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Personalizing the Treatment of Substance Use Disorders

• Nora D. Volkow , M.D.

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The opioid crisis in the United States has brought drug addiction to the forefront of the public mind and to the attention of health care personnel, organizations, and agencies. The epidemic of overdoses, beginning with those caused by prescription opioid analgesics and then broadening to include heroin and fentanyl and its analogs, has prompted major initiatives in local communities, states, and at the federal level to treat addiction and pain more effectively. The crisis has highlighted an insulated addiction treatment system that for decades was segregated from the rest of health care because of stigma associated with addiction and, by extension, the medications used to treat it. Stigmatizing attitudes have been slow to erode, but the moralizing and punitive viewpoints of the past are gradually giving way to a medical and even a cultural consensus that addiction is a chronic disorder of the brain, one that is strongly influenced by social factors, and one that is also treatable.

Parallel research in animal models and brain-imaging studies in individuals with substance use disorders has given us an increasingly precise picture of their neurobiology, including molecular and synaptic changes and the neuronal circuits involved, along with the consequences of their disruption. Most people are exposed to addictive substances at some point in their lives, including alcohol and nicotine, and many use these substances recreationally without developing addiction. Similarly, many patients who use opioids to treat their pain don’t develop addiction. But in a subset of individuals who are vulnerable because of genetics, age, and other variables, repeated exposure to addictive drugs diminishes the capacity of basal ganglia circuits to respond to natural reward and to motivate the behaviors needed for survival and well-being, while enhancing the sensitivity of stress and emotional circuits, including those from the extended amygdala, triggering anxiety and dysphoria when not taking the drug and weakening prefrontal executive-control circuitry necessary for self-regulation ( 1 ).

These changes, along with learning mechanisms that tie expectation of reward to drug cues, intensify each other in a kind of perfect storm: Inability to feel reward from non-drug activities, including social interactions, takes away the enjoyment of life and increases social isolation. Intense symptoms of withdrawal drive a search for temporary relief, and constant reminders of the drug in the environment contribute to persistent craving and preoccupation with obtaining the drug. Weakened capacity to resist the urge to take the drug or follow through on resolutions to quit leads, very often, to relapse and the accompanying regret or shame at having failed. Further increasing relapse risk are the frequently associated symptoms of depression, anxiety, and impaired sleep.

Until recently, the development of treatments for addiction was aimed at bringing about cessation of drug consumption (abstinence), which was the outcome required for U.S. Food and Drug Administration (FDA) approval of medications for substance use disorders. However, our current understanding of the mechanistic processes underlying addiction identifies a much broader set of clinically beneficial outcomes. For example, reduction of use in a person who uses heroin could decrease his or her risk of overdose, and improvements in sleep, depression, or executive function could also reduce relapse risk. In addition, technological advances and our growing understanding of the underlying neurobiology have given us the opportunity to target discrete neurobiological processes and personalize interventions to the unique deficits in a given individual and across the course of an individual’s disorder. A dimensional, personalized, and dynamic approach to treating substance use disorders could draw from medication use, neuromodulation techniques, behavioral approaches, and their combinations as the individual moves toward recovery.

Alternative Endpoints

To achieve a dimensional approach to treatment requires thinking anew about how we develop new treatments and what we expect in a treatment.

The existing pharmacopoeia for substance use disorders is severely limited. The FDA has approved medications only for alcohol, nicotine, and opioid use disorders ( Table 1 ), and currently there are no approved medications for cannabis, cocaine, methamphetamine, or inhalant use disorders. The absence of medications to treat most substance use disorders and the limited number of existing medications for alcohol, nicotine, and opioid use disorders make development of new therapeutics a high priority. Yet drug development for substance use disorders faces great hurdles.

TABLE 1. Drugs approved by the FDA for treatment of substance use disorders

a AMPA=α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid; FDA=U.S. Food and Drug Administration; GABA=γ-aminobutyric acid; NMDA= N -methyl- d -aspartate.

TABLE 1. Drugs approved by the FDA for treatment of substance use disorders a

To obtain FDA approval for most substance use disorders, medications until recently had to demonstrate that they produce abstinence in a significant subset of patients, as measured by negative urine tests. However, the abstinence endpoint is a high bar to achieve, equivalent to requiring remission of pain from an analgesic or remission of depression from an antidepressant. Yet, the FDA granted approval of analgesics and antidepressants on the basis of reduction of symptom severity, not remission ( 2 ). The high bar for addiction medications has discouraged investment by the pharmaceutical industry, and significant public sector help was required to bring many of the currently available medications for substance use disorders to market, including buprenorphine, extended-release naltrexone, lofexidine, and naloxone nasal spray.

Treatment programs for substance use disorders inherited a dichotomous working definition of recovery from the 12-step world of past generations, where being completely “drug free” was not merely the gold standard but the only standard, short of which an addicted individual was regarded as having failed or would not be considered to be “recovering.” Yet evidence indicates that abstinence is not the only clinically relevant outcome for every individual and that alternative endpoints can contribute to recovery even when abstinence is not completely achieved.

Reduced alcohol use (measured as percentage of heavy drinking days) is now being used as an endpoint in clinical trials for treatments for alcohol use disorder. The FDA has also recently expressed its openness to considering endpoints other than abstinence as targets in medication development for other substance use disorders ( 3 , 4 ). Given the illegality of many addictive drugs, it has been argued that any reduction in use should be considered a benefit to the individual’s health and safety ( 5 ). Every time a person addicted to heroin must obtain the drug, he or she faces the risks associated with the drug trade as well as with exposure to fentanyl or a contaminant that could lead to overdose or poisoning.

Recently, researchers found in a pooled sample of study participants with cocaine use disorder that those who had high-frequency use at the start of the study and had reduced to low-frequency use by the end of the study showed outcomes at 1-year follow-up similar to those of participants who had quit altogether ( 6 ).

Treating the Dimensions of Substance Use Disorder

Endpoints other than abstinence may lead not only to treatments that are helpful in reducing drug use but also to the use of compounds that target specific neurobiological processes and symptoms relevant to addiction and the risk for relapse.

In April 2018, the FDA, in partnership with the Addiction Policy Forum and the National Institute on Drug Abuse (NIDA), convened a meeting to solicit input from patients with opioid use disorder as part of its Patient-Focused Drug Development initiative ( 7 ). Among other things, participants emphasized their desire for a more holistic and individualized approach to treatment, as well as their wish for medications that would address specific symptoms of withdrawal, such as cravings, depression, cognitive impairments, pain, and sleep problems. The same year, the FDA approved lofexidine for treating physical symptoms of opioid withdrawal during detoxification—the first approved drug for treating symptoms associated with opioid use disorder with a restricted purpose and not expected to lead, by itself, to continued abstinence. After detoxification, the individual would ideally be treated with naltrexone or buprenorphine as a longer-term treatment to help prevent relapse and achieve recovery. Other potential targets for medications are those that, while not addressing addiction directly, target major risk factors for relapse.

One such factor is insomnia, for it is frequently interrelated with substance use disorders, with each exacerbating the risk of the other. Findings of shared targets and circuits between disrupted sleep and addiction offer unique opportunities for treatment development. For example, while studying the role of orexin in narcolepsy, researchers serendipitously discovered an unusually high number of orexin-producing neurons in the postmortem brain of a heroin-addicted individual ( 8 ). They subsequently established in preclinical models and postmortem brain studies that long-term use of heroin was associated with an increase in orexin-producing neurons. Since orexin is already targeted by suvorexant, an FDA-approved drug for insomnia, NIDA is funding research to test its efficacy, along with that of other novel orexin receptor antagonists, as therapeutic agents in opioid use disorder.

Similarly, dysphoria and depression, which are frequently associated with protracted withdrawal, are another relevant area where our growing understanding of underlying neurocircuitry could guide selection of promising new targets. For example, the habenular complex is intricately involved in dysphoria and negative emotional states and is associated with depression ( 9 ) and addiction ( 10 ). Both alpha-5 nicotinic acetylcholine receptors and mu-opioid receptors are highly expressed in the habenula, where they modulate its activity, contributing to the adverse symptoms of withdrawal that follow nicotine and heroin discontinuation, respectively, and to the relief that follows during intoxication. Targeting the habenula has already been shown to be beneficial in animal models of addiction treatment ( 11 ), and it has been a target for deep brain stimulation for the treatment of depression ( 12 ).

Because of the high comorbidity of substance use disorder with depression, psychiatrists have used antidepressants off-label to treat their addicted patients, even though randomized clinical trials of antidepressants have failed to achieve the desired outcome of abstinence. Recognizing that improving depression could still be beneficial for patients with substance use disorders, studies should revisit the possible efficacy of antidepressants as an element of addiction treatment, using endpoints other than abstinence. Bupropion, which blocks the dopamine and norepinephrine transporters and is an approved antidepressant medication, is also approved for the treatment of nicotine addiction. Given the involvement of the mu-opioid receptor system in mood, it would be expected that targeting depression might have particular value in treating opioid use disorder; an interesting feature of the opioid partial agonist buprenorphine is that it has antidepressant properties ( 13 ), and opioid-addicted patients who have depression respond particularly well to this medication ( 14 ).

Another important therapeutic target is that of addressing social isolation, and while this might be optimally achieved with behavioral interventions, including group treatment, medications could still hold promise. Addicted individuals report reduced pleasure from social contact, as well as fear of the stigma attached to their drug use, and thus they tend to isolate themselves. Isolation in turn drives drug taking ( 15 ). Here again, we could take advantage of our increased understanding of the neurobiology of social attachment to bolster social connections. For example, oxytocin, a neurochemical involved in social bonding that also modulates key processes associated with addiction, including reward and stress responses, is being evaluated as a possible addiction treatment and may enhance the efficacy of psychosocial addiction treatments ( 16 , 17 ).

A dimensional approach to the treatment of substance use disorder is also relevant to neuromodulation. Early research has shown that transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) may be useful in reducing drug cravings, and TMS is already an approved therapy for treatment-resistant depression. Research is needed to study how TMS, tDCS, or peripheral nerve stimulation could be used to improve symptoms associated with addiction, from acute symptoms of withdrawal to the more protracted symptoms of dysphoria and sleep problems. As we understand better how to use neuromodulation technologies to modify brain circuits, it may create opportunities to strengthen specific circuits that can buffer or compensate for others that have been impaired by drug use or constitute a predisposing vulnerability.

Behavioral therapies are also suited to dimensional approaches to substance use disorder treatment. Considerable research already shows the benefits of cognitive-behavioral treatments in improving self-regulation and of contingency management in strengthening the degraded motivation to engage in non-drug-related activities, so clearly these modalities are effective for addressing specific dimensions of the addiction process. Similarly, behavioral treatments to improve executive function could help build resilience against relapse, as shown by methylphenidate’s reported ability to reduce impulsivity in individuals with cocaine use disorder ( 18 ).

Making Addiction Treatment More Dynamic and Personalized

Trajectories of use vary among people who use drugs, ranging from persistent use or declining use to cessation and relapse or sustained cessation. Studies of people who inject opioids, for example, have identified factors that, to some extent, are predictive of these trajectories ( 19 ). Being in a stable relationship, for instance, has been associated with early cessation (highlighting the importance of social support).

Addiction is an evolving disorder that changes through time and across the lifespan of the individual and one that has an unpredictable element that springs from the unique experiences an individual is exposed to. Some widely used behavioral treatments already accommodate and address this changeability of substance use disorder. Cognitive-behavioral therapy teaches the individual to identify external triggers and respond more appropriately to internal states (e.g., mood, craving) that place them at risk for relapse. New technologies are developing algorithms to identify indicators of relapse risk and incorporating them into wearable devices and smartphones with the goal of delivering an intervention in a timely, targeted manner. In the future, as big-data analytics and machine-learning algorithms yield more insight into behavioral and biological markers of relapse risk, tools or devices to avert relapse farther in advance may be developed.

Toward the Future

Neuroscience has revealed that addiction involves a set of interconnected processes that can be targeted strategically, rather than being a disorder defined principally by a single behavior (uncontrollable excessive drug use). Addiction medicine is also increasingly recognizing that factors traditionally associated with recovery are components of treatment. For example, for any meaningful recovery to occur, the individual must be able to integrate him- or herself into a socially meaningful environment. People with substance use disorders who are professionally active or engage in meaningful activity and have a caring family face less of a challenge than those who have no social supports and whose isolation places them at high risk for relapse. The integration of peer mentors, recovery coaching, and supportive housing into addiction treatment is an example of this shift, but more research is needed to determine the most effective ways to sustain social inclusion and to achieve recovery ( 20 ).

Addiction is a complex disorder that involves brain circuits necessary for survival and one that is strongly influenced by genes, development, and social factors. We now understand the underlying mechanisms well enough that we can turn this complexity into an opportunity to include these dimensions as targets for substance use disorder treatment, as well as to personalize interventions to accommodate the unique neurobiological characteristics and social contexts of individual patients.

Dr. Volkow is Director of the National Institute on Drug Abuse.

The author thanks Eric M. Wargo and Emily B. Einstein for their valuable help in the preparation of this article.

1 Koob GF, Volkow ND : Neurocircuitry of addiction . Neuropsychopharmacology 2010 ; 35:217–238 (erratum in Neuropsychopharmacology 2010 Mar; 35:1051) Crossref , Medline ,  Google Scholar

2 Volkow ND, Woodcock J, Compton WM, et al. : Medication development in opioid addiction: meaningful clinical end points . Sci Transl Med 2018 ; 10: eaan2595 Crossref , Medline ,  Google Scholar

3 Kiluk BD, Carroll KM, Duhig A, et al. : Measures of outcome for stimulant trials: ACTTION recommendations and research agenda . Drug Alcohol Depend 2016 ; 158:1–7 Crossref , Medline ,  Google Scholar

4 US Food and Drug Administration Draft Guidance (FDA): Opioid Use Disorder: Endpoints for Demonstrating Effectiveness of Drugs for Medication-Assisted Treatment: Guidance for Industry. Silver Spring, Md, FDA, August 2018. https://www.fda.gov/media/114948/download Google Scholar

5 McCann DJ, Ramey T, Skolnick P : Outcome measures in medication trials for substance use disorders . Curr Treat Options Psychiatry 2015 ; 2:113–121 Crossref ,  Google Scholar

6 Roos CR, Nich C, Mun CJ, et al. : Clinical validation of reduction in cocaine frequency level as an endpoint in clinical trials for cocaine use disorder . Drug Alcohol Depend 2019 ; 205: 107648 Crossref , Medline ,  Google Scholar

7 Center for Drug Evaluation and Research, US Food and Drug Administration: The Voice of the Patient: A Series of Reports From the US Food and Drug Administration’s (FDA’s) Patient-Focused Drug Development Initiative: Opioid Use Disorder. Rockville, Md, Center for Drug Evaluation and Research, 2018. https://www.fda.gov/media/124391/download Google Scholar

8 Thannickal TC, John J, Shan L, et al. : Opiates increase the number of hypocretin-producing cells in human and mouse brain and reverse cataplexy in a mouse model of narcolepsy . Sci Transl Med 2018 ; 10: eaao4953 Crossref , Medline ,  Google Scholar

9 Lawson RP, Nord CL, Seymour B, et al. : Disrupted habenula function in major depression . Mol Psychiatry 2017 ; 22:202–208 Crossref , Medline ,  Google Scholar

10 Velasquez KM, Molfese DL, Salas R : The role of the habenula in drug addiction . Front Hum Neurosci 2014 ; 8:174 Crossref , Medline ,  Google Scholar

11 Friedman A, Lax E, Dikshtein Y, et al. : Electrical stimulation of the lateral habenula produces enduring inhibitory effect on cocaine seeking behavior . Neuropharmacology 2010 ; 59:452–459 Crossref , Medline ,  Google Scholar

12 Morishita T, Fayad SM, Higuchi MA, et al. : Deep brain stimulation for treatment-resistant depression: systematic review of clinical outcomes . Neurotherapeutics 2014 ; 11:475–484 Crossref , Medline ,  Google Scholar

13 Serafini G, Adavastro G, Canepa G, et al. : The efficacy of buprenorphine in major depression, treatment-resistant depression, and suicidal behavior: a systematic review . Int J Mol Sci 2018 ; 19:2410 Crossref ,  Google Scholar

14 Dreifuss JA, Griffin ML, Frost K, et al. : Patient characteristics associated with buprenorphine/naloxone treatment outcome for prescription opioid dependence: results from a multisite study . Drug Alcohol Depend 2013 ; 131:112–118 Crossref , Medline ,  Google Scholar

15 Venniro M, Zhang M, Caprioli D, et al. : Volitional social interaction prevents drug addiction in rat models . Nat Neurosci 2018 ; 21:1520–1529 Crossref , Medline ,  Google Scholar

16 Stauffer CS, Moschetto JM, McKernan SM, et al. : Oxytocin-enhanced motivational interviewing group therapy for methamphetamine use disorder in men who have sex with men: study protocol for a randomized controlled trial . Trials 2019 ; 20:145 Crossref , Medline ,  Google Scholar

17 Lee MR, Weerts EM : Oxytocin for the treatment of drug and alcohol use disorders . Behav Pharmacol 2016 ; 27:640–648 Crossref , Medline ,  Google Scholar

18 Goldstein RZ, Woicik PA, Maloney T, et al. : Oral methylphenidate normalizes cingulate activity in cocaine addiction during a salient cognitive task . Proc Natl Acad Sci USA 2010 ; 107:16667–16672 Crossref , Medline ,  Google Scholar

19 Dong H, Hayashi K, Singer J, et al. : Trajectories of injection drug use among people who use drugs in Vancouver, Canada, 1996–2017: growth mixture modeling using data from prospective cohort studies . Addiction 2019 ; 114:2173–2186 Crossref , Medline ,  Google Scholar

20 Substance Abuse and Mental Health Services Administration (SAMHSA): Social Inclusion (web page). Rockville, Md, SAMHSA, 2019. https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/social-inclusion Google Scholar

• Ghazaleh Soleimani , Ph.D. ,
• Juho Joutsa , M.D., Ph.D. ,
• Khaled Moussawi , M.D., Ph.D. ,
• Shan H. Siddiqi , M.D. ,
• Rayus Kuplicki , Ph.D. ,
• Marom Bikson , Ph.D. ,
• Martin P. Paulus , M.D., Ph.D. ,
• Michael D. Fox , M.D., Ph.D. ,
• Colleen A. Hanlon , Ph.D. ,
• Hamed Ekhtiari , M.D., Ph.D.
• Lara N. Coughlin , Ph.D. ,
• Paul Pfeiffer , M.D. , M.S. ,
• Dara Ganoczy , M.P.H. ,
• Lewei A. Lin , M.D. , M.S.
• Ned H. Kalin , M.D.

• Substance Use Disorder Treatment
• Opioid Use Disorder
• Alcohol Use Disorder
• Nicotine Use Disorder

• Open access
• Published: 13 November 2021

Risk and protective factors of drug abuse among adolescents: a systematic review

• Azmawati Mohammed Nawi 1 ,
• Rozmi Ismail 2 ,
• Fauziah Ibrahim 2 ,
• Mohd Rohaizat Hassan 1 ,
• Mohd Rizal Abdul Manaf 1 ,
• Noh Amit 3 ,
• Norhayati Ibrahim 3 &
• Nurul Shafini Shafurdin 2  

BMC Public Health volume  21 , Article number:  2088 ( 2021 ) Cite this article

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Drug abuse is detrimental, and excessive drug usage is a worldwide problem. Drug usage typically begins during adolescence. Factors for drug abuse include a variety of protective and risk factors. Hence, this systematic review aimed to determine the risk and protective factors of drug abuse among adolescents worldwide.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was adopted for the review which utilized three main journal databases, namely PubMed, EBSCOhost, and Web of Science. Tobacco addiction and alcohol abuse were excluded in this review. Retrieved citations were screened, and the data were extracted based on strict inclusion and exclusion criteria. Inclusion criteria include the article being full text, published from the year 2016 until 2020 and provided via open access resource or subscribed to by the institution. Quality assessment was done using Mixed Methods Appraisal Tools (MMAT) version 2018 to assess the methodological quality of the included studies. Given the heterogeneity of the included studies, a descriptive synthesis of the included studies was undertaken.

Out of 425 articles identified, 22 quantitative articles and one qualitative article were included in the final review. Both the risk and protective factors obtained were categorized into three main domains: individual, family, and community factors. The individual risk factors identified were traits of high impulsivity; rebelliousness; emotional regulation impairment, low religious, pain catastrophic, homework completeness, total screen time and alexithymia; the experience of maltreatment or a negative upbringing; having psychiatric disorders such as conduct problems and major depressive disorder; previous e-cigarette exposure; behavioral addiction; low-perceived risk; high-perceived drug accessibility; and high-attitude to use synthetic drugs. The familial risk factors were prenatal maternal smoking; poor maternal psychological control; low parental education; negligence; poor supervision; uncontrolled pocket money; and the presence of substance-using family members. One community risk factor reported was having peers who abuse drugs. The protective factors determined were individual traits of optimism; a high level of mindfulness; having social phobia; having strong beliefs against substance abuse; the desire to maintain one’s health; high paternal awareness of drug abuse; school connectedness; structured activity and having strong religious beliefs.

The outcomes of this review suggest a complex interaction between a multitude of factors influencing adolescent drug abuse. Therefore, successful adolescent drug abuse prevention programs will require extensive work at all levels of domains.

Peer Review reports

Introduction

Drug abuse is a global problem; 5.6% of the global population aged 15–64 years used drugs at least once during 2016 [ 1 ]. The usage of drugs among younger people has been shown to be higher than that among older people for most drugs. Drug abuse is also on the rise in many ASEAN (Association of Southeast Asian Nations) countries, especially among young males between 15 and 30 years of age. The increased burden due to drug abuse among adolescents and young adults was shown by the Global Burden of Disease (GBD) study in 2013 [ 2 ]. About 14% of the total health burden in young men is caused by alcohol and drug abuse. Younger people are also more likely to die from substance use disorders [ 3 ], and cannabis is the drug of choice among such users [ 4 ].

Adolescents are the group of people most prone to addiction [ 5 ]. The critical age of initiation of drug use begins during the adolescent period, and the maximum usage of drugs occurs among young people aged 18–25 years old [ 1 ]. During this period, adolescents have a strong inclination toward experimentation, curiosity, susceptibility to peer pressure, rebellion against authority, and poor self-worth, which makes such individuals vulnerable to drug abuse [ 2 ]. During adolescence, the basic development process generally involves changing relations between the individual and the multiple levels of the context within which the young person is accustomed. Variation in the substance and timing of these relations promotes diversity in adolescence and represents sources of risk or protective factors across this life period [ 6 ]. All these factors are crucial to helping young people develop their full potential and attain the best health in the transition to adulthood. Abusing drugs impairs the successful transition to adulthood by impairing the development of critical thinking and the learning of crucial cognitive skills [ 7 ]. Adolescents who abuse drugs are also reported to have higher rates of physical and mental illness and reduced overall health and well-being [ 8 ].

The absence of protective factors and the presence of risk factors predispose adolescents to drug abuse. Some of the risk factors are the presence of early mental and behavioral health problems, peer pressure, poorly equipped schools, poverty, poor parental supervision and relationships, a poor family structure, a lack of opportunities, isolation, gender, and accessibility to drugs [ 9 ]. The protective factors include high self-esteem, religiosity, grit, peer factors, self-control, parental monitoring, academic competence, anti-drug use policies, and strong neighborhood attachment [ 10 , 11 , 12 , 13 , 14 , 15 ].

The majority of previous systematic reviews done worldwide on drug usage focused on the mental, psychological, or social consequences of substance abuse [ 16 , 17 , 18 ], while some focused only on risk and protective factors for the non-medical use of prescription drugs among youths [ 19 ]. A few studies focused only on the risk factors of single drug usage among adolescents [ 20 ]. Therefore, the development of the current systematic review is based on the main research question: What is the current risk and protective factors among adolescent on the involvement with drug abuse? To the best of our knowledge, there is limited evidence from systematic reviews that explores the risk and protective factors among the adolescent population involved in drug abuse. Especially among developing countries, such as those in South East Asia, such research on the risk and protective factors for drug abuse is scarce. Furthermore, this review will shed light on the recent trends of risk and protective factors and provide insight into the main focus factors for prevention and control activities program. Additionally, this review will provide information on how these risk and protective factors change throughout various developmental stages. Therefore, the objective of this systematic review was to determine the risk and protective factors of drug abuse among adolescents worldwide. This paper thus fills in the gaps of previous studies and adds to the existing body of knowledge. In addition, this review may benefit certain parties in developing countries like Malaysia, where the national response to drugs is developing in terms of harm reduction, prison sentences, drug treatments, law enforcement responses, and civil society participation.

This systematic review was conducted using three databases, PubMed, EBSCOhost, and Web of Science, considering the easy access and wide coverage of reliable journals, focusing on the risk and protective factors of drug abuse among adolescents from 2016 until December 2020. The search was limited to the last 5 years to focus only on the most recent findings related to risk and protective factors. The search strategy employed was performed in accordance with the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) checklist.

A preliminary search was conducted to identify appropriate keywords and determine whether this review was feasible. Subsequently, the related keywords were searched using online thesauruses, online dictionaries, and online encyclopedias. These keywords were verified and validated by an academic professor at the National University of Malaysia. The keywords used as shown in Table  1 .

Selection criteria

The systematic review process for searching the articles was carried out via the steps shown in Fig.  1 . Firstly, screening was done to remove duplicate articles from the selected search engines. A total of 240 articles were removed in this stage. Titles and abstracts were screened based on the relevancy of the titles to the inclusion and exclusion criteria and the objectives. The inclusion criteria were full text original articles, open access articles or articles subscribed to by the institution, observation and intervention study design and English language articles. The exclusion criteria in this search were (a) case study articles, (b) systematic and narrative review paper articles, (c) non-adolescent-based analyses, (d) non-English articles, and (e) articles focusing on smoking (nicotine) and alcohol-related issues only. A total of 130 articles were excluded after title and abstract screening, leaving 55 articles to be assessed for eligibility. The full text of each article was obtained, and each full article was checked thoroughly to determine if it would fulfil the inclusion criteria and objectives of this study. Each of the authors compared their list of potentially relevant articles and discussed their selections until a final agreement was obtained. A total of 22 articles were accepted to be included in this review. Most of the excluded articles were excluded because the population was not of the target age range—i.e., featuring subjects with an age > 18 years, a cohort born in 1965–1975, or undergraduate college students; the subject matter was not related to the study objective—i.e., assessing the effects on premature mortality, violent behavior, psychiatric illness, individual traits, and personality; type of article such as narrative review and neuropsychiatry review; and because of our inability to obtain the full article—e.g., forthcoming work in 2021. One qualitative article was added to explain the domain related to risk and the protective factors among the adolescents.

PRISMA flow diagram showing the selection of studies on risk and protective factors for drug abuse among adolescents.2.2. Operational Definition

Drug-related substances in this context refer to narcotics, opioids, psychoactive substances, amphetamines, cannabis, ecstasy, heroin, cocaine, hallucinogens, depressants, and stimulants. Drugs of abuse can be either off-label drugs or drugs that are medically prescribed. The two most commonly abused substances not included in this review are nicotine (tobacco) and alcohol. Accordingly, e-cigarettes and nicotine vape were also not included. Further, “adolescence” in this study refers to members of the population aged between 10 to 18 years [ 21 ].

Data extraction tool

All researchers independently extracted information for each article into an Excel spreadsheet. The data were then customized based on their (a) number; (b) year; (c) author and country; (d) titles; (e) study design; (f) type of substance abuse; (g) results—risks and protective factors; and (h) conclusions. A second reviewer crossed-checked the articles assigned to them and provided comments in the table.

Quality assessment tool

By using the Mixed Method Assessment Tool (MMAT version 2018), all articles were critically appraised for their quality by two independent reviewers. This tool has been shown to be useful in systematic reviews encompassing different study designs [ 22 ]. Articles were only selected if both reviewers agreed upon the articles’ quality. Any disagreement between the assigned reviewers was managed by employing a third independent reviewer. All included studies received a rating of “yes” for the questions in the respective domains of the MMAT checklists. Therefore, none of the articles were removed from this review due to poor quality. The Cohen’s kappa (agreement) between the two reviewers was 0.77, indicating moderate agreement [ 23 ].

The initial search found 425 studies for review, but after removing duplicates and applying the criteria listed above, we narrowed the pool to 22 articles, all of which are quantitative in their study design. The studies include three prospective cohort studies [ 24 , 25 , 26 ], one community trial [ 27 ], one case-control study [ 28 ], and nine cross-sectional studies [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. After careful discussion, all reviewer panels agreed to add one qualitative study [ 46 ] to help provide reasoning for the quantitative results. The selected qualitative paper was chosen because it discussed almost all domains on the risk and protective factors found in this review.

A summary of all 23 articles is listed in Table  2 . A majority of the studies (13 articles) were from the United States of America (USA) [ 25 , 26 , 27 , 29 , 30 , 31 , 34 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ], three studies were from the Asia region [ 32 , 33 , 38 ], four studies were from Europe [ 24 , 28 , 40 , 44 ], and one study was from Latin America [ 35 ], Africa [ 43 ] and Mediterranean [ 45 ]. The number of sample participants varied widely between the studies, ranging from 70 samples (minimum) to 700,178 samples (maximum), while the qualitative paper utilized a total of 100 interviewees. There were a wide range of drugs assessed in the quantitative articles, with marijuana being mentioned in 11 studies, cannabis in five studies, and opioid (six studies). There was also large heterogeneity in terms of the study design, type of drug abused, measurements of outcomes, and analysis techniques used. Therefore, the data were presented descriptively.

After thorough discussion and evaluation, all the findings (both risk and protective factors) from the review were categorized into three main domains: individual factors, family factors, and community factors. The conceptual framework is summarized in Fig.  2 .

Conceptual framework of risk and protective factors related to adolescent drug abuse

DOMAIN: individual factor

Risk factors.

Almost all the articles highlighted significant findings of individual risk factors for adolescent drug abuse. Therefore, our findings for this domain were further broken down into five more sub-domains consisting of personal/individual traits, significant negative growth exposure, personal psychiatric diagnosis, previous substance history, comorbidity and an individual’s attitude and perception.

Personal/individual traits

Chuang et al. [ 29 ] found that adolescents with high impulsivity traits had a significant positive association with drug addiction. This study also showed that the impulsivity trait alone was an independent risk factor that increased the odds between two to four times for using any drug compared to the non-impulsive group. Another longitudinal study by Guttmannova et al. showed that rebellious traits are positively associated with marijuana drug abuse [ 27 ]. The authors argued that measures of rebelliousness are a good proxy for a youth’s propensity to engage in risky behavior. Nevertheless, Wilson et al. [ 37 ], in a study involving 112 youths undergoing detoxification treatment for opioid abuse, found that a majority of the affected respondents had difficulty in regulating their emotions. The authors found that those with emotional regulation impairment traits became opioid dependent at an earlier age. Apart from that, a case-control study among outpatient youths found that adolescents involved in cannabis abuse had significant alexithymia traits compared to the control population [ 28 ]. Those adolescents scored high in the dimension of Difficulty in Identifying Emotion (DIF), which is one of the key definitions of diagnosing alexithymia. Overall, the adjusted Odds Ratio for DIF in cannabis abuse was 1.11 (95% CI, 1.03–1.20).

Significant negative growth exposure

A history of maltreatment in the past was also shown to have a positive association with adolescent drug abuse. A study found that a history of physical abuse in the past is associated with adolescent drug abuse through a Path Analysis, despite evidence being limited to the female gender [ 25 ]. However, evidence from another study focusing at foster care concluded that any type of maltreatment might result in a prevalence as high as 85.7% for the lifetime use of cannabis and as high as 31.7% for the prevalence of cannabis use within the last 3-months [ 30 ]. The study also found significant latent variables that accounted for drug abuse outcomes, which were chronic physical maltreatment (factor loading of 0.858) and chronic psychological maltreatment (factor loading of 0.825), with an r 2 of 73.6 and 68.1%, respectively. Another study shed light on those living in child welfare service (CWS) [ 35 ]. It was observed through longitudinal measurements that proportions of marijuana usage increased from 9 to 18% after 36 months in CWS. Hence, there is evidence of the possibility of a negative upbringing at such shelters.

Personal psychiatric diagnosis

The robust studies conducted in the USA have deduced that adolescents diagnosed with a conduct problem (CP) have a positive association with marijuana abuse (OR = 1.75 [1.56, 1.96], p  < 0.0001). Furthermore, those with a diagnosis of Major Depressive Disorder (MDD) showed a significant positive association with marijuana abuse.

Previous substance and addiction history

Another study found that exposure to e-cigarettes within the past 30 days is related to an increase in the prevalence of marijuana use and prescription drug use by at least four times in the 8th and 10th grades and by at least three times in the 12th grade [ 34 ]. An association between other behavioral addictions and the development of drug abuse was also studied [ 29 ]. Using a 12-item index to assess potential addictive behaviors [ 39 ], significant associations between drug abuse and the groups with two behavioral addictions (OR = 3.19, 95% CI 1.25,9.77) and three behavioral addictions (OR = 3.46, 95% CI 1.25,9.58) were reported.

Comorbidity

The paper by Dash et al. (2020) highlight adolescent with a disease who needs routine medical pain treatment have higher risk of opioid misuse [ 38 ]. The adolescents who have disorder symptoms may have a risk for opioid misuse despite for the pain intensity.

Individual’s attitudes and perceptions

In a study conducted in three Latin America countries (Argentina, Chile, and Uruguay), it was shown that adolescents with low or no perceived risk of taking marijuana had a higher risk of abuse (OR = 8.22 times, 95% CI 7.56, 10.30) [ 35 ]. This finding is in line with another study that investigated 2002 adolescents and concluded that perceiving the drug as harmless was an independent risk factor that could prospectively predict future marijuana abuse [ 27 ]. Moreover, some youth interviewed perceived that they gained benefits from substance use [ 38 ]. The focus group discussion summarized that the youth felt positive personal motivation and could escape from a negative state by taking drugs. Apart from that, adolescents who had high-perceived availability of drugs in their neighborhoods were more likely to increase their usage of marijuana over time (OR = 11.00, 95% CI 9.11, 13.27) [ 35 ]. A cheap price of the substance and the availability of drug dealers around schools were factors for youth accessibility [ 38 ]. Perceived drug accessibility has also been linked with the authorities’ enforcement programs. The youth perception of a lax community enforcement of laws regarding drug use at all-time points predicted an increase in marijuana use in the subsequent assessment period [ 27 ]. Besides perception, a study examining the attitudes towards synthetic drugs based on 8076 probabilistic samples of Macau students found that the odds of the lifetime use of marijuana was almost three times higher among those with a strong attitude towards the use of synthetic drugs [ 32 ]. In addition, total screen time among the adolescent increase the likelihood of frequent cannabis use. Those who reported daily cannabis use have a mean of 12.56 h of total screen time, compared to a mean of 6.93 h among those who reported no cannabis use. Adolescent with more time on internet use, messaging, playing video games and watching TV/movies were significantly associated with more frequent cannabis use [ 44 ].

Protective factors

Individual traits.

Some individual traits have been determined to protect adolescents from developing drug abuse habits. A study by Marin et al. found that youth with an optimistic trait were less likely to become drug dependent [ 33 ]. In this study involving 1104 Iranian students, it was concluded that a higher optimism score (measured using the Children Attributional Style Questionnaire, CASQ) was a protective factor against illicit drug use (OR = 0.90, 95% CI: 0.85–0.95). Another study found that high levels of mindfulness, measured using the 25-item Child Acceptance and Mindfulness Measure, CAMM, lead to a slower progression toward injectable drug abuse among youth with opioid addiction (1.67 years, p  = .041) [ 37 ]. In addition, the social phobia trait was found to have a negative association with marijuana use (OR = 0.87, 95% CI 0.77–0.97), as suggested [ 31 ].

According to El Kazdouh et al., individuals with a strong belief against substance use and those with a strong desire to maintain their health were more likely to be protected from involvement in drug abuse [ 46 ].

DOMAIN: family factors

The biological factors underlying drug abuse in adolescents have been reported in several studies. Epigenetic studies are considered important, as they can provide a good outline of the potential pre-natal factors that can be targeted at an earlier stage. Expecting mothers who smoke tobacco and alcohol have an indirect link with adolescent substance abuse in later life [ 24 , 39 ]. Moreover, the dynamic relationship between parents and their children may have some profound effects on the child’s growth. Luk et al. examined the mediator effects between parenting style and substance abuse and found the maternal psychological control dimension to be a significant variable [ 26 ]. The mother’s psychological control was two times higher in influencing her children to be involved in substance abuse compared to the other dimension. Conversely, an indirect risk factor towards youth drug abuse was elaborated in a study in which low parental educational level predicted a greater risk of future drug abuse by reducing the youth’s perception of harm [ 27 , 43 ]. Negligence from a parental perspective could also contribute to this problem. According to El Kazdouh et al. [ 46 ], a lack of parental supervision, uncontrolled pocket money spending among children, and the presence of substance-using family members were the most common negligence factors.

While the maternal factors above were shown to be risk factors, the opposite effect was seen when the paternal figure equipped himself with sufficient knowledge. A study found that fathers with good information and awareness were more likely to protect their adolescent children from drug abuse [ 26 ]. El Kazdouh et al. noted that support and advice could be some of the protective factors in this area [ 46 ].

DOMAIN: community factors

• Risk factor

A study in 2017 showed a positive association between adolescent drug abuse and peers who abuse drugs [ 32 , 39 ]. It was estimated that the odds of becoming a lifetime marijuana user was significantly increased by a factor of 2.5 ( p  < 0.001) among peer groups who were taking synthetic drugs. This factor served as peer pressure for youth, who subconsciously had desire to be like the others [ 38 ]. The impact of availability and engagement in structured and unstructured activities also play a role in marijuana use. The findings from Spillane (2000) found that the availability of unstructured activities was associated with increased likelihood of marijuana use [ 42 ].

• Protective factor

Strong religious beliefs integrated into society serve as a crucial protective factor that can prevent adolescents from engaging in drug abuse [ 38 , 45 ]. In addition, the school connectedness and adult support also play a major contribution in the drug use [ 40 ].

The goal of this review was to identify and classify the risks and protective factors that lead adolescents to drug abuse across the three important domains of the individual, family, and community. No findings conflicted with each other, as each of them had their own arguments and justifications. The findings from our review showed that individual factors were the most commonly highlighted. These factors include individual traits, significant negative growth exposure, personal psychiatric diagnosis, previous substance and addiction history, and an individual’s attitude and perception as risk factors.

Within the individual factor domain, nine articles were found to contribute to the subdomain of personal/ individual traits [ 27 , 28 , 29 , 37 , 38 , 39 , 40 , 43 , 44 ]. Despite the heterogeneity of the study designs and the substances under investigation, all of the papers found statistically significant results for the possible risk factors of adolescent drug abuse. The traits of high impulsivity, rebelliousness, difficulty in regulating emotions, and alexithymia can be considered negative characteristic traits. These adolescents suffer from the inability to self-regulate their emotions, so they tend to externalize their behaviors as a way to avoid or suppress the negative feelings that they are experiencing [ 41 , 47 , 48 ]. On the other hand, engaging in such behaviors could plausibly provide a greater sense of positive emotions and make them feel good [ 49 ]. Apart from that, evidence from a neurophysiological point of view also suggests that the compulsive drive toward drug use is complemented by deficits in impulse control and decision making (impulsive trait) [ 50 ]. A person’s ability in self-control will seriously impaired with continuous drug use and will lead to the hallmark of addiction [ 51 ].

On the other hand, there are articles that reported some individual traits to be protective for adolescents from engaging in drug abuse. Youth with the optimistic trait, a high level of mindfulness, and social phobia were less likely to become drug dependent [ 31 , 33 , 37 ]. All of these articles used different psychometric instruments to classify each individual trait and were mutually exclusive. Therefore, each trait measured the chance of engaging in drug abuse on its own and did not reflect the chance at the end of the spectrum. These findings show that individual traits can be either protective or risk factors for the drugs used among adolescents. Therefore, any adolescent with negative personality traits should be monitored closely by providing health education, motivation, counselling, and emotional support since it can be concluded that negative personality traits are correlated with high risk behaviours such as drug abuse [ 52 ].

Our study also found that a history of maltreatment has a positive association with adolescent drug abuse. Those adolescents with episodes of maltreatment were considered to have negative growth exposure, as their childhoods were negatively affected by traumatic events. Some significant associations were found between maltreatment and adolescent drug abuse, although the former factor was limited to the female gender [ 25 , 30 , 36 ]. One possible reason for the contrasting results between genders is the different sample populations, which only covered child welfare centers [ 36 ] and foster care [ 30 ]. Regardless of the place, maltreatment can happen anywhere depending on the presence of the perpetrators. To date, evidence that concretely links maltreatment and substance abuse remains limited. However, a plausible explanation for this link could be the indirect effects of posttraumatic stress (i.e., a history of maltreatment) leading to substance use [ 53 , 54 ]. These findings highlight the importance of continuous monitoring and follow-ups with adolescents who have a history of maltreatment and who have ever attended a welfare center.

Addiction sometimes leads to another addiction, as described by the findings of several studies [ 29 , 34 ]. An initial study focused on the effects of e-cigarettes in the development of other substance abuse disorders, particularly those related to marijuana, alcohol, and commonly prescribed medications [ 34 ]. The authors found that the use of e-cigarettes can lead to more severe substance addiction [ 55 ], possibly through normalization of the behavior. On the other hand, Chuang et al.’s extensive study in 2017 analyzed the combined effects of either multiple addictions alone or a combination of multiple addictions together with the impulsivity trait [ 29 ]. The outcomes reported were intriguing and provide the opportunity for targeted intervention. The synergistic effects of impulsiveness and three other substance addictions (marijuana, tobacco, and alcohol) substantially increased the likelihood for drug abuse from 3.46 (95%CI 1.25, 9.58) to 10.13 (95% CI 3.95, 25.95). Therefore, proper rehabilitation is an important strategy to ensure that one addiction will not lead to another addiction.

The likelihood for drug abuse increases as the population perceives little or no harmful risks associated with the drugs. On the opposite side of the coin, a greater perceived risk remains a protective factor for marijuana abuse [ 56 ]. However, another study noted that a stronger determinant for adolescent drug abuse was the perceived availability of the drug [ 35 , 57 ]. Looking at the bigger picture, both perceptions corroborate each other and may inform drug use. Another study, on the other hand, reported that there was a decreasing trend of perceived drug risk in conjunction with the increasing usage of drugs [ 58 ]. As more people do drugs, youth may inevitably perceive those drugs as an acceptable norm without any harmful consequences [ 59 ].

In addition, the total spent for screen time also contribute to drug abuse among adolescent [ 43 ]. This scenario has been proven by many researchers on the effect of screen time on the mental health [ 60 ] that leads to the substance use among the adolescent due to the ubiquity of pro-substance use content on the internet. Adolescent with comorbidity who needs medical pain management by opioids also tend to misuse in future. A qualitative exploration on the perspectives among general practitioners concerning the risk of opioid misuse in people with pain, showed pain management by opioids is a default treatment and misuse is not a main problem for the them [ 61 ]. A careful decision on the use of opioids as a pain management should be consider among the adolescents and their understanding is needed.

Within the family factor domain, family structures were found to have both positive and negative associations with drug abuse among adolescents. As described in one study, paternal knowledge was consistently found to be a protective factor against substance abuse [ 26 ]. With sufficient knowledge, the father can serve as the guardian of his family to monitor and protect his children from negative influences [ 62 ]. The work by Luk et al. also reported a positive association of maternal psychological association towards drug abuse (IRR 2.41, p  < 0.05) [ 26 ]. The authors also observed the same effect of paternal psychological control, although it was statistically insignificant. This construct relates to parenting style, and the authors argued that parenting style might have a profound effect on the outcomes under study. While an earlier literature review [ 63 ] also reported such a relationship, a recent study showed a lesser impact [ 64 ] with regards to neglectful parenting styles leading to poorer substance abuse outcomes. Nevertheless, it was highlighted in another study that the adolescents’ perception of a neglectful parenting style increased their odds (OR 2.14, p  = 0.012) of developing alcohol abuse, not the parenting style itself [ 65 ]. Altogether, families play vital roles in adolescents’ risk for engaging in substance abuse [ 66 ]. Therefore, any intervention to impede the initiation of substance use or curb existing substance use among adolescents needs to include parents—especially improving parent–child communication and ensuring that parents monitor their children’s activities.

Finally, the community also contributes to drug abuse among adolescents. As shown by Li et al. [ 32 ] and El Kazdouh et al. [ 46 ], peers exert a certain influence on other teenagers by making them subconsciously want to fit into the group. Peer selection and peer socialization processes might explain why peer pressure serves as a risk factor for drug-abuse among adolescents [ 67 ]. Another study reported that strong religious beliefs integrated into society play a crucial role in preventing adolescents from engaging in drug abuse [ 46 ]. Most religions devalue any actions that can cause harmful health effects, such as substance abuse [ 68 ]. Hence, spiritual beliefs may help protect adolescents. This theme has been well established in many studies [ 60 , 69 , 70 , 71 , 72 ] and, therefore, could be implemented by religious societies as part of interventions to curb the issue of adolescent drug abuse. The connection with school and structured activity did reduce the risk as a study in USA found exposure to media anti-drug messages had an indirect negative effect on substances abuse through school-related activity and social activity [ 73 ]. The school activity should highlight on the importance of developmental perspective when designing and offering school-based prevention programs [75].

Limitations

We adopted a review approach that synthesized existing evidence on the risk and protective factors of adolescents engaging in drug abuse. Although this systematic review builds on the conclusion of a rigorous review of studies in different settings, there are some potential limitations to this work. We may have missed some other important factors, as we only included English articles, and article extraction was only done from the three search engines mentioned. Nonetheless, this review focused on worldwide drug abuse studies, rather than the broader context of substance abuse including alcohol and cigarettes, thereby making this paper more focused.

Conclusions

This review has addressed some recent knowledge related to the individual, familial, and community risk and preventive factors for adolescent drug use. We suggest that more attention should be given to individual factors since most findings were discussed in relation to such factors. With the increasing trend of drug abuse, it will be critical to focus research specifically on this area. Localized studies, especially those related to demographic factors, may be more effective in generating results that are specific to particular areas and thus may be more useful in generating and assessing local control and prevention efforts. Interventions using different theory-based psychotherapies and a recognition of the unique developmental milestones specific to adolescents are among examples that can be used. Relevant holistic approaches should be strengthened not only by relevant government agencies but also by the private sector and non-governmental organizations by promoting protective factors while reducing risk factors in programs involving adolescents from primary school up to adulthood to prevent and control drug abuse. Finally, legal legislation and enforcement against drug abuse should be engaged with regularly as part of our commitment to combat this public health burden.

Data availability and materials

All data generated or analysed during this study are included in this published article.

Nation, U. World Drug Report 2018 (United Nations publication, Sales No. E.18X.XI.9. United Nation publication). 2018. Retrieved from https://www.unodc.org/wdr2018

Google Scholar  

Degenhardt L, Stockings E, Patton G, Hall WD, Lynskey M. The increasing global health priority of substance use in young people. Lancet Psychiatry. 2016;3(3):251–64. https://doi.org/10.1016/S2215-0366(15)00508-8 Elsevier Ltd.

Article   PubMed   Google Scholar  

Ritchie H, Roser M. Drug Use - Our World in Data: Global Change Data Lab; 2019. https://ourworldindata.org/drug-use [10 June 2020]

Holm S, Sandberg S, Kolind T, Hesse M. The importance of cannabis culture in young adult cannabis use. J Subst Abus. 2014;19(3):251–6.

Luikinga SJ, Kim JH, Perry CJ. Developmental perspectives on methamphetamine abuse: exploring adolescent vulnerabilities on brain and behavior. Progress Neuro Psychopharmacol Biol Psychiatry. 2018;87(Pt A):78–84. https://doi.org/10.1016/j.pnpbp.2017.11.010 Elsevier Inc.

Article   CAS   Google Scholar  

Ismail R, Ghazalli MN, Ibrahim N. Not all developmental assets can predict negative mental health outcomes of disadvantaged youth: a case of suburban Kuala Lumpur. Mediterr J Soc Sci. 2015;6(1):452–9. https://doi.org/10.5901/mjss.2015.v6n5s1p452 .

Article   Google Scholar  

Crews F, He J, Hodge C. Adolescent cortical development: a critical period of vulnerability for addiction. Pharmacol Biochem Behav. 2007;86(2):189–99. https://doi.org/10.1016/j.pbb.2006.12.001 .

Article   CAS   PubMed   Google Scholar  

Schulte MT, Hser YI. Substance use and associated health conditions throughout the lifespan. Public Health Rev. 2013;35(2). https://doi.org/10.1007/bf03391702 Technosdar Ltd.

Somani, S.; Meghani S. Substance Abuse among Youth: A Harsh Reality 2016. doi: https://doi.org/10.4172/2165-7548.1000330 , 6, 4.

Book   Google Scholar  

Drabble L, Trocki KF, Klinger JL. Religiosity as a protective factor for hazardous drinking and drug use among sexual minority and heterosexual women: findings from the National Alcohol Survey. Drug Alcohol Depend. 2016;161:127–34. https://doi.org/10.1016/j.drugalcdep.2016.01.022 .

Article   PubMed   PubMed Central   Google Scholar  

Goliath V, Pretorius B. Peer risk and protective factors in adolescence: Implications for drug use prevention. Soc Work. 2016;52(1):113–29. https://doi.org/10.15270/52-1-482 .

Guerrero LR, Dudovitz R, Chung PJ, Dosanjh KK, Wong MD. Grit: a potential protective factor against substance use and other risk behaviors among Latino adolescents. Acad Pediatr. 2016;16(3):275–81. https://doi.org/10.1016/j.acap.2015.12.016 .

National Institutes on Drug Abuse. What are risk factors and protective factors? National Institute on Drug Abuse (NIDA); 2003. Retrieved from https://www.drugabuse.gov/publications/preventing-drug-use-among-children-adolescents/chapter-1-risk-factors-protective-factors/what-are-risk-factors

Nguyen NN, Newhill CE. The role of religiosity as a protective factor against marijuana use among African American, White, Asian, and Hispanic adolescents. J Subst Abus. 2016;21(5):547–52. https://doi.org/10.3109/14659891.2015.1093558 .

Schinke S, Schwinn T, Hopkins J, Wahlstrom L. Drug abuse risk and protective factors among Hispanic adolescents. Prev Med Rep. 2016;3:185–8. https://doi.org/10.1016/j.pmedr.2016.01.012 .

Macleod J, Oakes R, Copello A, Crome PI, Egger PM, Hickman M, et al. Psychological and social sequelae of cannabis and other illicit drug use by young people: a systematic review of longitudinal, general population studies. Lancet. 2004;363(9421):1579–88. https://doi.org/10.1016/S0140-6736(04)16200-4 .

Moore TH, Zammit S, Lingford-Hughes A, Barnes TR, Jones PB, Burke M, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet. 2007;370(9584):319–28. https://doi.org/10.1016/S0140-6736(07)61162-3 .

Semple DM, McIntosh AM, Lawrie SM. Cannabis as a risk factor for psychosis: systematic review. J Psychopharmacol. 2005;19(2):187–94. https://doi.org/10.1177/0269881105049040 .

Nargiso JE, Ballard EL, Skeer MR. A systematic review of risk and protective factors associated with nonmedical use of prescription drugs among youth in the united states: A social ecological perspective. J Stud Alcohol Drugs. 2015;76(1):5–20. https://doi.org/10.15288/jsad.2015.76.5 .

Guxensa M, Nebot M, Ariza C, Ochoa D. Factors associated with the onset of cannabis use: a systematic review of cohort studies. Gac Sanit. 2007;21(3):252–60. https://doi.org/10.1157/13106811 .

Susan MS, Peter SA, Dakshitha W, George CP. The age of adolescence. Lancet Child Adolesc Health. 2018;2(Issue 3):223–8. https://doi.org/10.1016/S2352-4642(18)30022-1 .

Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, et al. The mixed methods appraisal tool (MMAT) version 2018 for information professionals and researchers. Educ Inf. 2018;34(4):285–91. https://doi.org/10.3233/EFI-180221 .

McHugh ML. Interrater reliability: The kappa statistic. Biochem Med. 2012;22(3):276–82. https://doi.org/10.11613/bm.2012.031 .

Cecil CAM, Walton E, Smith RG, Viding E, McCrory EJ, Relton CL, et al. DNA methylation and substance-use risk: a prospective, genome-wide study spanning gestation to adolescence. Transl Psychiatry. 2016;6(12):e976. https://doi.org/10.1038/tp.2016.247 Nature Publishing Group.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Kobulsky JM. Gender differences in pathways from physical and sexual abuse to early substance use. Child Youth Serv Rev. 2017;83:25–32. https://doi.org/10.1016/j.childyouth.2017.10.027 .

Luk JW, King KM, McCarty CA, McCauley E, Stoep A. Prospective effects of parenting on substance use and problems across Asian/Pacific islander and European American youth: Tests of moderated mediation. J Stud Alcohol Drugs. 2017;78(4):521–30. https://doi.org/10.15288/jsad.2017.78.521 .

Guttmannova K, Skinner ML, Oesterle S, White HR, Catalano RF, Hawkins JD. The interplay between marijuana-specific risk factors and marijuana use over the course of adolescence. Prev Sci. 2019;20(2):235–45. https://doi.org/10.1007/s11121-018-0882-9 .

Dorard G, Bungener C, Phan O, Edel Y, Corcos M, Berthoz S. Is alexithymia related to cannabis use disorder? Results from a case-control study in outpatient adolescent cannabis abusers. J Psychosom Res. 2017;95:74–80. https://doi.org/10.1016/j.jpsychores.2017.02.012 .

Chuang CWI, Sussman S, Stone MD, Pang RD, Chou CP, Leventhal AM, et al. Impulsivity and history of behavioral addictions are associated with drug use in adolescents. Addict Behav. 2017;74:41–7. https://doi.org/10.1016/j.addbeh.2017.05.021 .

Gabrielli J, Jackson Y, Brown S. Associations between maltreatment history and severity of substance use behavior in youth in Foster Care. Child Maltreat. 2016;21(4):298–307. https://doi.org/10.1177/1077559516669443 .

Khoddam R, Jackson NJ, Leventhal AM. Internalizing symptoms and conduct problems: redundant, incremental, or interactive risk factors for adolescent substance use during the first year of high school? Drug Alcohol Depend. 2016;169:48–55. https://doi.org/10.1016/j.drugalcdep.2016.10.007 .

Li SD, Zhang X, Tang W, Xia Y. Predictors and implications of synthetic drug use among adolescents in the gambling Capital of China. SAGE Open. 2017;7(4):215824401773303. https://doi.org/10.1177/2158244017733031 .

Marin S, Heshmatian E, Nadrian H, Fakhari A, Mohammadpoorasl A. Associations between optimism, tobacco smoking and substance abuse among Iranian high school students. Health Promot Perspect. 2019;9(4):279–84. https://doi.org/10.15171/hpp.2019.38 .

Miech RA, O’Malley PM, Johnston LD, Patrick ME. E-cigarettes and the drug use patterns of adolescents. Nicotine Tob Res. 2015;18(5):654–9. https://doi.org/10.1093/ntr/ntv217 .

Schleimer JP, Rivera-Aguirre AE, Castillo-Carniglia A, Laqueur HS, Rudolph KE, Suárez H, et al. Investigating how perceived risk and availability of marijuana relate to marijuana use among adolescents in Argentina, Chile, and Uruguay over time. Drug Alcohol Depend. 2019;201:115–26. https://doi.org/10.1016/j.drugalcdep.2019.03.029 .

Traube DE, Yarnell LM, Schrager SM. Differences in polysubstance use among youth in the child welfare system: toward a better understanding of the highest-risk teens. Child Abuse Negl. 2016;52:146–57. https://doi.org/10.1016/j.chiabu.2015.11.020 .

Wilson JD, Vo H, Matson P, Adger H, Barnett G, Fishman M. Trait mindfulness and progression to injection use in youth with opioid addiction. Subst Use Misuse. 2017;52(11):1486–93. https://doi.org/10.1080/10826084.2017.1289225 .

Dash GF, Feldstein Ewing SW, Murphy C, Hudson KA, Wilson AC. Contextual risk among adolescents receiving opioid prescriptions for acute pain in pediatric ambulatory care settings. Addict Behav. 2020;104:106314. https://doi.org/10.1016/j.addbeh.2020.106314 Epub 2020 Jan 11. PMID: 31962289; PMCID: PMC7024039.

Osborne V, Serdarevic M, Striley CW, Nixon SJ, Winterstein AG, Cottler LB. Age of first use of prescription opioids and prescription opioid non-medical use among older adolescents. Substance Use Misuse. 2020;55(14):2420–7. https://doi.org/10.1080/10826084.2020.1823420 .

Zuckermann AME, Qian W, Battista K, Jiang Y, de Groh M, Leatherdale ST. Factors influencing the non-medical use of prescription opioids among youth: results from the COMPASS study. J Subst Abus. 2020;25(5):507–14. https://doi.org/10.1080/14659891.2020.1736669 .

De Pedro KT, Esqueda MC, Gilreath TD. School protective factors and substance use among lesbian, gay, and bisexual adolescents in California public schools. LGBT Health. 2017;4(3):210–6. https://doi.org/10.1089/lgbt.2016.0132 .

Spillane NS, Schick MR, Kirk-Provencher KT, Hill DC, Wyatt J, Jackson KM. Structured and unstructured activities and alcohol and marijuana use in middle school: the role of availability and engagement. Substance Use Misuse. 2020;55(11):1765–73. https://doi.org/10.1080/10826084.2020.1762652 .

Ogunsola OO, Fatusi AO. Risk and protective factors for adolescent substance use: a comparative study of secondary school students in rural and urban areas of Osun state, Nigeria. Int J Adolesc Med Health. 2016;29(3). https://doi.org/10.1515/ijamh-2015-0096 .

Doggett A, Qian W, Godin K, De Groh M, Leatherdale ST. Examining the association between exposure to various screen time sedentary behaviours and cannabis use among youth in the COMPASS study. SSM Population Health. 2019;9:100487. https://doi.org/10.1016/j.ssmph.2019.100487 .

Afifi RA, El Asmar K, Bteddini D, Assi M, Yassin N, Bitar S, et al. Bullying victimization and use of substances in high school: does religiosity moderate the association? J Relig Health. 2020;59(1):334–50. https://doi.org/10.1007/s10943-019-00789-8 .

El Kazdouh H, El-Ammari A, Bouftini S, El Fakir S, El Achhab Y. Adolescents, parents and teachers’ perceptions of risk and protective factors of substance use in Moroccan adolescents: a qualitative study. Substance Abuse Treat Prevent Policy. 2018;13(1):–31. https://doi.org/10.1186/s13011-018-0169-y .

Sussman S, Lisha N, Griffiths M. Prevalence of the addictions: a problem of the majority or the minority? Eval Health Prof. 2011;34(1):3–56. https://doi.org/10.1177/0163278710380124 .

Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev. 2010;30(2):217–37. https://doi.org/10.1016/j.cpr.2009.11.004 .

Ricketts T, Macaskill A. Gambling as emotion management: developing a grounded theory of problem gambling. Addict Res Theory. 2003;11(6):383–400. https://doi.org/10.1080/1606635031000062074 .

Williams AD, Grisham JR. Impulsivity, emotion regulation, and mindful attentional focus in compulsive buying. Cogn Ther Res. 2012;36(5):451–7. https://doi.org/10.1007/s10608-011-9384-9 .

National Institutes on Drug Abuse. Drugs, brains, and behavior the science of addiction national institute on drug abuse (nida). 2014. Retrieved from https://www.drugabuse.gov/sites/default/files/soa_2014.pdf

Hokm Abadi ME, Bakhti M, Nazemi M, Sedighi S, Mirzadeh Toroghi E. The relationship between personality traits and drug type among substance abuse. J Res Health. 2018;8(6):531–40.

Longman-Mills S, Haye W, Hamilton H, Brands B, Wright MGM, Cumsille F, et al. Psychological maltreatment and its relationship with substance abuse among university students in Kingston, Jamaica, vol. 24. Florianopolis: Texto Contexto Enferm; 2015. p. 63–8.

Rosenkranz SE, Muller RT, Henderson JL. The role of complex PTSD in mediating childhood maltreatment and substance abuse severity among youth seeking substance abuse treatment. Psychol Trauma Theory Res Pract Policy. 2014;6(1):25–33. https://doi.org/10.1037/a0031920 .

Krishnan-Sarin S, Morean M, Kong G, et al. E-Cigarettes and “dripping” among high-school youth. Pediatrics. 2017;139(3). https://doi.org/10.1542/peds.2016-3224 .

Adinoff B. Neurobiologic processes in drug reward and addiction. Harvard review of psychiatry. NIH Public Access. 2004;12(6):305–20. https://doi.org/10.1080/10673220490910844 .

Kandel D, Kandel E. The gateway hypothesis of substance abuse: developmental, biological and societal perspectives. Acta Paediatrica. 2014;104(2):130–7.

Dempsey RC, McAlaney J, Helmer SM, Pischke CR, Akvardar Y, Bewick BM, et al. Normative perceptions of Cannabis use among European University students: associations of perceived peer use and peer attitudes with personal use and attitudes. J Stud Alcohol Drugs. 2016;77(5):740–8.

Cioffredi L, Kamon J, Turner W. Effects of depression, anxiety and screen use on adolescent substance use. Prevent Med Rep. 2021;22:101362. https://doi.org/10.1016/j.pmedr.2021.101362 .

Luckett T, NewtonJohn T, Phillips J, et al. Risk of opioid misuse in people with cancer and pain and related clinical considerations:a qualitative study of the perspectives of Australian general practitioners. BMJ Open. 2020;10(2):e034363. https://doi.org/10.1136/bmjopen-2019-034363 .

Lipari RN. Trends in Adolescent Substance Use and Perception of Risk from Substance Use. The CBHSQ Report. Substance Abuse Mental Health Serv Admin. 2013; Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27656743 .

Muchiri BW, dos Santos MML. Family management risk and protective factors for adolescent substance use in South Africa. Substance Abuse. 2018;13(1):24. https://doi.org/10.1186/s13011-018-0163-4 .

Becoña E, Martínez Ú, Calafat A, Juan M, Fernández-Hermida JR, Secades-Villa R. Parental styles and drug use: a review. In: Drugs: Education, Prevention and Policy: Taylor & Francis; 2012. https://doi.org/10.3109/09687637.2011.631060 .

Berge J, Sundel K, Ojehagen A, Hakansson A. Role of parenting styles in adolescent substance use: results from a Swedish longitudinal cohort study. BMJ Open. 2016;6(1):e008979. https://doi.org/10.1136/bmjopen-2015-008979 .

Opara I, Lardier DT, Reid RJ, Garcia-Reid P. “It all starts with the parents”: a qualitative study on protective factors for drug-use prevention among black and Hispanic girls. Affilia J Women Soc Work. 2019;34(2):199–218. https://doi.org/10.1177/0886109918822543 .

Martínez-Loredo V, Fernández-Artamendi S, Weidberg S, Pericot I, López-Núñez C, Fernández-Hermida J, et al. Parenting styles and alcohol use among adolescents: a longitudinal study. Eur J Invest Health Psychol Educ. 2016;6(1):27–36. https://doi.org/10.1989/ejihpe.v6i1.146 .

Baharudin MN, Mohamad M, Karim F. Drug-abuse inmates maqasid shariah quality of lifw: a conceotual paper. Hum Soc Sci Rev. 2020;8(3):1285–94. https://doi.org/10.18510/hssr.2020.83131 .

Henneberger AK, Mushonga DR, Preston AM. Peer influence and adolescent substance use: a systematic review of dynamic social network research. Adolesc Res Rev. 2020;6(1):57–73. https://doi.org/10.1007/s40894-019-00130-0 Springer.

Gomes FC, de Andrade AG, Izbicki R, Almeida AM, de Oliveira LG. Religion as a protective factor against drug use among Brazilian university students: a national survey. Rev Bras Psiquiatr. 2013;35(1):29–37. https://doi.org/10.1016/j.rbp.2012.05.010 .

Kulis S, Hodge DR, Ayers SL, Brown EF, Marsiglia FF. Spirituality and religion: intertwined protective factors for substance use among urban American Indian youth. Am J Drug Alcohol Abuse. 2012;38(5):444–9. https://doi.org/10.3109/00952990.2012.670338 .

Miller L, Davies M, Greenwald S. Religiosity and substance use and abuse among adolescents in the national comorbidity survey. J Am Acad Child Adolesc Psychiatry. 2000;39(9):1190–7. https://doi.org/10.1097/00004583-200009000-00020 .

Moon SS, Rao U. Social activity, school-related activity, and anti-substance use media messages on adolescent tobacco and alcohol use. J Hum Behav Soc Environ. 2011;21(5):475–89. https://doi.org/10.1080/10911359.2011.566456 .

Simone A. Onrust, Roy Otten, Jeroen Lammers, Filip smit, school-based programmes to reduce and prevent substance use in different age groups: what works for whom? Systematic review and meta-regression analysis. Clin Psychol Rev. 2016;44:45–59. https://doi.org/10.1016/j.cpr.2015.11.002 .

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Acknowledgements

The authors acknowledge The Ministry of Higher Education Malaysia and The Universiti Kebangsaan Malaysia, (UKM) for funding this study under the Long-Term Research Grant Scheme-(LGRS/1/2019/UKM-UKM/2/1). We also thank the team for their commitment and tireless efforts in ensuring that manuscript was well executed.

Financial support for this study was obtained from the Ministry of Higher Education, Malaysia through the Long-Term Research Grant Scheme-(LGRS/1/2019/UKM-UKM/2/1). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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World Drug Day report highlights spike in drug use, increased trafficking

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The UN agency tackling crime and drug abuse (UNODC) released its annual World Drug Report on Wednesday warning that there are now nearly 300 million users globally, alongside an increase in trafficking.

The  International Day against Drug Abuse and Illicit Trafficking, or World Drug Day, is commemorated every year on June 26 and aims to increase action in achieving a drug-free world.

This year’s campaign recognises that “ effective drug policies must be rooted in science, research, full respect for human rights , compassion, and a deep understanding of the social, economic, and health implications of drug use”.

Ghada Waly, Executive Director of UNODC , said that providing evidence-based treatment and support to all those affected by drug use is needed, “while targeting the illicit drug market and investing much more in prevention”.

New threat from nitazenes

Drug production, trafficking, and use continue to exacerbate instability and inequality, while causing untold harm to people’s health, safety and well-being. — Ghada Waly

In the decade to 2022, the number of people using illicit drugs increased to 292 million, the UNODC report says.

It noted that most users worldwide consume cannabis – 228 million people - while 60 million people worldwide consume opioids, 30 million people use amphetamines, 23 million use cocaine and 20 million take ecstasy.

Further, UNODC found that there was an increase in overdose deaths following the emergence of nitazenes – a group of synthetic opioids potentially more dangerous than fentanyl – in several high-income countries.

Trafficking in the Triangle

The drug report noted that traffickers in the Golden Triangle, a region in Southeast Asia, have found ways to integrate themselves into other illegal markets, such as wildlife trafficking, financial fraud, and illegal resource extraction.

“Displaced, poor and migrant communities” bear the brunt of this criminal activity and on occasion are forced to engage in opium farming or illegal resource extraction for their survival; this can lead to civilians becoming drug users or fall into debt at the mercy of crime groups.

Environmental fallout

These illegal crimes contribute to environmental degradation via deforestation, toxic waste dumping and chemical contamination.

“Drug production, trafficking, and use continue to exacerbate instability and inequality, while causing untold harm to people’s health, safety and well-being,” UNODC’s Ms. Waly said.

Cocaine surge and cannabis legalisation

In 2022, cocaine production hit a record high with 2,757 tons produced – a 20 per cent increase from 2021.

The increase in supply and demand of the product was accompanied by a surge of violence in nations along the supply chain, especially in Ecuador and Caribbean countries. There was also a spike in health problems within some destination countries in Western and Central Europe.

Similarly, harmful usage of cannabis surged as the product was legalized across Canada, Uruguay, and 27 jurisdictions in the United States, much of which was laced with high-THC (delta9-tetrahydrocannabinol) content - which is believed to be the main ingredient behind the psychoactive effect of the drug.

This led to an increase in the rate of attempted suicides among regular cannabis users in Canada and the US.

The hope for World Drug Day

The UNODC report highlights that the “ right to health is an internationally recognized human right that belongs to all human beings , regardless of a person’s drug use status or whether a person is imprisoned, detained or incarcerated”.

UNODC’s calls for governments, organizations and communities to collaborate on establishing evidence-based plans that will fight against drug trafficking and organized crime.

The agency also hopes communities will assist in “fostering resilience against drug use and promoting community-led solutions".

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• Indian J Psychiatry
• v.52(Suppl1); 2010 Jan

Substance use and addiction research in India

Pratima murthy.

Department of Psychiatry, De-Addiction Centre, National Institute of Mental Health and Neuro Sciences, Bangalore - 560 029, India

N. Manjunatha

B. n. subodh, prabhat kumar chand, vivek benegal.

Substance use patterns are notorious for their ability to change over time. Both licit and illicit substance use cause serious public health problems and evidence for the same is now available in our country. National level prevalence has been calculated for many substances of abuse, but regional variations are quite evident. Rapid assessment surveys have facilitated the understanding of changing patterns of use. Substance use among women and children are increasing causes of concern. Preliminary neurobiological research has focused on identifying individuals at high risk for alcohol dependence. Clinical research in the area has focused primarily on alcohol and substance related comorbidity. There is disappointingly little research on pharmacological and psychosocial interventions. Course and outcome studies emphasize the need for better follow-up in this group. While lack of a comprehensive policy has been repeatedly highlighted and various suggestions made to address the range of problems caused by substance use, much remains to be done on the ground to prevent and address these problems. It is anticipated that substance related research publications in the Indian Journal of Psychiatry will increase following the journal having acquired an ‘indexed’ status.

INTRODUCTION

Substance use has been a topic of interest to many professionals in the area of health, particularly mental health. An area with enormous implications for public health, it has generated a substantial amount of research. In this paper we examine research in India in substance use and related disorders. Substance use includes the use of licit substances such as alcohol, tobacco, diversion of prescription drugs, as well as illicit substances.

METHODOLOGY

For this review, we have carried out a systematic web-based review of the Indian Journal of Psychiatry (IJP). The IJP search included search of both the current and archives section and an issue-to-issue search of articles with any title pertaining to substance use. This has included original articles, reviews, case series and reports with significant implications. Letters to editor and abstracts of annual conference presentations have not been included.

Publications in other journals were accessed through a Medlar search (1992-2009) and a Pubmed search (1950-2009). Other publications related to substance use available on the websites of international and national agencies have also been reviewed. In this review, we focus mainly on publications in the IJP and have selectively reviewed the literature from other sources.

For the sake of convenience, we discuss the publications under the following areas: Epidemiology, clinical issues (diagnosis, psychopathology, comorbidity), biological studies (genetics, imaging, electrophysiology, and vulnerability), interventions and outcomes as well as community interventions and policies. There is a vast amount of literature on tobacco use and consequences in international and national journals, but this is outside the scope of this review. Tobacco is mentioned in this review of substance use to highlight that it should be remembered as the primary licit substance of abuse in our country.

The number of articles (area wise) available from IJP, other Indian journals and international journals are indicated in Figures ​ Figures1 1 and ​ and2. 2 . A majority of the publications in international journals relate to tobacco, substance use co-morbidity and miscellaneous areas like animal studies.

Publications in the area of substance use and related disorders

Break up of areas of publication

EPIDEMIOLOGY

Much of the earlier epidemiological research has been regional and it has been very difficult to draw inferences of national prevalence from these studies.

Regional studies

Studies between 1968 until 2000 have been primarily on alcohol use [ Table 1 ]. They have varied in terms of populations surveyed (ranged from 115 to 16,725), sampling procedures (convenient, purposive and representative), focus of enquiry (alcohol use, habitual excessive use, alcohol abuse, alcoholism, chronic alcoholism, alcohol and drug abuse and alcohol dependence), location (urban, rural or both, Slums), in the screening instruments used (survey questionnaires and schedules, semi-structured interviews, quantity frequency index, Michigan Alcohol Screening Test (MAST) etc). Alcohol ‘use/abuse’ prevalence in different regions has thus varied from 167/1000 to 370/1000; ‘alcohol addiction’ or ‘alcoholism’ or ‘chronic alcoholism’ from 2.36/1000 to 34.5/1000; alcohol and drug use/abuse from 21.4 to 28.8/1000. A meta-analysis by Reddy and Chandrashekhar[ 26 ] (1998) revealed an overall substance use prevalence of 6.9/1000 for India with urban and rural rates of 5.8 and 7.3/1000 population. The rates among men and women were 11.9 and 1.7% respectively.

Regional epidemiological studies in substance use: A summary

U - Urban; R - Rural; Sl - Slum; SR - Semi-rural; NM - Not mentioned

Regional studies between 2001 and 2007 continue to reflect this variability. Currently, the interest is to look at hazardous alcohol use. A study in southern rural India[ 27 ] showed that 14.2% of the population surveyed had hazardous alcohol use on the AUDIT. A similar study in the tertiary hospital[ 28 ] showed that 17.6% admitted patients had hazardous alcohol use.

The only incidence study on alcohol use from Delhi[ 17 ] found that annual incidence of nondependent alcohol use and dependent alcohol use among men was 3 and 2 per 1000 persons in a total cohort of 2,937 households.

National Studies

The National Household Survey of Drug Use in the country[ 29 ] is the first systematic effort to document the nation-wide prevalence of drug use [ Table 2 ]. Alcohol (21.4%) was the primary substance used (apart from tobacco) followed by cannabis (3.0%) and opioids (0.7%). Seventeen to 26% of alcohol users qualified for ICD 10 diagnosis of dependence, translating to an average prevalence of about 4%. There was a marked variation in alcohol use prevalence in different states of India (current use ranged from a low of 7% in the western state of Gujarat (officially under Prohibition) to 75% in the North-eastern state of Arunachal Pradesh. Tobacco use prevalence was high at 55.8% among males, with maximum use in the age group 41-50 years.

Nationwide studies on substance use prevalence

H-H - House to house survey; M - Male; F - Female; A - Alcohol, C - Cannabis; O - Opioids; T - Tobacco

The National Family Health Survey (NFHS)[ 30 ] provides some insights into tobacco and alcohol use. The changing trends between NFHS 2 and NFHS 3 reflect an increase in alcohol use among males since the NFHS 2, and an increase in tobacco use among women.

The Drug Abuse Monitoring System,[ 29 ] which evaluated the primary substance of abuse in inpatient treatment centres found that the major substances were alcohol (43.9%), opioids (26%) and cannabis (11.6%).

Patterns of substance use

Rapid situation assessments (RSA) are useful to study patterns of substance use. An RSA by the UNODC in 2002[ 31 ] of 4648 drug users showed that cannabis (40%), alcohol (33%) and opioids (15%) were the major substances used. A Rapid Situation and Response Assessment (RSRA) among 5800 male drug users[ 32 ] revealed that 76% of the opioid users currently injected buprenorphine, 76% injected heroin, 70% chasing and 64% using propoxyphene. Most drug users concomitantly used alcohol (80%). According to the World Drug Report,[ 33 ] of 81,802 treatment seekers in India in 2004-2005, 61.3% reported use of opioids, 15.5% cannabis, 4.1% sedatives, 1.5% cocaine, 0.2% amphetamines and 0.9% solvents.

Special populations

In the last decade, there has been a shift in viewing substance use and abuse as an exclusive adult male phenomenon to focusing on the problem in other populations. In the GENACIS study[ 34 ] covering a population of 2981 respondents [1517 males; 1464 females], across five districts of Karnataka, 5.9% of all female respondents (N =87) reported drinking alcohol at least once in the last 12 months, compared to 32.7% among male respondents (N = 496). Special concerns with women’s drinking include the fetal alcohol spectrum effects described with alcohol use during pregnancy.[ 35 ]

Abuse of other substances among women has largely been studied through Rapid Assessment Surveys. A survey of 1865 women drug users by 110 NGOs across the country[ 36 ] revealed that 25% currently were heroin users, 18% used dextropropoxyphene, 11% opioid containing cough syrups and 7% buprenorphine. Eighty seven per cent concomitantly used alcohol and 83% used tobacco. Twenty five per cent of respondents had lifetime history of injecting drug use and 24% had been injecting in the previous month. There are serious sexually transmitted disease risks, including HIV that women partners and drug users face.[ 36 , 37 ]

Substance use in medical fraternity

As early as 1977, a drug abuse survey in Lucknow among medical students revealed that 25.1% abused a drug at least once in a month. Commonly abused drugs included minor tranquilizers, alcohol, amphetamines, bhang and non barbiturate sedatives. In a study of internees on the basis of a youth survey developed by the WHO in 1982,[ 38 ] 22.7% of males ‘indulged in alcohol abuse’ at least once in a month, 9.3% abused cannabis, followed by tranquilizers. Common reasons cited were social reasons, enjoyment, curiosity and relief from psychological stress. Most reported that it was easy to obtain drugs like marijuana and amphetamines. Substance use among medical professionals has become the subject of recent editorials.[ 39 , 40 ]

Substance use among children

The Global Youth Tobacco Survey[ 41 ] in 2006 showed that 3.8% of students smoke and 11.9% currently used smokeless tobacco. Tobacco as a gateway to other drugs of abuse has been the topic of a symposium.[ 42 ]

A study of 300 street child laborers in slums of Surat in 1993[ 43 ] showed that 135 (45%) used substances. The substances used were smoking tobacco, followed by chewable tobacco, snuff, cannabis and opioids. Injecting drug use[ 44 ] is also becoming apparent among street children as are inhalants.[ 45 ]

A study in the Andamans[ 46 ] shows that onset of regular use of alcohol in late childhood and early adolescence is associated with the highest rates of consumption in adult life, compared to later onset of drinking.

Studies in other populations

A majority of 250 rickshaw pullers interviewed in New Delhi[ 47 ] in 1986 reported using tobacco (79.2%), alcohol (54.4%), cannabis (8.0%) and opioids (0.8%). The substances reportedly helped them to be awake at night while working. In a study of prevalence of psychiatric illness in an industrial population[ 48 ] in 2007, harmful use/dependence on substances (42.83%) was the most common psychiatric condition. A study among industrial workers from Goa on hazardous alcohol use using the AUDIT and GHQ 12 estimated a prevalence of 211/1000 with hazardous drinking.[ 19 ]

Hospital-based studies

These studies have basically described profiles of substance use among patients and include patterns of alcohol use,[ 49 – 53 ] opioid use,[ 54 – 56 ] pediatric substance use,[ 57 ] female substance use,[ 58 ] children of alcoholics[ 59 ] and geriatric substance use.[ 60 ]

Alcohol misuse has been implicated in 20% of brain injuries[ 61 ] and 60% of all injuries in the emergency room setting.[ 62 ] In a retrospective study of emergency treatment seeking in Sikkim between 2000 and 2005,[ 63 ] substance use emergencies constituted 1.16% of total psychiatric emergencies. Alcohol withdrawal was the commonest cause for reporting to the emergency (57.4%).

Effects of substance use disorders

Mortality and morbidity due to alcohol and tobacco have been extensively reviewed elsewhere[ 35 , 64 – 66 ] and are beyond the scope of this review. The effects of cannabis have also been reviewed.[ 67 ] Mortality with injecting drug use is a serious concern with increase in crude mortality rates to 4.25 among injecting drug users compared to the general population.[ 68 ] Increased susceptibility to HIV/AIDS and other sexually transmitted diseases has been reported with alcohol[ 69 ] as well as injecting drug use.[ 70 ]

Clinical issues

Harmful alcohol use patterns among admitted patients in general hospital has highlighted the importance of routine screening and intervention in health care settings.[ 71 ]

Peer influence is a significant factor for heroin initiation.[ 72 ] Precipitants of relapse (dysfunction, stress and life events) differ among alcohol and opioid dependents.[ 73 ] Chronologies in the development of dependence have been evaluated in alcohol dependence.[ 74 , 75 ]

Craving a common determinant of relapse has been shown to reduce with increase in length of period of abstinence.[ 76 ]

Alcohol dependence constitutes a significant group among the psychiatric population in the Armed Forces.[ 77 ] A study of personality factors[ 78 ] among 100 alcohol dependent persons showed significantly high neuroticism, extroversion, anxiety, depression, psychopathic deviation, stressful life events and significantly low self-esteem as compared with normal control subjects. Alcohol dependence causes impairment in set shifting, visual scanning and response inhibition abilities and relative abstinence has been found to improve this deficit.[ 79 , 80 ] Alcohol use has had a significant association with head injury and cognitive deficits.[ 81 , 82 ] Persistent drinking is associated with persisting memory deficits in head injured alcohol dependent patients.[ 82 ] Mild intellectual impairment has been demonstrated in patients with bhang and ganja dependence.[ 83 – 86 ]

Kumar and Dhawan[ 87 ] found that health related reasons like death/physical complications due to drug use in peers and patients themselves, knowledge of HIV and difficulties in accessing veins were the main reason for reverse transition (shift from parenteral to inhalation route).

Evaluation and assessment

Diagnostic issues have focused on cross-system agreement[ 88 ] between ICD-10 and DSM IV, variability in diagnostic criteria across MAST, RDC, DSM and ICD[ 89 ] and suitability of MAST as a tool for detecting alcoholism.[ 90 ] The CIWA-A was found useful in monitoring alcohol withdrawal syndrome.[ 91 ]

The utility of liver functions for diagnosis of alcoholism and monitoring recovery has been demonstrated in clinical settings.[ 92 – 94 ] A range of hepatic dysfunction has been demonstrated through liver biopsies.[ 95 ]

A few studies have focused on scale development for motivation[ 96 , 97 ] and addiction related dysfunction[ 98 ] (Brief Addiction Rating Scale). An evaluation of two psychomotor tests comparing smokers and non-smokers found no differences across the two groups.[ 99 ]

Typology research has included validation of Babor’s[ 100 ] cluster A and B typologies, age of onset typology,[ 101 ] and a review on typology of alcoholism.[ 102 ]

Craving plays an important role in persistence of substance use and relapse. Frequency of craving has been shown to decrease with increase in length of abstinence among heroin dependent patients. Socio-cultural factors did not influence the subjective experience of craving.[ 76 ]

In a study of heroin dependent patients, their self-report moderately agreed with urinalysis using thin layer chromatography (TLC), gas liquid chromatography (GLC) and high performance liquid chromatography (HPLC).[ 103 ] The authors, however, recommend that all drug dependence treatment centers have facilities for drug testing in order to validate self-report.

Comorbidity/dual diagnosis

Cannabis related psychopathology has been a favorite topic of enquiry in both retrospective[ 104 , 105 ] and prospective studies[ 106 ] and vulnerability to affective psychosis has been highlighted. The controversial status of a specific cannabis withdrawal syndrome and cannabis psychosis has been reviewed.[ 67 ]

High life time prevalence of co-morbidity (60%) has been demonstrated among both opioid and alcohol dependent patients.[ 107 ] In alcohol dependence, high rates of depression and cluster B personality disorders[ 54 , 108 ] and phobia[ 109 ] have been demonstrated, but the need to revaluate for depressive symptoms after detoxification has been highlighted.[ 110 ] It is necessary to evaluate for ADHD, particularly in early onset alcohol dependent patients.[ 111 ] Seizures are overrepresented in subjects with alcohol and merit detailed evaluation.[ 112 ] Delirium and convulsions can also complicate opioid withdrawal states.[ 113 , 114 ] Skin disease,[ 115 ] and sexual dysfunction[ 116 ] have also been the foci of enquiry. Phenomenological similarities between alcoholic hallucinosis and paranoid schizophrenia have been discussed.[ 117 ] Opioid users with psychopathology[ 118 ] have diverse types of psychopathology as do users of other drugs.[ 119 ]

In a study of 22 dual diagnosed schizophrenia patients, substance use disorder preceded the onset of schizophrenic illness in the majority.[ 120 ] While one study found high rates of comorbid substance use (54%) in patients with schizophrenia with comorbid substance users showing more positive symptoms[ 121 ] which remitted more rapidly in the former group,[ 122 ] other studies suggest that substance use comorbidity in schizophrenia is low, and is an important contributor to better outcome in schizophrenia in developing countries like India.[ 123 , 124 ]

The diagnosis and management of dual diagnosis has been reviewed in detail.[ 125 ]

Social factors

Co-dependency has been described in spouses of alcoholics and found to correlate with the Addiction Severity scores of their husbands.[ 126 ] Coping behavior described among wives of alcoholics include avoidance, indulgence and fearful withdrawal.[ 127 ] These authors did not find any differences in personality between wives of alcoholics compared to controls.[ 128 ] Delusional jealousy and fighting behavior of substance abusers/dependents are important determinants of suicidal attempts among their spouses.[ 129 ] Parents of narcotic dependent patients, particularly mothers also show significant distress.[ 130 ]

BIOLOGY OF ADDICTION

An understanding of the cellular and molecular mechanisms of drug dependence has led to a reformulation of the etiology of this complex disorder.[ 131 ] An understanding of specific neurotransmitter systems has led to the development of specific pharmacotherapies for these disorders.

Cellular and molecular mechanisms

Altered alcohol metabolism due to polymorphisms in the alcohol metabolizing enzymes may influence clinical and behavioral toxicity due to alcohol. Erythrocyte aldehyde dehydrogenase was demonstrated to be suitable as a peripheral trait marker for alcohol dependence.[ 132 ] Single nucleotide polymorphism of the ALDH 2 gene has been studied in six Indian populations and provides the baseline for future studies in alcoholism.[ 133 ] An evaluation of ADH 1B and ALDH 2 gene polymorphism in alcohol dependence showed a high frequency of the ALDH2*2/*2 genotype among alcohol-dependent subjects.[ 134 ] DRD2 polymorphisms have been studied in patients with alcohol dependence, but a study in an Indian population failed to show a positive association. Genetic polymorphisms of the opioid receptor µ1 has been associated with alcohol and heroin addiction in a population from Eastern India.[ 135 ]

Neuro-imaging and electrophysiological studies

Certain individuals may develop early and severe problems due to alcohol misuse and be poorly responsive to treatment. Such vulnerability has been related to individual differences in brain functioning [ Figure 3 ]. Individuals with a high family history of alcoholism (specifically of the early-onset type, developing before 25 years of age) display a cluster of disinhibited behavioral traits, usually evident in childhood and persisting into adulthood.[ 136 ]

Brain volume differences between children and adolescents at high risk and low risk for alcohol dependence

Early onset drinking may be influenced by delayed brain maturation. Alcohol-naïve male offspring of alcohol-dependent fathers have smaller (or slowly maturing) brain volumes compared to controls in brain areas responsible for attention, motivation, judgment and learning.[ 137 , 138 ] The lag is hypothesized to work through a critical function of brain maturation-perhaps delayed myelination (insulation of brain pathways).

Functionally, this is thought to create a state of central nervous system hyperexcitability or disinhibition.[ 139 ] Individuals at risk have also been shown to have specific electro-physiological characteristics such as reduced amplitude of the P300 component of the event related potential.[ 140 , 141 ] Auditory P300 abnormalities have also been demonstrated among opiate dependent men and their male siblings.[ 142 ]

Such brain disinhibition is manifest by a spectrum of behavioral abnormalities such as inattention (low boredom thresholds), hyperactivity, impulsivity, oppositional behaviors and conduct problems, which are apparent from childhood and persist into adulthood. These brain processes not only promote impulsive risk-taking behaviors like early experimentation with alcohol and other substances but also appear to increase the reinforcement from alcohol while reducing the subjective appreciation of the level of intoxication, thus making it more likely that these individuals are likely not only to start experimenting with alcohol use at an early age but are more likely to have repeated episodes of bingeing.[ 143 ]

INTERVENTIONS, COURSE AND OUTCOME

Although there are a few review articles on pharmacological treatment of alcoholism,[ 144 , 145 ] there is a dearth of randomized studies on relapse prevention treatment in our setting.

Treatment of complications of substance use has been confined to case reports. A case report of thiamine resistant Wernicke Korsakoff Syndrome[ 146 ] successfully treated with a combination of magnesium sulphate and thiamine. Another case of subclinical psychological deterioration[ 147 ] (alcoholic dementia) improved with thiamine and vitamin B supplementation.

Pharmacological intervention

A randomized double blind study compared the effectiveness of detoxification with either lorazepam or chlordiazepoxide among hundred alcohol dependent inpatients with simple withdrawal. Lorazepam was found to be as effective as the more traditional drug chlordiazepoxide in attenuating alcohol withdrawal symptoms as assessed using the revised Clinical Institute Withdrawal Assessment for Alcohol scale.[ 148 ] This has implications for treatment in peripheral settings where liver function tests may not be available. However, benzodiazepines must be used carefully and monitored as dependence is very common.[ 149 ]

In a study closer to the real-world situation from Mumbai, 100 patients with alcohol dependence with stable families were randomized to receive disulfiram or topiramate. At the end of nine months, though patients on topiramate had less craving, a greater proportion of patients on disulfiram were abstinent (90% vs. 56%). Patients in the disulfiram group also had a longer time to their first drink and relapse.[ 150 ] Similar studies by the same authors and with similar methodology had earlier found that disulfiram was superior to acamprosate and Naltrexone. Though the study lacked blinding, it had an impressively low (8%) dropout rate.[ 151 , 152 ] A chart based review has shown there was no significant difference with regard to abstinence among the patients prescribed acamprosate, naltrexone or no drugs. Although patients on acamprosate had significantly better functioning, lack of randomization and variations in base line selection parameters may have influenced these findings.[ 153 ] Short term use of disulfiram among alcohol dependence patients with smoking was not associated with decrease pulmonary function test (FEV 1 ) and airway reactivity.[ 154 ]

Usefulness of clonidine for opioid detoxification has been described by various authors. These studies date back to 1980 when there was no alternative treatment for opioid dependence and clonidine emerged as the treatment of choice for detoxification in view of its anti adrenergic activity.[ 155 – 157 ] Sublingual buprenorphine for detoxification among these patients was reported as early as 1992. At that time the dose used was much lower, i.e. 0.6 -1.2 mg/ day which is in contrast to the current recommended dose of 6-16 mg/day. Comparison of buprenorphine (0.6-1.2 mg/ day) and clonidine (0.3-0.9 mg/day) for detoxification found no difference among treatment non completers. Maximum drop out occurred on the fifth day when withdrawal symptoms were very high.[ 158 ] A 24- week outcome study of buprenorphine maintenance in opiate users showed high retention rates of 81.5%, reduction in Addiction Severity Index scores and injecting drug use. Use of slow release oral morphine for opioid maintenance has also been reported.[ 159 ] Effectiveness of baclofen in reducing withdrawal symptoms among three patients with solvent dependence is reported.[ 160 ]

Psychosocial

Psychoeducational groups have been found to facilitate recovery in alcohol and drug dependence.[ 161 ] Family intervention therapy in addition to pharmacotherapy was shown to reduce the severity of alcohol intake and improve the motivation to stop alcohol in a case-control design study.[ 162 ] Several community based models of care have been developed with encouraging results.[ 163 ]

Course and outcome

An evaluation after five years, of 800 patients with alcohol dependence treated at a de-addiction center, found that 63% had not utilized treatment services beyond one month emphasizing the need to retain patients in follow-up.[ 164 ]

In a follow-up study on patients with alcohol dependence, higher income and longer duration of in-patient treatment were found to positively correlate with improved outcome at three month follow up. Outcome data was available for 52% patients; 81% of those maintained abstinence.[ 165 ] Maximum attrition was between three to six months. In a similar study among in-patients, 46% were abstinent. The drop out rate was 10% at the end of one year.[ 101 ] Studies done in the community setting have shown the effectiveness of continued care in predicting better outcome in alcohol dependence. In one study the patient group from a low socio-economic status who received weekly follow up or home visit at a clinic located within the slum showed improvement at the end of month 3, 6 and 9, and one year, in comparison with a control group that received no active follow-up intervention.[ 166 ] In a one-year prospective study of outcome following de-addiction treatment, poor outcome was associated with higher psychosocial problems, family history of alcoholism and more follow-up with mental health services.[ 167 ]

COMMUNITY INTERVENTIONS AND POLICIES

The camp approach for treatment of alcohol dependence was popularized by the TTK hospital camp approach at Manjakkudi in Tamil Nadu.[ 168 ] Treatment of alcohol and drug abuse in a camp setting as a model of drug de-addiction in the community through a 10 day camp treatment was found to have good retention rates and favorable outcome at six months.

Community perceptions of substance related problems are useful to understand for policy development. In a 1981 study in urban and rural Punjab of 1031 respondents, 45% felt people could not drink without producing bad effects on their health, 26.2% felt they could have one or two drinks per month without affecting their health. About one third felt it was alright to have one or two drinks on an occasion. 16.9% felt it was normal to drink ‘none at all’. Alcoholics were identified by behavior such as being dead drunk, drinking too much, having arguments and fights and creating public nuisance. Current users gave the most permissive responses and non-users the most restrictive responses regarding the norms for drinking.[ 169 ] The influence of cultural norms[ 170 ] has led the tendency to view drugs as ‘good’ and ‘bad’.

Simulations done in India have demonstrated that implementing a nationwide legal drinking age of 21 years in India, can achieve about 50-60 % of the alcohol consumption reducing effects compared to prohibition.[ 171 ] However, recently there are attempts to increase the permissible legal alcohol limit. This kind of contrarian approach does not make for coherent policy.

It has been argued that the 1970s saw an overzealous implementation of a simplistic model of supply and demand.[ 171 ] A presidential address[ 172 ] in 1991 emphasized the need for a multipronged approach to addressing alcohol-related problems. Existing programs have been identified as being patchy, poorly co-ordinated and poorly funded. Primary, secondary and tertiary approaches were discussed. The address highlighted the need for supply and demand side measures to address this significant public health problem. It highlighted the political and financial power of the alcohol industry and the social ambivalence to drinking. More recently, the need to have interventions for harmful and hazardous use, the need to develop evidence based combinations of pharmacotherapy and psychosocial interventions and stepped care solutions have been highlighted.[ 173 ] Standard treatment guidelines for alcohol and other drug use disorders have suggested specific measures at the primary, secondary and tertiary health care level, including at the solo physician level.[ 174 ] An earlier report in 1988 on training general practitioners on management of alcohol related problems[ 175 ] suggests that their involvement in alcohol and health education was modest, involvement in control and regulatory activities minimal, and they perceived no role in the development of a health and alcohol policy.

There have been reviews of the National Master Plan 1994, which envisaged different responsibilities for the Ministries of Health and the Ministry of Welfare (presently Social Justice and Empowerment) and the Drug Dependence Program 1996.[ 176 , 177 ] A proposal for adoption of a specialty section on addiction medicine[ 178 ] includes the development of a dedicated webpage, co-ordinated CMEs, commissioning of position papers, promoting demand reduction strategies and developing a national registry.

SUMMARY AND CONCLUSIONS

While epidemiological research has now provided us with figures for national-level prevalence, it would be prudent to recognize that there are regional differences in substance use prevalence and patterns. It is also prudent to recognize the dynamic nature of substance use. There is thus a need for periodic national surveys to determine changing prevalence and incidence of substance use. Substance use is associated with significant mortality and morbidity. Substance use among women and children is increasingly becoming the focus of attention and merits further research. Pharmaceutical drug abuse and inhalant use are serious concerns. For illicit drug use, rapid assessment surveys have provided insights into patterns and required responses. Drug related emergencies have not been adequately studied in the Indian context.

Biological research has focused on two broad areas, neurobiology of vulnerability and a few studies on molecular genetics. There is a great need for translation research based on the wider body of basic and animal research in the area.

Clinical research has primarily focused on alcohol. An area which has received relatively more attention in substance related comorbidity. There is very little research on development and adaptation of standardized tools for assessment and monitoring, and a few family studies. Ironically, though several evidence based treatments have now become available in the country, there are very few studies examining the utilization and effectiveness of these treatments, given that most treatment is presently unsubsidized and dependent on out of pocket expenditure. Both pharmacological and psychosocial interventions have disappointingly attracted little research. Course and outcome studies emphasize the need for better follow-up in this group.

While a considerable number of publications have lamented the lack of a coherent policy, the need for human resource enhancement and professional training and recommended a stepped-care multipronged approach, much remains to be done on the ground.

Finally, publication interest in the Indian Journal of Psychiatry in the area of substance use will undoubtedly increase, with the journal having become indexed.

Source of Support: Nil

Conflict of Interest: None declared