC are possible to improve patient empowerment and engagement with care, possibly leading to increase in retention and better treatment outcomes.

Within- and between-person associations with drug use disorder among adolescents and emerging adults presenting to an urban emergency department

BACKGROUND

The distinction between within- and between-person associations with drug use disorder (DUD) has implications for intervention targets and content. We used longitudinal data from youth entering an urban emergency department (ED) to identify factors related to changes in DUD diagnosis, with particular emphasis on alcohol use.

METHODS

Research staff recruited youth age 14-24 (n = 599) reporting any past six-month drug use from a Level-1 ED; participants were assessed at baseline and four biannual follow-ups. Participants self-reported validated measurements of peer/parental behaviors, violence/crime exposure, drug use self-efficacy, and alcohol use. Research staff performed diagnostic interviews for DUD with nine substances, post-traumatic stress disorder (PTSD), and major depressive disorder (MDD). We used repeated measures logistic regression models with person-level covariate means, and person-mean-centered covariates, as separate variables, to separate within- and between-person covariate effects.

RESULTS

Among 2,630 assessments, 1,128 (42.9 %) were DUD diagnoses; 21.7 % were co-diagnoses with multiple drugs. Positive (aOR = 0.81, 95 %CI:[0.70, 0.94]) and negative (aOR = 1.73, 95 %CI:[1.45, 2.07]) peer behaviors related to DUD, primarily through between-person effects. Parental support (aOR = 0.92, 95 %CI:[0.83, 0.99]), community violence/crime (aOR = 1.28, 95 %CI:[1.14, 1.44]), PTSD/MDD diagnosis (aOR = 1.36, 95 %CI:[1.04, 1.79]), and alcohol use quantity (aOR = 1.06, 95 %CI:[1.02, 1.11]) were associated with DUD, showing primarily within-person effects. Other factors, such as interpersonal violence involvement (aOR = 1.47, 95 %CI:[1.21, 1.78]), showed both within- and between-person effects.

CONCLUSIONS

DUD is prevalent in this population, and within-person changes in DUD are predictable. Within-person effects suggest the importance of addressing escalating alcohol use, enhancing parental support, crime/violence exposure, and other mental health diagnoses as part of DUD intervention.

The Prevalence of Substance Misuse and its Effects among Omani College Students: A Cross-sectional Study

Objectives

Many studies have confirmed that the use of alcohol, tobacco, and cannabis is prevalent among university students. This study aimed to assess the prevalence of substance misuse among college students in Oman, identifying the most commonly used substances, and reviewing the effect of substance misuse on the students’ performance.

Methods

This cross-sectional study was conducted in a higher learning institution in an urban setting in Oman from April 2018 to December 2018. A descriptive, self-administered online questionnaire, the Alcohol, Smoking, and Substance Involvement Screening Test, version 3.0 (Arabic version), adapted from the World Health Organization was sent to 12 000 students at the college. The sample size was calculated using online software (Raosoft), with a margin of error of 5% and a confidence level of 95%.

Results

A total of 375 students responded (response rate = 3.1%). The overall lifetime prevalence for any substance misuse (including tobacco and alcohol) among the participants was 41.3%, with the overall prevalence without tobacco or alcohol at 29.9%. Tobacco was the most common substance used, with a prevalence of around 23.5%, followed by alcohol at 10.7%. Male students had a significantly higher rate of substance abuse, for any substance, compared to female students (p < 0.001). There was a significant correlation between tobacco use, alcohol misuse, and misuse of other substances. Most of the adverse effects attributed to substance misuse reported by the respondents in this study were social (27.7%) and health-related (25.8%) problems. The impact of substance abuse on their performance was also high (23.8%). Furthermore, 15.4% of the respondents had financial problems, and 4.7%% were struggling with legal issues. Notably, only 49.1% of the respondents perceived that substance misuse was a serious problem.

Conclusions

Although college students are expected to be more aware of the negative impacts of substance misuse, this study found a high prevalence of smoking, alcohol, and other substance misuses among the group of Omani college students. Further research in this field is essential, and the results of this study have shed light on a critical problem among Omani college students. It is hoped that the findings of this study will be used and built on in future research to recognize students at risk of substance misuse from early school life, leading to early intervention, and potentially preventing the possible negative consequences.

Independent risk factors for chronic illicit substance use during pregnancy

OBJECTIVE

We aimed to determine the incidence of chronic illicit substance use during pregnancy and to identify associated risk factors.

DESIGN

A 2-year time-matched retrospective maternal quality control database (n = 4,470) analysis of parturients with chronic illicit substance use compared to controls.

SETTING

A tertiary academic medical center located in a rural setting.

RESULTS

The rate of chronic illicit substance use was 1.95 percent. Demographic factors associated with chronic illicit substance use in pregnancy-included lower body mass index (BMI; OR: 0.93; 95 percent CI: 0.89-0.96, p < 0.0001), higher gravidity (OR: 1.24; 95 percent CI: 1.13-1.36, p < 0.0001), higher parity (OR: 1.38; 95 percent CI: 1.22-1.57, p < 0.0001), and more live births (OR: 1.30; 95 percent CI: 1.16-1.46, p < 0.0001). A history of smoking (OR: 10.51; 95 percent CI: 5.69-19.42, p < 0.0001), alcohol use (OR: 48.98; 95 percent CI: 17.33-138.40, p < 0.0001), anxiety (OR: 1.88; 95 percent CI: 1.16-3.05, p = 0.01), depression (OR: 2.44; 95 percent CI: 1.55-3.85, p = 0.0001), transfer on admission (OR: 2.12; 95 percent CI: 1.16-3.87, p = 0.01), payor insurance (OR: 2.12, 95 percent CI: 2.10-5.04, p < 0.0001), and Apgar scores < 7 at 1 minute (OR: 0.50; 95 percent CI: 0.25-1.00, p = 0.049) were significant. Multiple variable logistic regression-revealed BMI, smoking, alcohol use, and Apgar score <7 at 1 minute as significant factors.

CONCLUSIONS

Awareness of these factors can assist in identifying and treating parturients with chronic illicit substance use.

Community-Based Participatory Research: Engaging Youth to Provide Perspective on Risk and Protective Factors

BACKGROUND

The Pennsylvania Youth Survey (PAYS) is administered biennially to adolescents; it covers knowledge, attitudes, and behaviors about risk and protective factors.

PURPOSE

This study explored 8th, 10th, and 12th grade students' attitudes and beliefs about current trends regarding drugs, alcohol, and mental health.

METHODS

We asked persons a series of questions in semi-structured focus groups (102 participants) while they were being presented with the PAYS data.

RESULTS

Participants expressed significant insight on root causes of risk behaviors. They recommended a decreased emphasis on grades and class rank, and recommended addressing mental health stigma, educating about vaping and marijuana effects, and obtaining support from families, schools, and communities.

CONCLUSION

Youth expressed interest in being an integral part of the planning and decision-making efforts that impact them. Our results support the Whole School, Community, and Child (WSCC) model.

Legal Performance-Enhancing Substances and Substance Use Problems Among Young Adults

BACKGROUND

Legal performance-enhancing substance(s) (PES) (eg, creatine) are widely used among adolescent boys and young men; however, little is known about their temporal associations with substance use behaviors.

METHODS

We analyzed prospective cohort data from the National Longitudinal Study of Adolescent to Adult Health, Waves I to IV (1994-2008). Logistic regressions were used to first assess adolescent substance use (Wave I) and use of legal PES (Wave III) and second to assess use of legal PES (Wave III) and subsequent substance use-associated risk behaviors (Wave IV), adjusting for potential confounders.

RESULTS

Among the sample of 12 133 young adults aged 18 to 26 years, 16.1% of young men and 1.2% of young women reported using legal PES in the past year. Adolescent alcohol use was prospectively associated with legal PES use in young men (odds ratio 1.39; 95% confidence interval [CI] 1.13-1.70). Among young men, legal PES use was prospectively associated with higher odds of problematic alcohol use and drinking-related risk behaviors, including binge drinking (adjusted odds ratio [aOR] 1.35; 95% CI 1.07-1.71), injurious and risky behaviors (aOR 1.78; 95% CI 1.43-2.21), legal problems (aOR 1.52; 95% CI 1.08-2.13), cutting down on activities and socialization (aOR 1.91; 95% CI 1.36-2.78), and emotional or physical health problems (aOR 1.44; 95% CI 1.04-1.99). Among young women, legal PES use was prospectively associated with higher odds of emotional or physical health problems (aOR 3.00; 95% CI 1.20-7.44).

CONCLUSIONS

Use of legal PES should be considered a gateway to future problematic alcohol use and drinking-related risk behaviors, particularly among young men.

Intrapersonal psychological empowerment profiles on ethnic identity, social support, and lifetime drug use among Hispanic adolescent girls

The abbreviated Sociopolitical Control Scale for Youth (SPCS-Y) factor structure, used to measure intrapersonal psychological empowerment, was tested among a sample of Hispanic adolescent girls (N = 490). Confirmatory factor analysis and latent class analyses were conducted, and five distinct cluster groups emerged. Multivariate analysis of covariance was used to examine conceptually related variables and support the two-factor structure and validity of the scale. Participants with higher levels of intrapersonal psychological empowerment also had high social support, ethnic identity, and lower levels of alcohol and drug use. Findings support the use of the scale on Hispanic adolescent girls and contribute to alcohol and drug use prevention research.

State Medical Marijuana Laws and Associated Marijuana Use, Attitudes, and Perceived Social Norms among Adolescents in the U.S

Statewide medical marijuana laws (MMLs) in the U.S. may be associated with adolescent marijuana use behavior, attitudes toward marijuana use, and social norms. This study used data from the National Study on Drug Use and Health (2013-2016) to examine the associations of state MML with marijuana use, use frequency, and attitudes and perceived peer and parental social norms toward using marijuana. Propensity-score matching was used to reduce selection bias between states with and without MML (matched N = 50,000). Results showed that adolescents residing in states with MML had higher odds of using marijuana in the past month and past year (OR = 1.45 and 1.49; ps < .001), higher marijuana use frequencies in the past month (β = 0.12, p < .001), relatively more neutral attitudes toward marijuana use (β = - 0.06, p < .001), and weaker perception of peer and parental disapproval of marijuana use (β = - 0.04 and -0.02, ps < .001). Our findings suggested that for the states that have implemented MML, special efforts should be strengthened to prevent and reduce adolescent marijuana use. For the states that have not yet implemented MML, the associations between MML and adolescent marijuana use attitudes and perceived norms should be taken into account when legislating medical marijuana and designing prevention and intervention efforts.

Individual and Environmental Factors Associated with Tobacco Smoking, Alcohol Abuse and Illegal Drug Consumption in University Students: A Mediating Analysis

Substance abuse is a major and prevalent public health concern among university students. Tobacco smoking, risky alcohol behavior, and illegal drug consumption may lead to health problems and behavioral and academic issues. Several individual and environmental factors associate with substance abuse in this population, and the mediating effect of alcohol abuse in the relationship between tobacco smoking and drug consumption is yet to be explored. The purposes of this study were to evaluate the association of individual and environmental factors and substance use, and to analyze the relationship between tobacco smoking, alcohol abuse, and drug consumption, considering alcohol abuse as a possible mediator. A total of 550 Spanish undergraduate and postgraduate students completed several questionnaires regarding their smoking status, alcohol use, and drug consumption during the last six months. Bivariate and multivariate analyses were conducted to explore associations between factors. Direct, indirect and mediating effects were tested using a partial least squares approach (PLS-SEM). The results indicated that substance abuse is associated with being male, living with other students, and combined substance consumption. PLS-SEM showed a significant effect of tobacco smoking and alcohol abuse on drug consumption. Alcohol abuse plays a mediating role in the relationship between tobacco smoking and drug use.

Gender Differences in Socio-ecological Determinants of Alcohol Use Among Hispanic Adolescents

BACKGROUND

Compared to other racial groups, Hispanic/Latino(a) adolescents experience higher rates of alcohol (ab)use and alcohol-related problems. Evidence suggests there are gender differences in alcohol use patterns indicating the likelihood of gender differences in how various determinants influence alcohol use among the genders. Assessing the mechanisms that contribute to Hispanic adolescents' alcohol use requires an understanding of the multidimensional social and environmental processes that operate together to impact their alcohol use. In this study, we examined socio-ecological determinants of Hispanic adolescent alcohol use by gender.

METHODS

Data from 10th grade Hispanic/Latino(a) students (N = 781) from four high schools in Los Angeles were used to examine associations between socio-ecological characteristics and adolescent alcohol use by gender.

RESULTS

Overall, 37.5% of participants reported past 30-day alcohol use. Among boys, alcohol use was associated with intrapersonal (not qualifying for reduced lunch), interpersonal (mother's education and peer drinking), and institutional (alcohol-prone school club membership) determinants. Among girls, alcohol use was associated with intrapersonal (academic achievement) and interpersonal (parent and peer alcohol use behavior) determinants.

CONCLUSIONS

Prevention and intervention efforts need to take into consideration the gender differences in social-ecological risk and protective factors when designing educational or intervention programs and services targeted at Hispanic adolescents. This is crucial to addressing multi-component factors that influence their substance use behavior.

Adolescent drug exposure: A review of evidence for the development of persistent changes in brain function

Over the past decade, many studies have indicated that adolescence is a critical period of brain development and maturation. The refinement and maturation of the central nervous system over this prolonged period, however, makes the adolescent brain highly susceptible to perturbations from acute and chronic drug exposure. Here we review the preclinical literature addressing the long-term consequences of adolescent exposure to common recreational drugs and drugs-of-abuse. These studies on adolescent exposure to alcohol, nicotine, opioids, cannabinoids and psychostimulant drugs, such as cocaine and amphetamine, reveal a variety of long-lasting behavioral and neurobiological consequences. These agents can affect development of the prefrontal cortex and mesolimbic dopamine pathways and modify the reward systems, socio-emotional processing and cognition. Other consequences include disruption in working memory, anxiety disorders and an increased risk of subsequent drug abuse in adult life. Although preventive and control policies are a valuable approach to reduce the detrimental effects of drugs-of-abuse on the adolescent brain, a more profound understanding of their neurobiological impact can lead to improved strategies for the treatment and attenuation of the detrimental neuropsychiatric sequelae.

Mis-anaesthetized society: expectancies and recreational use of ketamine in Taiwan

Background

The popularity of ketamine for recreational use has been increasing in Asia, including Taiwan. Still, little known about the pattern of ketamine expectancies and whether such patterns are related to ketamine use. This study aimed to examine whether the positive and negative ketamine expectancies are differentially associated with ketamine-using behavior, and whether such relationship may differ by early-onset use of tobacco or alcohol.

Methods

Participants were recruited using respondent-driven sampling (RDS) among regular tobacco and alcohol users, aged 18 to 50, residing in Taipei from 2007 to 2010. Totally 1115 participants (with an age distribution skewed to the right, median = 26; interquartile range: 22–32) had information on substance use and completed a 12-item ketamine expectancies questionnaire (with 6 positive and 6 negative statements). Using two axes of High and Low expectancies, the four combinations of binary positive and binary negative ketamine expectancies were created. Each participant’s drug-using experience was categorized into illicit drug naïve, exclusive ketamine use, polydrug ketamine use, or other illicit drug use. Using the weights in the network output by RDS Analysis Tool, multivariable logistic regression analysis was then conducted.

Results

The weighted prevalence was 2.4% for exclusive ketamine use, 9.0% for polydrug ketamine use, and 9.1% for the other illicit drug use. Ketamine users (11.4%) had greater positive expectancies and lower negative expectancies, particularly the combination of High Positive with Low Negative, as compared to the illicit drug-naïve or other illicit drug users. After adjustment for early-onset tobacco (or alcohol) use and sociodemographic characteristics, High Positive, Low Negative, and their combination of High Positive-Low Negative expectancies remained strongly associated with ketamine uses, without evidence of moderation from early-onset use of tobacco or alcohol.

Conclusions

Positive and negative ketamine expectancies were associated in opposite directions with ketamine use, independent of early-onset use of tobacco or alcohol. Our results indicate ketamine expectancies as possible targets for future intervention and prevention of ketamine use, with a less confrontational feedback on decreasing an individual’s positive expectancies is essential in preventing young people from the initiation of ketamine use.

Evidence for public health on novel psychoactive substance use: a mixed-methods study

Background

Novel psychoactive substances (NPSs) contribute to the public health impact of substance misuse. This report provides research evidence addressing 11 research questions related to NPSs, covering types, patterns and settings of use; supply sources; and implications for policy and practice.

Methods

The study used a conceptually linked three-phase mixed-methods design with a shared conceptual framework based on multiple-context risk and protective factors. Phase 1 was a quantitative phase involving secondary data analysis of the longitudinal Belfast Youth Development Study (BYDS), a latent class analysis using the 2039 BYDS participants. Phase 2 was an extensive qualitative analysis via narrative interviews with participants, sampled from BYDS, drug/alcohol services and prisons, to explore NPS use trajectories. Phase 3 was the final quantitative phase; generalisability of the shared risk factor part of the model was tested using the manual three-step approach to examine risk factors associated with latent class membership. The quantitative and qualitative analyses were integrated, thus allowing emerging findings to be further explored.

Results

The data suggest that NPSs have a place within a range of polydrug use trajectories. Models showed no distinctive NPS class, with no clear evidence of differential risks for NPS use compared with the use of other substances. From the qualitative analysis, a taxonomy of groups was derived that explored how and where NPSs featured in a range of trajectories. This taxonomy was used to structure the analysis of factors linked to use within a risk and protective framework. Drivers for use were considered alongside knowledge, perceptions and experience of harms. Suggestions about how interventions could best respond to the various patterns of use – with special consideration of synthetic cannabinoids (SCs), including how they relate to the use of heroin and the potential for NPSs to operate as a ‘snare’ to more problem use – were also presented.

Limitations

The study was conducted during 2016/17; generalisability beyond this sample and time point is limited. The level of missing data for some of the BYDS analysis was a limitation, as was the fact that the BYDS data were collected in 2011, so in a different context from the data collected during the narrative interviews. The Psychoactive Substances Act 2016 (Great Britain. Psychoactive Substances Act 2016. London: The Stationery Office; 2016) came into force during qualitative fieldwork and, although not particularly influential in this study, may be influential in future work. It is acknowledged that many of the data related to SCs and mephedrone. Although drug use was measured by self-report, the strength of rapport within interviews, reflective diaries and methodological acceptability checks helped to mitigate self-report bias.

Conclusions

NPSs continue to present significant challenges for legislation and monitoring, researching and developing interventions. Understanding of usage patterns remains poor, with most information based on populations and settings where problems have already occurred. This research contributes to the evidence base by providing much needed further empirical data on the lived experiences of NPS users across a range of settings. In the light of these data, implications for policy and practice are discussed.

Future work

Future research must generate improved epidemiological data on the extent, patterns and motivations for use longitudinally. The uniqueness of the information concerning SC use points to a specific set of findings not evidenced in other literature (e.g. intensity of SC withdrawal). Future research should focus on the symbiotic link between SC and heroin use.

Funding

The National Institute for Health Research Public Health Research programme.

Medical marijuana legalization and associated illicit drug use and prescription medication misuse among adolescents in the U.S

BACKGROUND

Use of illicit drugs and misuse of prescription medications among U.S. adolescents have been major public health issues. As over half of the states have implemented medical marijuana laws (MMLs), it is unclear if MML implementation is associated with use of illicit drugs and misuse of prescription medications among adolescents.

METHODS

This study used data from the 2013-2014 National Survey of Drug Use and Health and included adolescents aged 12-18 with a total of 26,826 participants after the propensity-score matching used to reduce selection bias between states that had and had not implemented MML. Seven logistic regressions were conducted to examine MML implementation and associated use of illicit drugs (including cocaine/crack, heroin, hallucinogens, and inhalants) and misuse of prescription medications (including pain relievers, tranquilizers/sedatives, and stimulants), controlling for sociodemographics and use of cigarettes, alcohol, and marijuana.

RESULTS

Adolescents residing in the states that had legalized medical marijuana were more likely to use cocaine/crack and heroin in the past 12 months (OR = 1.63, 2.61, respectively; both ps < 0.05). However, MML implementation was not associated with the likelihood of using other illicit drugs or misusing prescription medications.

CONCLUSIONS

The study findings suggest that for the states that have implemented MML, policy and educational interventions should as well be implemented to prevent not only marijuana use but also use of other harder drugs such as cocaine/crack and heroin among adolescents. States that have yet implemented MML should consider the possible associations between MML implementation and use of other illicit drugs when legislating MML.

When Marijuana Is Used before Cigarettes or Alcohol: Demographic Predictors and Associations with Heavy Use, Cannabis Use Disorder, and Other Drug-related Outcomes

Recent loosening of state and federal policy restrictions on marijuana, along with changes in social norms regarding marijuana use and decreases in prevalence of other types of substance use, may lead to increases in youth initiating marijuana before other types of substances such as alcohol and tobacco. We investigated predictors and potential consequences of initiating marijuana before other drugs for youth aged 12-21-years in the USA. Nationally representative, cross-sectional survey data from the US National Survey on Drug Use and Health supplied self-reported age of first marijuana, cigarettes, alcohol, other tobacco, and other illegal drug use among 12-21-year-old samples from 2004 to 2014 (n = 275,559). We first examined the degree to which initiating marijuana use first was associated with sex, age, race/ethnicity, and survey year. Then, we examined whether using marijuana first predicted heavy marijuana use, cannabis use disorder (CUD), alcohol use disorder (AUD), nicotine dependence (ND), or lifetime use of other illegal drugs. Among all survey youth (substance users and non-users), the proportion using marijuana first increased from 4.8 to 8.8% from 2004 to 2014. Those using marijuana first (vs. alcohol or cigarettes first) were more likely to be male and older and Black, American Indian/Alaskan Native, multiracial, or Hispanic than White or Asian. Among substance users and adjusting for age of onset and the number of substances used, using marijuana first was associated higher odds of heavy current marijuana use and CUD. In recent years, youth have been increasingly likely to use marijuana as their first drug and sequence of initiation is associated with race/ethnicity, gender, and age. Using marijuana first might increase the chance of heavy use and CUD.

Do Classes of Polysubstance Use in Adolescence Differentiate Growth in Substances Used in the Transition to Young Adulthood?

BACKGROUND

Past studies have differentiated classes of polysubstance use in adolescence, however, the associations of adolescent polysubstance use classes with longitudinal substance use trajectories from adolescence to young adulthood have not been studied.

OBJECTIVE

The current study examined substance use classes during adolescence and longitudinal trajectories of each substance used across the transition to young adulthood.

METHOD

Data were collected biennially from 662 youth and followed 10 years across six measurement assessments. Using baseline data (T1), latent class analysis was used to identify classes of polysubstance use (cigarette, alcohol, marijuana, and illicit drug use) during adolescence. Using T2 through T6 data, we fit latent growth models for cigarette, alcohol, marijuana, and illicit drug use to examine longitudinal trajectories of each substance used by class.

RESULTS

A three-class model fit the data best and included a poly-use class, that had high probabilities of use among all substances, a co-use class, that had high probabilities of use among alcohol and marijuana, and a low-use class that had low probabilities of use among all substances. We then examined trajectories of each substance used by class. Strong continuity of substance use was found by class across 14 years. Additionally, for some substances, higher average levels of use of at age 14 were associated with change in growth of other substances used over time. Conclusions/Importance: Efforts that only target a single drug type may be missing an important opportunity to reduce the use and subsequent consequences related to the use of multiple substances.

Epidemiology of adolescent substance use in Norfolk schools

BACKGROUND

The pattern of alcohol and substance use is changing, with the introduction of novel psychoactive substances, the internet as a means of acquisition and variations in drug purity and price. Alcohol and substance use among adolescents is associated with behavioural, mental health, health and social difficulties; arising at a vulnerable period in their development. Little is known about adolescent substance use in the UK, especially in rural areas.

AIM

To investigate the prevalence of substance use amongst young people, aged 16-21 years, in Norfolk schools.

DESIGN

Cross sectional questionnaire survey.

METHOD

Pupils from two, sixth form colleges in Norfolk answered a self-report questionnaire designed to measure prevalence, age of onset and frequency of use for alcohol, tobacco, illicit substances including new psychoactive substances as well as demographic data.

RESULTS

A total of 482 students completed the survey (68% participation rate). Life-time use of alcohol was reported by 442 (91.7%) students and over half the pupils had tried tobacco (52.5%, n=253). About 40.7% reported cannabis use and nearly one-fifth (18.9%, n=91) reported using 3,4-methylenedioxymethamphetamine (MDMA); 41.1% (n=198) students reported using 'any drug' and 23.2% (n=112) 'using an illicit drug other than cannabis' and 8.7% (n=42) reported the use of a novel psychoactive substance.

CONCLUSION

The most widely used substances were alcohol, tobaccos and cannabis; in keeping with European trends. Over the past decade a decline in alcohol and drug use by adolescents has been seen in the UK. However, since 2010 this decline has slowed with an increase in substance use noted in the past 2 years. This study provides evidence to support this trend. The findings demonstrate differences between the use of substances by pupils in this Norfolk sample compared to national surveys and more urbanized areas. These regional differences can be used to assist the development of local interventions targeting substance use among adolescents.

[Effect of Non-alcoholic Beverage Intake in Children on Alcoholic Beverage Drinking and Smoking]

　The early intake of alcohol and/or nicotine in childhood or adolescence is one of risk factors for alcohol and/or nicotine dependence in adult. Recently, non-alcoholic beverages with less than 0.00% alcohol are on sale for adults as substitutes for alcoholic beverages without strict legal limitations. However, it is unclear whether non-alcoholic beverages could be a risk factor in drinking and smoking in childhood or adolescence. The purpose of the present survey is to clarify the effect of non-alcoholic beverage intake in children on alcoholic beverage drinking and smoking. We examined as follows: the experience of alcoholic or non-alcoholic beverage intake, and of smoking in elementary school pupils and/or their family members, and interest in or motivation for drinking and smoking in the pupils. As a result, the percentage of alcoholic or non-alcoholic beverage intake, and of smoking in the pupils were 16.8% or 21.9%, and 0.3%, respectively. The number of family members took the alcoholic or non-alcoholic beverage was larger in the pupils took it compared to the pupils did not take it. In the pupils who experienced the non-alcoholic beverage intake, interest in or motivation for drinking alcoholic beverages and/or smoking is higher than in those who did not. These findings indicate that non-alcoholic beverage intake is related to drinking and smoking. We will introduce drug abuse prevention education on the risk of drug dependence among childhood or adolescents based on the findings of this survey.

Assessing the longitudinal stability of latent classes of substance use among gay, bisexual, and other men who have sex with men

BACKGROUND

Association between substance use and HIV-risk among gay and bisexual men (GBM) is well documented. However, their substance use patterns are diverse, and it is unknown whether self-reported use patterns are stable over time.

METHODS

Sexually-active GBM, aged >16 years, were recruited in Metro Vancouver using respondent-driven sampling and followed across 5 study visits at six-month intervals (n = 449). To identify distinct patterns of substance use and their longitudinal stability, Latent Transition Analysis (LTA) was conducted for drugs reported by at least 30 participants. Intraclass correlation coefficients (ICC) quantified the stability of class assignments.

RESULTS

Six classes characterizing 'limited drug use' (i.e., low use of all drugs, except alcohol), 'conventional drug use' (i.e., use of alcohol, marijuana, and tobacco), 'club drug use' (i.e., use of alcohol, cocaine, and psychedelics), 'sex drug use' (i.e., use of alcohol, crystal meth, GHB, poppers, and erectile dysfunction drugs), 'street drug use' (i.e., use of alcohol and street opioids) and 'assorted drug use' (i.e., use of most drugs) were identified. Across five visits (2.5 years), 26.3% (n = 118/449) of GBM transitioned between classes. The prevalence of limited use trended upwards (Baseline:24.5%, Visit 5:28.3%, p < 0.0001) and assorted use trended downwards (13.4%-9.6%, p = 0.001). All classes had strong longitudinal stability (ICC > 0.97).

CONCLUSION

The stability of latent substance use patterns highlight the utility of these measures in identifying patterns of substance use among people who use drugs - potentially allowing for better assessment of these groups and interventions related to their health.

Smoking Cessation for Those Pursuing Recovery from Substance Use Disorders

This article summarizes the literature regarding the similar biopsychosocial mechanisms of tobacco use and alcohol and substance use disorders, and the evidence for and against the provision of tobacco cessation for those in treatment for alcohol and substance use disorders. The practicality of treatment, focusing on methods, timing, and breadth of intervention strategies, are also presented. Common methodologies that may be used across tobacco use and alcohol and substance use disorder to prevent lapse and relapse are discussed. Physicians can and should adhere to the policy that tobacco use is a common and dangerous comorbid condition that demands concomitant treatment.

Applying the Problem Behavior Theory to Adolescent Drug Use Among a Cross-Sectional Sample of Boys Participating in a Community-Based Youth Organization

BACKGROUND

Drug use remains an important public health concern in the United States, and understanding drug use among young adolescents is vital towards improving the health of the population.

OBJECTIVE

This study applied the Problem Behavior Theory (PBT) to lifetime drug use among a cross-sectional sample of Boy Scouts (N = 770). The PBT provides a conceptual framework for identifying risk and protective factors for adolescent problem behaviors, including drug use.

METHODS

Scouts reported their drug use and socio-demographics, and were assessed on several risk and protective factors. For analyses, sociodemographic and risk and protective factors were selected according to the framework provided by PBT, and use of each drug was regressed logistically on these selected factors. Final logistic models were assessed for goodness of fit and discriminatory power.

RESULTS

The PBT demonstrated discriminatory power for all drugs (Tjur's R² values ≥.29), but fell sharply for illicit drug use (Tjur's R² =.20). There were no consistent correlates of drug use. Conclusions/Importance: The PBT had less explanatory power for illicit drug use compared to tobacco, alcohol, and marijuana, which suggests different risk and protective factors were associated with illicit drug use.

Exploring the association between initial serum alcohol concentration and polysubstance use: More than a simple "gateway drug" effect?

Introduction

Polysubstance abuse (PSA) is a significant problem affecting our society. In addition to negatively affecting the health and well-being of substance users, alcohol and/or drug abuse is also associated with heavy injury burden. The goal of this study was to determine if elevated serum alcohol (EtOH) levels on initial trauma evaluation correlate with the simultaneous presence of other substances of abuse (SOAs). We hypothesized that PSA would be more common among patients who present with EtOH levels in excess of the legal blood alcohol content (BAC) (≥0.10%).

Methods

An audit of trauma registry records from January 2009 to June 2015 was performed. Abstracted data included patient demographics, BAC measurements, all available formal determinations of urine/serum "drug screening," Glasgow Coma Scale (GCS) assessments, injury mechanism/severity, and 30-day mortality. Stratification of BAC was based on the 0.10% cutoff. Parametric and nonparametric statistical testing was performed, as appropriate, with significance set at α = 0.05.

Results

We analyzed 1550 patients (71% males, mean age: 38.7 years) who had both EtOH and SOA screening. Median GCS was 15 (interquartile range [IQR]: 14-15). Median ISS was 9 (IQR: 5-17). Overall 30-day mortality was 4.25%, with no difference between elevated (≥0.10) and normal (<0.10) EtOH groups. For the overall study sample, the median BAC was 0.10% (IQR: 0-0.13). There were 1265 (81.6%) patients with BAC <0.10% and 285 (18.4%) patients with BAC ≥0.10%. The two groups were similar in terms of mechanism of injury (both, ∼95% blunt). Patients with BAC ≥0.10% on initial trauma evaluation were significantly more likely to have the findings consistent with PSA (e.g., EtOH + additional substance) than patients with BAC <0.10% (377/1265 [29.8%] vs. 141/285 [49.5%], respectively, P < 0.001). Among polysubstance users, BAC ≥0.10% was significantly associated with cocaine, marijuana, and opioid use.

Conclusions

This study confirms that a significant proportion of trauma patients with admission BAC ≥0.10% present with the evidence of additional substance use. Cocaine and opioids were most strongly associated with acute alcohol intoxication. Our findings support the need for further research in this important area of public health concern. In addition, specific efforts should focus on primary identification, remediation of withdrawal symptoms, prevention of drug-drug interactions, and early PSA intervention.

Problematic khat use as a possible risk factor for harmful use of other psychoactive substances: a mixed method study in Ethiopia

BACKGROUND

Substance use disorders along with neuropsychiatric disorders contributed about 14% of the global burden of disease. Harmful alcohol use, is a known contributor for many harms (accidents, suicide, violence, and complication of other psychiatric and medical disorders). In the Western countries, alcohol and nicotine are gateway drugs to cannabis use, and cannabis use is a risk factor for other illicit drugs such as cocaine and heroin. Khat use is another psychoactive substance which is common in East African and Arabian Peninsula. But there is a knowledge gap regarding the position of khat use or problematic khat use in sequential progression of different psychoactive substances. Therefore, we aimed to understand and investigate the relationship of problematic khat use and other psychoactive substances in Ethiopia.

METHODS

Exploratory mixed methods study was employed. Quantitative cross sectional survey was done among 102 khat users, and 4 focus group discussions and 11 in-depth interviews were conducted to understand the pathways between khat use and other psychoactive substances use in 2014. Non random sampling (purposive and snowballing) was employed for both quantitative and qualitative studies. Khat users from khat cafeterias, shops, and from other open markets of khat in Addis Ababa were invited to participate.

RESULT

Currently significant majorities of khat users (86.3%) used at least one other psychoactive substance after they started khat use. The prevalence of harmful drinking was 53.9% among khat users. Problematic khat use was a significant predictor of harmful drinking (p < 0.05). About one from ten respondents engaged to risky sexual behavior pushed by the effect of khat after chewing.

CONCLUSION

The proportion of psychoactive substances use especially harmful drinking among khat users was observed higher compared to other cross sectional surveys conducted among general population. In Ethiopia, intervention and policy on harmful alcohol use could consider problematic khat use as one possible risky factor. A rigorous methodology which could test gateway hypothesis of problematic psychoactive substances use could be warranted.

Parental Identification and Response to Adolescent Substance Use and Substance Use Disorders

Previous research showing that parents tend to underestimate adolescent substance use is consistent with concerns that adolescent substance use may develop because parents delay in reacting to it. However, little research has examined parental decisions regarding how and when to intervene on adolescent substance use. This study examines the actions that parents report they would take after a) discovering substance use to intoxication and b) when they believe their child has a substance use problem. Internet surveys were conducted asking parents (N = 975) how they would respond to a) evidence of their child's use to intoxication and b) their child's significant problem with either alcohol, cannabis, prescription opioids, or illicit drugs. While parental response to alcohol and cannabis intoxication focused on talking with their children (34% and 45% respectively) and punishment (30% and 18% respectively), parents were significantly more likely to report help-seeking behaviors when responding to prescription opioid or illicit drug use intoxication (37% and 30% respectively). More effective public health initiatives are needed to provide parents with practical strategies to address adolescent substance use and to increase parental engagement in the services offered by addiction specialists.

Binge drinking and illicit drug use among adolescent students

OBJECTIVE

To estimate the prevalence of illicit drug use and its association with binge drinking and sociodemographic factors among adolescent students.

METHODS

This is a cross-sectional study with probabilistic conglomerate sampling, involving 1,154 students, aged 13 to 19 years old, from the public school system, in the city of Olinda, State of Pernambuco, Brazil, carried out in 2014. We used the Youth Risk Behavior Survey questionnaire, validated for use with Brazilian adolescents. The Chi-square test (≤ 0.05) and Poisson regression analysis were used to estimate the prevalence ratios, with 95% confidence intervals.

RESULTS

Use in life of illicit drugs was four times more prevalent among students who reported binge drinking (95%CI 3.19-5.45). Being in the age group of 16 to 19 years, being male, and having no religion were also significantly associated with illicit drug use.

CONCLUSIONS

The prevalence of use in life of illicit drugs was higher in this study than in other studies carried out in Brazil and it was strongly associated with binge drinking. This factor was associated with gender, age, and religion.

OBJETIVO

Estimar a prevalência do uso de drogas ilícitas e sua associação com binge drinking e fatores sociodemográficos entre estudantes adolescentes.

MÉTODOS

Estudo transversal com amostra probabilística por conglomerado, envolvendo 1.154 estudantes, de 13 a 19 anos de idade, da rede pública de ensino, no município de Olinda, PE, 2014. Foi utilizado o questionário Youth Risk Behavior Survey, validado para uso com adolescentes brasileiros. Para análise dos dados foi utilizado o teste do Qui-quadrado (≤ 0,05) e análise de regressão de Poisson, para estimar razões de prevalência, com intervalos com 95% de confiança.

RESULTADOS

O uso na vida de drogas ilícitas foi quatro vezes mais prevalente entre os estudantes que relataram o binge drinking (IC95% 3,19-5,45). Estar na faixa etária de 16 a 19 anos, ser do sexo masculino e não ter religião também foram significativamente associados ao uso de drogas ilícitas.

CONCLUSÕES

A prevalência do uso de drogas ilícitas na vida foi superior a outros estudos realizados no Brasil e esteve fortemente associado ao binge drinking. Esse fator mostrou associação com gênero, idade e religião.

National Trends in Substance Use and Use Disorders Among Youth

OBJECTIVE

To examine trends in the 12-month prevalence of patterns of substance use and substance use disorders (SUDs) among US youth during 2002 through 2014.

METHOD

Data were from 288,300 persons 12 to 17 years old who participated in the 2002 to 2014 National Surveys on Drug Use and Health. Descriptive analyses and bivariable and multivariable logistic regressions were applied.

RESULTS

During 2002 through 2014, among US youth, the 12-month prevalence of any substance use decreased by 27.1% (from 43.2% to 31.5%); among youth users, the 12-month prevalence of SUDs decreased by 28.9% (from 27.0% to 19.2%), and the ratio of substance dependence to abuse decreased from 2.2 to 1.6. Multiple substance use was common and was associated with SUDs. During 2002 through 2014, the prevalence of using marijuana and alcohol only, using marijuana only, and having marijuana use disorders only increased, whereas most other trends were downward. Increases in age at first substance use were associated with downward trends in any substance use. Upward trends in age at first substance use, youth and parental strong disapproval of cigarette use, and youths' seatbelt-wearing prevalence and downward trends in substance use patterns were associated with the downward trend in SUDs among youth users.

CONCLUSION

The 12-month prevalence of any substance use among youth and SUDs among youth users decreased during 2002 through 2014. Postponing age at first use of any substance is critical among youth in the United States. Future research is needed to better understand the interrelations between specific risk and protective factors, age at first substance use, substance use patterns, and SUDs among youth users.

Impact of Perceived Risk and Friend Influence on Alcohol and Marijuana Use Among Students

We performed a secondary analysis of Adolescent Health Risk Behavior Survey data ( N = 937), examining associations between lifetime alcohol and marijuana use with intrapersonal (i.e., risk perceptions) and interpersonal (e.g., peer approval and behavior) factors. Multinomial and binary logistic regression analyses contend students reporting lifetime alcohol use-compared to students who had never used alcohol or marijuana-perceived lower alcohol risk ( p < .001), higher friend drinking approval ( p < .001), and greater friend drinking ( p = .003). Using both alcohol and marijuana in one's life was associated with being in public schools ( p = .010), higher grade levels ( p = .001), lower perceived alcohol ( p = .011) and marijuana use risk ( p = .003), higher friend approval of alcohol ( p < .001) and marijuana use ( p < .001), and believed more friends used alcohol ( p < .001). Compared to lifetime alcohol only, perceived friend academic performance decreased the risk of lifetime alcohol and marijuana use ( p = .043). Findings are beneficial to school nurses with students experiencing effects associated with substance use.