Substance Abuse Research Paper

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Substance abuse is construed here as the use of one or more substances which may include tobacco, alcohol, and illicit drugs (marijuana, cocaine, or heroin). This entry addresses substance abuse and related life problems. The generic definition of substance abuse is based on several concepts. First is level of use: an individual uses the substance frequently. Second is the concept of abuse: using the substance causes significant problems for the individual in important life domains such as work performance or social relationships with significant others. Third is the concept of dependence: the individual may use the substance in increasingly larger amounts, spend much time getting it and using it, and experience negative physiological or psychological states when the substance is reduced or withdrawn. Although the application of these criteria varies somewhat for different life stages (e.g., adolescence vs. adulthood) and for different drugs of abuse, when all of the defining conditions are met, then the individual can be diagnosed as having the disorder of substance abuse or substance dependence. It is recognized that there is heterogeneity within a group of persons who all meet sufficient diagnostic criteria for a substance abuse disorder, and for some disorders (particularly alcohol abuse), evidence for subtypes has been reported. However, in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV), the core conditions are similar across diagnoses for all drugs of abuse, and the only diagnostic distinction allowed is between substance dependence and substance abuse. This entry examines epidemiologic findings on the prevalence of substance use and current knowledge about protective and risk factors for substance abuse.

Substance Abuse Research Paper Outline

I. Introduction

II. Epidemiologic Findings on Substance Use and Abuse

A. Prevalence of Substance Use and Multiple Use

B. Prevalence of Substance Abuse

C. Temporal Trends

D. Variation by Gender, Socioeconomic Status, and Ethnicity

E. Comorbidity of Substance Abuse and Mental Disorder

F. Treatment Rate

III. Protective and Risk Factors

A. Definitions

B. Protective Factors

1. Gender

2. Temperament

3. Intelligence and Verbal Skills

4. Executive Functions and Problem Solving

5. Family Support and Relationships with Significant Others

6. Academic Achievement

7. Religiosity

8. Perceived Harmfulness of Drugs

9. Perceived Disapproval for Use

C. Risk Factors

1. Gender

2. White Ethnicity

3. Lower Socioeconomic Status

4. Family History of Substance Abuse

5. Temperament

6. Poor Parental Relationship and Supervision

7. Early Onset

8. Poor Self-Control

9. Novelty Seeking and Risk Taking

10. Anger, Hostility, and Aggression

11. Avoidant and Helplessness Coping

12. Tolerance for Deviance

13. Conduct Disorder and Antisocial Personality Disorder

14. Negative Life Events

15. Affiliation with Peer Users

IV. Summary

I. Introduction

Within the general population there are many persons who have tried cigarettes, alcohol, or marijuana at some time in their lives. There is a substantial proportion of persons who use substances in a consistent but infrequent pattern, such as persons who occasionally have a glass of wine with meals or who drink beer on social occasions. The number of persons who exhibit frequent, high-intensity substance use, however, is a smaller proportion of the population. For example, if the overall amount of alcohol use in the population is broken down, it is evident that a large part of total consumption is attributable to a small part of the population; these are the persons who would be characterized as heavy users. From the group of heavy users, some persons who meet the necessary defining conditions would be described as affected by diagnosable alcohol abuse or (if more severe) alcohol dependence. The prevalence of persons who have tried a substance, and the relative proportions of occasional users, heavy users, and abusers, differ considerably across drugs of abuse. For example, the proportion of the population who have tried cocaine is relatively small, but cocaine (particularly smokable or “crack” cocaine) is sufficiently addictive that a large proportion of triers move rapidly to abuse-dependence status.

Several themes about substance abuse emerge in this entry. First is the concept of multiple risk factors. One way to approach substance abuse is to think about finding the particular factor that is responsible, for example, having an “alcoholic gene,” or being the child of a substance-abusing parent, or living in a poor inner-city area. Although each of these factors has some relevance for predicting substance abuse, research does not support the notion that there is one single cause of substance abuse; for example, although having an alcoholic parent increases children’s risk for alcoholism, the majority of adult alcoholics do not have a family history of alcoholism. Instead of indicating a single cause, research indicates that it is a combination of environmental, personal, and social factors that puts some persons on a trajectory of life experiences that ultimately involves an extent and type of use that are indicative of substance abuse disorder. To understand and predict substance abuse, it is essential to consider information about the total number of environmental, personal, and social risk factors and protective factors that impinge on an individual.

A second theme is multiple use. It is possible to find individuals who show only a high level of cigarette smoking, or only a high level of alcohol use, or only the use of an illicit drug (e.g., heroin or cocaine) with nothing else. However, such individuals are statistically rare in the population. Instead, it is more common to find that an individual with a high level of one type of substance use also shows high levels of other types of substance use. Although people have a clear stereotypic picture for the kind of person labeled “alcoholic,” they often miss the fact that persons diagnosed with alcohol abuse also tend to be cigarette smokers; correspondingly, the kinds of persons labeled as “drug abusers,” because they inject heroin, also tend to have high rates of alcohol, cocaine, and other drug use. The phenomenon of multiple use has been identified consistently in both adolescent samples and adult samples. However, the causal basis for the co-occurrence of tobacco, alcohol, and illicit drug use has not been definitively established at this time.

The third theme is comorbidity. Recent research with general population samples has found that individuals with a substance abuse disorder have elevated rates for other mental health disorders, including anxiety or depressive disorders. Demonstration of substantial comorbidity of substance abuse with mental health disorders is a relatively recent development. The reasons for the comorbidities are not completely understood, but the phenomenon is believed to have significant implications for treatment of substance abusers.

In the context of these themes, this entry summarizes current knowledge about substance abuse from the perspective of epidemiologic research, with epidemiologic data on the prevalence of substance abuse and the comorbidity of substance abuse with other disorders. Risk factors and protective factors, conditions that increase or decrease the likelihood that an individual will be affected by substance abuse, are explored because recent work has shown that it is the balance between risk and protective factors that may be crucial for helping to steer an individual toward or away from substance abuse. Risk and protective factors have been studied in both adolescent and adult populations, so findings from both types of research are considered.

II. Epidemiologic Findings on Substance Use and Abuse

A. Prevalence of Substance Use and Multiple Use

What proportion of the population engages in substance use? This question is addressed by studies that inquire about whether a person has ever used, or currently uses, a given substance (population prevalence). Surveys administered to samples of adolescents or adults include questions about the extent to which the person has used the substance, for example, Have you ever smoked marijuana? or Have you smoked marijuana in the past 30 days? Additional questions may establish whether the adolescent is a regular user (e.g., smokes every day or usually drinks alcohol several times a month). For adolescents, detailed information on substance use prevalence is available from household surveys and studies of school students. A large study of high school seniors, Monitoring the Future (MF), conducts repeated annual surveys to track current trends in adolescent substance use.

In thinking about substance abuse, it is important to note that substance use typically begins in adolescence. Around age 12 years, prevalence rates for regular tobacco and alcohol use are low, single-digit figures, but these rates increase steadily over adolescence; by age 18, rates of regular use for tobacco, alcohol, and marijuana range from 15 to 30% of the adolescent population. Use of illicit drugs (e.g., heroin and cocaine) is relatively infrequent in the general population of adolescents, but increases markedly during young adulthood (ages 18 to 25 years), with declines thereafter. However, users of illicit drugs in adulthood typically have a history of prior substance use in adolescence.

Adolescent data show variation for rates of use across different substances. Survey data for high school seniors from 1994 show that for cigarette smoking, 62% have smoked a cigarette at some time in their lives and 19% are current daily smokers. For alcohol, 80% have tried alcohol at some time, 50% had alcohol in the past month, and 28% engaged in what is defined as heavy drinking (five or more drinks on one occasion) during the past 2 weeks. Rates of use of illicit substances are lower but not negligible. Among high school seniors, 38% have tried marijuana at some time in their lives and 19% have used it recently (past 30 days); 16% have tried amphetamines without a medical prescription and 4% have used them recently; 6 % have tried cocaine and 2% have used it recently; 1% have tried heroin and 0.3% have used it recently.

Data from samples of the adult general population (ages 18 to 65) in some ways mirror the relative rates of use found in adolescence, with alcohol use fairly prevalent, cigarette smoking intermediate, and rates of illicit drug use relatively low in comparison. The 1995 National Household Survey (NHS) indicated that 29% of U.S. adults are regular smokers. For alcohol use, data from the Epidemiologic Catchment Area Study (ECA) showed that 12% of U.S. adults are total abstainers, 60% engage in social drinking, and 14 % can be characterized as heavy drinkers (seven or more drinks at least one evening a week for several months), but are not diagnosable as alcohol abusers. For the illegal substances, 5 % of adults are characterized in NHS data as marijuana users (used in past month), 1% as heroin users, and 0.7% as cocaine users. Other research, discussed subsequently, indicates that rates of substance use vary considerably across particular subgroups of the population.

The phenomenon of multiple substance use begins in adolescence. Studies of adolescent samples show substantial interrelationships for tobacco, alcohol, and marijuana use from early ages. The correlation between continuous scores for involvement in various types of substance use is around r – .35 in early adolescence (age 12 years), and the magnitude of the correlations increases with age to r = .60 or more in later adolescence (age 16 years). These data indicate that the great majority of adolescents who use one substance also use others regularly.

This pattern of multiple use continues into adulthood. In general population samples of adults there are substantial correlations among tobacco, alcohol, and caffeine use. The recent NHS data indicated similar findings, showing that persons who smoked cigarettes were more likely to use alcohol and illicit drugs (marijuana and cocaine). Alcohol use, particularly heavy use, was also correlated with several types of illicit drug use.

The evidence on multiple use has important implications for treatment programs. Many substance abuse treatment programs are specifically focused on one substance (e.g., alcoholism treatment) and may not provide mechanisms for dealing with other types of substance use. In addition, there are significant clinical questions as to whether the therapist and client should try to address different issues in treatment (e.g., simultaneous alcohol abuse treatment and smoking cessation) versus whether treatment should focus on only one addiction problem and how that problem should be selected, that is, which problem should be dealt with first. These questions are beginning to be addressed in clinical research.

B. Prevalence of Substance Abuse

What part of the population can be characterized as affected by substance abuse? This question has been addressed by several recent studies conducted in the United States. Researchers conducted interviews in homes with a large sample of persons who were selected randomly so that they are representative of the U.S. population. The respondents were given a lengthy interview that asked detailed questions about whether they recently experienced signs and symptoms relevant for diagnosis of various mental disorders. An individual’s responses were combined to determine whether he or she met the diagnostic criteria for a given disorder, either at some time in his or her life (lifetime prevalence) or in the past 6 to 12 months (current prevalence).

General population research indicates that substance abuse affects a significant proportion of the adult population. The most recent U.S. study, the National Comorbidity Survey (NCS), showed that one in four persons in the population will experience a substance abuse disorder at some time in his or her life. Data from the ECA and NCS studies, which used somewhat different interviews, indicate that 17 to 27% of the population met the criteria for having a substance abuse disorder at some time in their life, and 6 to 11% evidenced a substance abuse disorder within the past 6 months to 1 year. Thus, even with stringent diagnostic criteria, substance abuse is not a rare disorder.

In relative terms, substance abuse has a prevalence comparable to other disorders. For example, NCS data showed that 19% of the population have had an affective disorder at some time in their life, and 25 % have had an anxiety disorder at some time; this compares with a lifetime prevalence of 27% for substance abuse. Considering only episodes within the last year, 11% of the population experienced a depressive disorder, 17% experienced an anxiety disorder, and 11% experienced a substance abuse disorder. Thus substance abuse represents a significant part of the mental health burden in the population.

Within the several types of substance abuse disorders, alcohol abuse is the most frequent. The NCS showed a lifetime prevalence of 14% for alcohol dependence and a lifetime prevalence of other substance dependence for 8 % of the population. Data on specific dependence-abuse diagnoses from the ECA study showed lifetime prevalences of 4.3 % for marijuana, 1.7% for amphetamines, 0.7% for opiates, and 0.2% for cocaine. These studies did not report data for tobacco dependence, a recently added diagnostic category, so the relative prevalence for this substance is currently unclear.

A noteworthy aspect of substance abuse is that it is episodic. The few studies that have made repeated observations of adult substance abusers (e.g., alcoholics) show that rates of use vary widely over time, including many periods of minimal use together with some episodes of heavy or “binge” drinking. This aspect is mirrored in findings from the prevalence studies, which show that many more persons have had a substance abuse disorder sometime in their lives compared with the number who have a current disorder. One may speculate that together these findings suggest that rates of substance use are partly responsive to environmental conditions that are relatively short-term (e.g., argument with a significant other) or longer term (e.g., unemployment). However, there has been little research involving longitudinal observations of substance abuse episodes, and interpretation of the available findings is somewhat inferential at this time.

C. Temporal Trends

Is the prevalence of substance abuse increasing or decreasing in the population? Data from the NHS on prevalence of substance use have shown a steady decline in cigarette smoking among U.S. adults, from a prevalence around 44% in 1975 to a prevalence of around 299/0 in 1995. This was accompanied with substantial decreases in marijuana use (compared with a peak in the mid 1970s) and cocaine use (from a peak in the late 1980s) and a modest decline in current alcohol use. In contrast to population trends in overall use, however, is evidence from the recent ECA and NCS studies that concur in finding rates of mental health disorders to be elevated among persons born in more recent years. This has been interpreted as indicating that the prevalence of psychopathology is increasing in the general population.

Regular studies of adolescents provide a more precise picture of how the frequency of particular types of substance use is changing over time. Although this research does not provide diagnostic indices, it does provide yearly standardized data on the prevalence of substance use among adolescents (which has implications for their use as adults). Cigarette smoking among high school seniors has steadily declined since 1975, paralleling the decline in smoking among adults, whereas rates of overall alcohol use have not shown large changes. Rates of adolescents’ marijuana use were declining during the 1980s, but began to increase around 1992. This increase in marijuana use has been paralleled by increases in cigarette smoking among younger adolescents (age 13 years). This worrisome trend is currently the subject of considerable attention and public policy debate.

D. Variation by Gender, Socioeconomic Status, and Ethnicity

Substance abuse is not randomly distributed in the population, and attention to how the prevalence of substance abuse differs across demographic subgroups of the population provides a valuable perspective on the nature of these disorders. The nature of the demographic differences, however, depends on the type of substance involved. With regard to gender, adult alcohol abuse is more common among males. For example, NCS data showed the lifetime prevalence of alcohol dependence was 20% for males and 8% for females; and although the rate of the disorder among females is not trivial, the disorder is 2.5 times more frequent among males. Similar findings are usually noted for substance abuse other than alcoholism; for example, in NCS data, the prevalence of other drug dependence was 9% for males and 6% for females. The only type of substance use consistently found greater for women is tranquilizer use, consistent with the female differential found for anxiety disorders. Even this picture is unclear, because much of the total consumption of anxiolytic drugs is from medical prescription; when studies distinguish between prescribed and nonprescribed tranquilizer use, males have higher rates of nonprescribed tranquilizer use (which often goes along with illicit drug use).

It is difficult to know which aspect of these findings deserves more emphasis. On the one hand, the prevalence of alcohol abuse among males is substantial, and it can be anticipated that a considerable proportion of males will experience diagnosable alcohol abuse at some time in their lives. On the other hand, the rate of substance abuse among women is not zero, and considering the broad-band diagnosis of any substance abuse/dependence, NCS data showed that 18 % of women will have a substance abuse disorder at some time in their lives, compared with 35 % for males. Thus the risk for women is lower, but not negligible.

Drug abuse is more prevalent among persons of lower socioeconomic status. The results of several large-scale studies show diagnoses of substance abuse to be more frequent among persons with lower income and education. This does not, of course, mean that substance abuse is absent among persons with high socioeconomic status, as shown, for example, in media portrayals of highly paid athletes and entertainment personalities who have used cocaine and other drugs. However, the greatest risk of substance abuse is at the lowest rungs of the socioeconomic ladder. Studies also indicate that the chronicity of substance abuse and other mental health disorders is greater for persons with low socioeconomic status, and that comorbid disorders are markedly more frequent for persons of low socioeconomic status. Thus, the burden of disorder is substantially greater for this part of the population. The picture is complicated a little by alcohol statistics; moderate drinking tends to be more frequent among persons of middle or higher education, but alcohol abuse is elevated for persons with lower income and occupational status.

Current findings on ethnicity and substance abuse are consistent in showing a lower prevalence among African Americans for most types of substance abuse. Data from the NCS indicate that African American adults have a lower rate of any substance abuse disorder compared with whites. This finding is comparable to ECA data, which showed lower rates of substance and alcohol abuse dependence among young African Americans than among whites. In these studies, Hispanics approach non-Hispanic whites in rates of disorder but generally are not higher. These findings are parallel to findings from studies of adolescents’ substance use, which consistently show African American adolescents as having the lowest rates of tobacco and alcohol use, Hispanic adolescents intermediate, and whites highest. These observations are balanced by studies of ethnic differentials in morbidity and mortality that show that adult African Americans are more affected by chronic disease, some of it substance-related. These findings have been interpreted as reflecting a greater impact of health risk factors in minority populations because of greater environmental stressors and reduced access to screening programs and medical care.

E. Comorbidity of Substance Abuse and Mental Disorder

The issue of comorbidity involves the following question: If a person has a substance abuse disorder, is he or she more likely also to have one or more other diagnoses of mental disorder compared with the base rate in the population? Recent epidemiologic studies have provided an answer to the question by studying the co-occurrence of diagnoses among persons in representative community samples. Results have shown that there is extensive comorbidity. For example, ECA data showed persons with alcohol abuse had twice the risk for mental disorder (compared with the population base rate), and persons with other drug abuse disorders showed a fourfold increase in risk for mental disorder. Among persons with alcohol abuse, the risk for other drug abuse disorder was 7 times greater, and there is also a high co-occurrence of substance abuse and antisocial personality. In other words, abuse of one substance increases by 7 times the risk of abusing another substance, and a person with alcohol or substance abuse has 2 to 4 times the risk of a mental disorder.

Comorbidity with alcohol or other substance abuse was found for affective disorders (particularly bipolar depression), anxiety disorders (particularly panic and obsessive-compulsive disorder), and schizophrenia. The NCS data showed that of persons with any lifetime disorder, only one-fifth (21%) had one disorder; the rest had two or three disorders. This indicates that the great majority of mental disorder is comorbid disorder. Moreover, comorbidity was related to chronicity: persons with a comorbid disorder were more likely to have had a recent experience of disorder and to have had more severe disorder. The degree of comorbidity was high among both treated and untreated parts of the population, but was found to be even greater among persons who had sought treatment.

The high degree of comorbidity found in these studies has major implications for treatment professionals. One implication is that clinicians who focus on treatment of mental health problems will actually be encountering a substantial number of persons with a co-occurring substance abuse problem. Another implication is that the high degree of comorbid mental disorders among substance abusers probably presents a significant impediment to treatment for this population. A number of clinical research studies are currently underway to investigate how the effectiveness of substance abuse treatment programs may be enhanced through recognition and treatment of other disorders.

F. Treatment Rate

One of the contributions of psychiatric epidemiology has been to determine what proportion of persons with mental illness receive professional treatment (the treatment rate). After determining whether a person has had a mental health disorder, researchers can then determine whether the person has received treatment at some time from a mental health professional (psychologist or psychiatrist), from other medical personnel (e.g., primary care physician), or from community agents who provide counseling and guidance (e.g., clergy).

Data on persons with affective disorders have indicated that only a minority receive professional treatment. The figure is usually around 25% for persons with depressive or anxiety disorder. The remainder of persons with clinical depression or anxiety either receive brief contact with a primary care physician or receive no professional treatment at all. The experience of persons with substance abuse disorders appears to be even worse. For example, of persons who had a substance abuse disorder within the past year, only 4% received treatment in any kind of substance abuse facility (either inpatient hospitalization, outpatient treatment, or a drop-in program). This low treatment rate may be the result of a range of factors, including limited availability of treatment, restrictions on insurance coverage for treatment of substance abuse, or personality characteristics associated with substance abuse (e.g., alienation and antisocial behavior) that discourage drug abusers from becoming involved with any kind of professional agency, but the evidence shows that only a small proportion of affected persons receives professional treatment. What encourages persons with substance abuse to seek treatment is an important question that has received relatively little attention.

The ECA study, which showed that primary-care physicians are a major source of treatment for mental disorders, included questions on whether a person had ever talked with their physician about an emotional problem or about substance abuse. Results showed that persons with any kind of emotional problem were unlikely to talk about it with the physician, and persons with substance abuse problems were particularly unlikely to do so. These findings suggest that health care providers encounter a substantial number of persons who are experiencing substance abuse, but frequently do not learn of this from their patients. This indicates that studying ways to increase recognition of substance abuse in treatment settings could be an avenue to opening treatment accessibility.

Given the evidence about the episodic nature of substance abuse and the relatively low utilization of professional treatment programs, a significant question has arisen: How do persons who are affected by alcohol or other substance abuse, but who do not receive formal treatment, deal with their problem? One possible answer to the question is that many persons draw on social support from significant others and learn to control the substance abuse problem on their own, either by reducing their use to a level where it is no longer problematic to themselves or others, or by ceasing it entirely. Another possible answer is that persons participate in informal self-help groups such as Alcoholics Anonymous, a widely available resource that promotes abstinence as the route to recovery. Although there is some evidence for both avenues of coping with substance abuse, this issue has been controversial because of evidence from studies of self-quitters suggesting that some persons may recover from alcohol abuse by learning self-control skills to reduce their use to low levels (controlled drinking). Research has explored the extent of recovery in untreated samples and has followed alcoholics in formal treatment programs to determine their subsequent experiences with abstinence, controlled drinking, or relapse. The present evidence indicates that recovery through controlled drinking occurs for only a small proportion of serious alcohol abusers. However, research on the comparative efficacy of self-change and formal inpatient or outpatient treatment is continuing. This remains an area where well-designed scientific research is needed to obtain more definitive answers.

III. Protective and Risk Factors

A. Definitions

The concept of protective factors and risk factors for substance abuse requires some discussion. A protective factor is an environmental, personal, or social variable that is related to a lower rate of substance abuse, either at the same point in time or over time. Such a factor could deter a person from becoming involved in substance use in the first place, or prevent a person from progressing to a high frequency and intensity of use. A risk factor is an environmental, personal, or social variable that is related to a higher rate of substance use or abuse; in the context of longitudinal research, the level of a risk factor at one point in time would predict the likelihood that a person will be a substance abuser at a later point in time. The concepts are linked in the sense that the level of protective factors may be particularly relevant for individuals with a high level of risk factors, so that substance use could be greatly reduced among persons who had a high level of risk factors but also had a high level of protective factors. Overall levels of protective factors and risk factors are not highly correlated, and protective factors may reduce the potentially adverse effect of risk factors. This is alternately called a buffering effect, in the sense that protective factors buffer a person from the impact of risk factors, or a resiliency effect, in the sense that protective factors enable persons to be resilient in the face of pressures that otherwise would operate to encourage substance use or abuse.

The ideal study of risk for substance abuse would use a wide range of biochemical, neurological, and psychological measures; obtain such measures from a large and representative sample; collect data on a range of outcomes, including psychiatric diagnosis, work performance, and social relationships; and follow the respondents from infancy through age 35. No single study exists that has all of these characteristics. Accordingly, current knowledge about protective and risk factors is derived from a variety of studies that were designed at different times over the past 40 years. They were conducted for differing periods with samples that span the range somewhere between childhood to young adulthood, and used a wide variety of measures. The discussion here is based on a composite of findings from studies of children, adolescents, and adults which have examined different aspects of risk for substance abuse.

Researchers have generally given more weight to knowledge derived from variables obtained at earlier measurement time points as predictors of adult substance abuse. The reason is that results may be ambiguous when study variables are measured at the same point in time as substance abuse in adulthood. For example, the finding of a correlation between depression and substance abuse is ambiguous because the depression may be a result of adverse consequences caused by the abuse, not a predictor. Although it may sound paradoxical to discuss variables measured at age 12, when there is virtually no cocaine use, in relation to cocaine use at age 25, such findings have significant interest because they precede the onset of the substance abuse. In addition, it is common to find drug abuse occurring in a context of multiple substance use and a history of prior substance use. Although many persons who experiment with substances in adolescence reduce or cease their use as they move into adulthood (a phenomenon called “maturing out”), there is evidence for stability of heavy use over time and this is a primary risk factor for substance abuse in adulthood.

B. Protective Factors

The following section presents a summary of knowledge about protective factors. The distinction between protective and risk factors can sometimes be arbitrary; for example, one could plausibly argue that high academic achievement is a protective factor or that low academic achievement is a risk factor. The discussion tries to classify factors according to observed main effects and buffering effects.

1. Gender

Gender could be characterized as a protective factor in the sense that girls have lower rates of substance use throughout adolescence and women have a lower prevalence of alcohol and other substance abuse disorder in adulthood. In addition, effects of adverse early environments (e.g., parental poverty and alcoholism) on substance use appear to be less for girls than for boys.

2. Temperament

Two dimensions of temperament precursors of adult personality characteristics that are observable in childhood and adolescence–have been related to substance abuse liability. Attentional orientation, the ability to focus attention and concentrate on tasks, is greater among persons with low levels of substance use. Positive emotionality, the tendency to be generally cheerful and happy, is also a protective factor and has been shown to buffer the impact of risk factors.

3. Intelligence and Verbal Skills

Although one might expect intelligence to be a protective factor, evidence on overall IQ is actually quite mixed. Rather, it is an advantage specifically on verbal ability in IQ tests that is consistently noted to be a protective factor. Whether verbal skills are protective because they facilitate the development of problemsolving ability or because they contribute to better interpersonal relationships with parents and peers is not currently known; it is recognized that both mechanisms are possible.

4. Executive Functions and Problem Solving

This concept refers to a set of interrelated abilities measured at the neuropsychological level as functions for planning, organization, and sequencing of activity, and measured at the behavioral level as dealing with problem situations by getting information, considering alternative courses of action, and thoughtfully selecting an alternative before acting. Higher levels of these abilities are present in children and adolescents who do not use substances, and the abilities protect against escalation and multiple use that occur for some individuals who are low on these functions. Executive functions are not strongly correlated with full-scale IQ and this domain of cognitive functioning is not merely a proxy for general intelligence.

5. Family Support and Relationships with Significant Others

A strong protective factor among adolescents is positive relationships with parents and other family members. The construct of family support includes feeling accepted and valued, and feeling that emotional support is available because one can talk to a parent when one has a problem and that one can receive advice and assistance from a parent for instrumental needs. To some extent this is independent of the number of parents in the home; although a single-parent household is a risk factor for substance use, the level of support in the household appears to be a more important factor. In adulthood, marriage is a protective factor with regard to substance abuse, and a supportive relationship (involving emotional and instrumental support) with a significant other is a protective factor–as long as the significant other is not a drug user.

6. Academic Achievement

This is a simple term for a complex construct. The basic finding is that adolescents who get good grades in school are less likely to be substance abusers as adults, hence academic achievement is a protective factor. This probably involves a constellation of characteristics, with higher-achieving individuals having positive attitudes toward school and valuing conventional achievement as a goal; getting support and assistance from parents for doing well; performing better in task situations and organizing behavior to meet requirements (e.g., completing homework on time); and behaving appropriately to meet the demands of the setting (e.g., sitting still in class and not “talking back” to teachers).

7. Religiosity

Substance use is lower among persons who hold religious beliefs. This construct is sometimes measured by asking respondents whether they belong to a church, temple, or other religious institution, and, if so, how often they attend; sometimes by asking whether they hold religious beliefs; and sometimes by asking whether they engage in prayer or meditation. Findings are generally robust across different measures of the construct of religiosity. Moreover, the protective effect is generally found across a number of different religious denominations. Some theorists have suggested that the effect of religiosity is mediated through an individual’s identification with conventional social values, but there have been few explicit tests of this proposition.

8. Perceived Harmfulness of Drugs

Persons who perceive substances to have adverse consequences (for health, social acceptance, or interpersonal relationships) are less likely to be substance users. This has been shown, in data from the MF study, to account for long-term trends in adolescent substance use. Where these attitudes come from has not been completely established, but research suggests some combination of communications from parents, personal observation, and exposure to educational programs.

9. Perceived Disapproval for Use

The perception that significant others (parents, friends, or spouse) disapprove of substance use is a deterrent to substance abuse. To some extent this may be a selfguided effect, because persons with relatively positive attitudes toward drugs will tend to gravitate toward persons who are drug users and who have favorable attitudes themselves; conversely, individuals who hold negative attitudes toward drugs will tend to select friends with similar views. However, the perceived attitudinal climate has been shown in longitudinal studies to be a deterrent to involvement in substance use.

C. Risk Factors

Risk factors for substance abuse make up what seems like a longer list. This may to some extent reflect an imbalance in the literature, with researchers tending to concentrate on finding variables that predict bad outcomes rather than protective variables that are related to good outcomes. It may partially reflect the nature of substance use, if there are many different types of factors that produce escalation of substance use among individuals who have experimented. In the listing that follows, it should be recognized that several of the risk factors are correlated. For example, parental alcohol abuse is typically related to discord and conflict between parents and children. The nature and reasons for correlations among risk factors is not well understood and is the subject of ongoing investigation, but the reader should keep in mind that the risk factors discussed here are not necessarily independent. In the following section, little attention is given to cultural issues. This is not because these issues are unimportant; cross-cultural work suggests that drug use rates, preferences, and practices vary widely across cultures. However, the epidemiologic studies have mostly been conducted in North American samples and the discussion is focused on this type of evidence.

1. Gender

Male gender may be construed as a risk factor for substance abuse. Not only are rates of alcohol and illicit drug use higher among male adolescents, but the differential increases with age. In adulthood, the prevalence of alcohol and other substance abuse disorders is consistently greater among men compared with women.

2. White Ethnicity

The prevalence of substance use and abuse is greater among whites, and the strength of relationships between predictive factors and substance use outcomes is consistently found to be greater among whites compared with African Americans. This does not necessarily mean that the predictors of drug abuse are different for whites and for members of ethnic groups, as predictive relationships for a given variable are often found to be significant in all ethnic groups, but predictive effects are typically greater for whites.

3. Lower Socioeconomic Status

The risk of substance use or abuse is greater for persons with lower socioeconomic status. This effect is observable beginning in adolescence for teenagers from families with lower education, hence this is a true predictive relationship. There is evidence that persons with substance abuse problems beginning in later adolescence or early adulthood may experience downward mobility, but this does not contradict the risk status that occurs early on. Studies conducted in adolescence have also shown the impact of risk factors on substance use to be greater among adolescents from lower-income families.

4. Family History of Substance Abuse

Persons with a history of alcoholism among parents and/or grandparents are at increased risk for alcoholism as adults. Evidence that this is attributable to genetic transmission has been shown by studies of twins and studies of adopted children, each type of research indicating a heritable basis for substance abuse liability. History of paternal alcoholism provides about a fourfold increase in children’s risk; for example, a study in Sweden showed that 18% of male children of alcoholic fathers became alcoholic as adults, compared with a rate of 4% for children of nonalcoholic fathers in the population studied. At the same time, it should be noted that the majority of children of alcoholic parents (over 80%) did not become alcoholic themselves, so the data indicate there may be many factors beside family history that contribute to influencing substance abuse.

5. Temperament

Two dimensions of temperament have been linked to greater liability for substance abuse. One is physical activity level, the tendency to be physically active and to be unable to sit still for long. The second is negative emotionality, the tendency to be easily frustrated, irritated, and angered. These characteristics are related to substance use at early ages and are found to be more prevalent in the histories of adult substance abusers. Negative emotionality and high activity level are also more common among children of substance abusers, and current research is exploring the possibility that effects of family history are partly transmitted by influencing the development of these temperament dimensions.

6. Poor Parental Relationship and Supervision

Discordant relationships between parents and children, with frequent arguments and conflict, predict adolescent substance use and are found to be more common in the life history of adult substance abusers. Accompanying family discord is poor parental monitoring and supervision of children, so that parents frequently do not know where the children are (when they are out of the home) or who they are with. A combination of poor relationship with parents and lax supervision may encourage a child to begin affiliating with deviance-prone peers who can introduce him or her to substances and encourage their use.

7. Early Onset

The age at which a person begins using substances predicts future substance abuse risk. Retrospective studies have shown that individuals who began using illicit substances before age 15 are more likely to be affected by substance abuse as adults, whereas persons who began substance use later in adolescence do not show this degree of risk. Although a considerable proportion of teenagers engage in minimal experimentation with tobacco and alcohol, it is the smaller proportion of individuals who engage in early, persistent substance use, including illicit drugs, who are at greatly increased risk.

8. Poor Self-Control

Lower ability for self-regulation of emotions and behavior is a risk factor for substance use and has been demonstrated among both adolescents and adults. The construct of poor self-control is a generalized one involving areas such as poor control of behavior in everyday situations (e.g., cutting in line), impatience in social interactions, low dependability in meeting responsibilities, acting without thinking, and less ability to calm down when upset and recover from irritations or embarrassments. Alternate labels given for this construct in the literature are impulsivity, disinhibition, or behavioral undercontrol. Although many persons will display one or two of these behaviors at some time, it is a high level of poor self-control across many situations that is indicated as a risk factor. It is important to note that poor self-control is not simply the absence of good self-control. Although these two dimensions are inversely related, they are not redundant and appear to derive from two different developmental systems. Good self-control has been shown to buffer the impact of poor self-control on substance use.

9. Novelty Seeking and Risk Taking

A personality constellation has been identified that involves constantly seeking novel experiences, trying new things for fun and thrills, becoming easily bored, and liking to be involved in risky or dangerous situations. This construct of novelty seeking (sometimes called sensation seeking or risk taking) has been linked to substance abuse liability in animal research and in human studies, with individuals who score high on novelty seeking shown to be at increased risk. There is evidence that this dimension has substantial heritability, and recent research with humans has suggested a linkage with dopamine, a neurotransmitter that is central for brain reward mechanisms. Thus, a psychobiological basis for the novelty-seeking dimension is credible at this time.

10. Anger, Hostility, and Aggression

This set of interrelated attributes involves feelings of alienation from others, cynical perceptions of hostile intent and distrust of others’ motives, and overt aggression toward others including verbal aggression such as teasing, blaming, and criticizing, and physical aggression such as damaging objects or hitting persons. Measures of anger are one of the strongest predictors of substance use in adolescence, and the temperament dimension of negative emotionality appears to be a precursor of this attribute. Irritability and anger are quite stable in childhood and adolescence, and these constructs have been shown to predict substance abuse liability over long time periods.

11. Avoidant and Helplessness Coping

In contrast to active types of coping, some persons may cope with problems by trying in various ways to avoid dealing with the problem or by disengaging from coping efforts entirely and taking the view that there is nothing they can do to cope. Measures of coping through avoidance and helplessness are related to increased risk for substance use and abuse over a wide range of ages, from early adolescence through later adult years; more traitlike measures, indexing perceived lack of control over the important things in one’s life, have also been related to substance use risk in prospective investigations. It is possible that avoidance and helplessness may be a consequence of poor self-control and low actual competence in domains such as academic or work performance; interrelations among these constructs are currently being investigated.

12. Tolerance for Deviance

This attitudinal dimension represents devaluation of conventional values and routes to accomplishment; for example, the belief that school (for adolescents) or work (for young adults) is boring and irrelevant together with endorsement of the attitude that behaviors such as lying, stealing, or fighting are not really so bad and that rule-breaking behavior is all right if one can get away with it. This attitudinal dimension may not be independent of other risk factors; adolescents who are doing poorly in school and who feel angry and alienated from their parents and community might tend to endorse these kinds of attitudes. However, it has been shown that this attitudinal dimension contributes to escalating involvement in substance use.

13. Conduct Disorder and Antisocial Personality Disorder

Substance use is found empirically to co-occur with conduct disorder in adolescence and with antisocial personality (ASP) in adulthood; in the latter case, substance use is one of the diagnostic criteria for ASP because it is highly associated with fighting, stealing, and involvement in other illegal behaviors. Substance use in adolescence is also found to co-occur with other adolescent problem behaviors, such as drunk driving and precocious, frequent sexual relations. The extent to which the diagnostic label is merely a convenient summary for dimensions such as poor self-control, anger, and risk-taking orientation is not known at present because studies have approached the question from such different perspectives. A recent retrospective study by Robins and McEvoy in 1990, using ECA data, did show that adult substance abuse disorder was best predicted by the total number of behavior problems in childhood; the presence of a conduct disorder diagnosis did not add additional ability for prediction of substance abuse.

14. Negative Life Events

Negative life events have been shown to precede the onset and escalation of substance use. In adolescent samples, it has been shown that both events occurring to family members (e.g., illness, unemployment) and events occurring directly to children (e.g., serious accidents) predict substance use, and statistical analyses have shown that negative life events are not simply a proxy for demographic factors. Research has indicated that negative events can be a consequence of other variables, such as poor self-control and tolerance for deviance, and can also be a predictor of other variables, such as deviant peer affiliations. The mechanism through which negative events influence substance use has not been completely established. Emotional distress evoked by negative events may be a predisposing factor for high-intensity substance use motivated by self-regulation of negative emotions. It is also possible that feelings of helplessness evoked by negative life experiences make individuals disengage from active modes of coping and seek out deviant companions who can provide hedonistic activities that help dampen the impact of negative experiences in other areas. Some evidence is available for both mechanisms.

15. Affiliation with Peer Users

Having friends who smoke, who engage in heavy drinking, and/or who use illicit drugs is generally indicated as being the final common pathway to substance use, predicted by many other risk factors and strongly related to an individual’s level of substance use. “Hanging out” with peer smokers and drinkers in early adolescence predicts subsequent escalation to high-intensity substance use, and studies of adult drug abusers show heavy use encouraged by involvement in a drug subculture that features a group of drinking companions or “shooting buddies.” It is unlikely that the operation of peer affiliations involves just overt social pressure; although this element is not absent in any group situation, the available evidence suggests that vulnerable persons experimenting with substances seek out affiliation with groups of known users and thereby involve themselves in a cyclical process that promotes higher levels of use and increasing identification with users over time.

IV. Summary

The statistics on the prevalence of substance abuse show that alcohol or other substance abuse occurs for a significant part of the population, often comorbid with other mental disorders. Whether substance abuse disorders are decreasing or increasing in the general population is not yet clear. Some evidence can be noted for promising trends, such as declines in tobacco and cocaine use, but this may be offset by other trends such as increases in marijuana use. The one clear conclusion from the current prevalence studies is that substance abuse is not going to go away soon, and continued prevention and treatment efforts are necessary and valuable for the health of the population.

Development of substance abuse is a complex process that is rooted in many factors. Having a single risk factor does not indicate that a person is likely to develop substance abuse. It is only when multiple risk factors are present that an individual has a substantial increase in risk. These factors span a wide range of areas including socioeconomic status, family history of substance abuse, patterns of temperament and personality, the individual’s own early history of use, patterns of stress and coping, attitudes about deviant behavior in general and substance use in particular, and choices of mates and companions. An individual’s profile on all of these attributes produces a trajectory that over time may steer the individual toward or away from the rocky shore of substance abuse; but as the number of risk factors one has increases, the probability of substance abuse increases.

Although substance abuse is expressed in adulthood, research suggests that liability is contributed by factors that are observable at early ages. Diagnosing an individual as alcoholic at age 30 does not explain how he or she ended up in that condition, and research conducted at younger ages indicates that dispositional attributes, learned ways of coping with situations and feelings, and relationships with parents and peers all are acting to influence an individual’s likelihood of substance use. Thus the study of substance abuse has much to gain from studying individual trajectories of use or nonuse over time, identifying early factors that make a minority of persons particularly vulnerable when pressures accumulate in adulthood. All the evidence suggests that prevention programs should begin early, and research has shown a number of modifiable factors that can reduce the likelihood of substance abuse.

Many persons with risk factors do not develop substance abuse. Protective factors such as supportive family relationships, self-regulation skills, and developed competencies (e.g., academic performance) serve to blunt the impact of adverse conditions. Again, the existence of a single factor does not guarantee a positive outcome, but persons whose environments contain several protective factors may be buffered against risk to a considerable extent. Research indicates it is the balance of protective and risk factors that is most important for understanding vulnerability versus resilience.

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