Early onset of drug and polysubstance use as predictors of injection drug use among adult drug users
Introduction
Extant literature has investigated the epidemiologic trends and risk factors associated with adolescent exposure to alcohol, cigarettes, and marijuana and the subsequent use of these substances beyond experimentation (For a review, see Latimer & Zur, 2010). In addition, a substantial body of research has provided evidence that early onset drug use has been associated with drug use problems in adulthood (Anthony and Petronis, 1995, Chen et al., 2009, Kandel et al., 1992); specifically, early onset of alcohol, marijuana, and cigarette use are indicators of potential later adulthood problems such as alcohol abuse and dependence or other drug dependence (Dawson et al., 2008, Grant, 1998, Grant and Dawson, 1997, Grant et al., 2001, King and Chassin, 2007). It stands to reason that this same line of research can be applied specifically to injection drug use (IDU), but remains a developmental trajectory that is infrequently addressed. This may be partially due to the fact that early onset substance use and later injection drug use are challenging to study in national data sets because illicit drug use in these large samples is often small (Hedden et al., 2010). In addition, many urban areas such as Baltimore have high rates of reported past year illicit drug dependence or abuse (SAMSHA, 2008) thereby increasing exposure to substance using environments.
The current paper seeks to address the association between early onset drug use and early onset polysubstance use with injection drug use, in particular, substance use at or before age 15 among a population of recent illicit drug users. Indicators of early substance use among this population may give practitioners insight into initial exposure to drug using environments that may extend to the use of injection drugs in adulthood. An investigation into this developmental trajectory of substance use has important public health concerns given the link between IDU and the associated risk of HIV and hepatitis C infection.
Nationally, the Substance Abuse and Mental Health Services Administration (SAMSHA, 2009) has reported an annual average rate of 425,000 IDUs over the age of 12 and a peak in IDU in young adults between the ages of 18 to 25. In addition, NIDA (2010) notes that IDUs are the highest risk group for HCV and HIV infection. On a local level, injection drug use continues to be a public health concern in low-income, inner-city neighborhoods such as Baltimore, Maryland, particularly with regard to HIV risk (Mitchell & Latimer, 2009) and infection (Fuller et al., 2005, Sherman et al., 2005). Research focusing on IDU in Baltimore has identified many factors contributing to IDU in this urban setting, including dropping out of high school, homelessness, physical violence (Fuller et al., 2002), and childhood sexual abuse (Ompad et al., 2005). Further, environmental factors such as low education levels, racial segregation and poverty (Fuller et al., 2005), co-occurring disorders of dependence (Arria, Fuller, Strathdee, Latkin, & Vlahov, 2002), race, sexual practices, smoking crack and marijuana (Fuller et al., 2001), and being younger at age of first alcohol, marijuana, and inhalant drug use contribute to the initiation of IDU (Sherman et al., 2005). Although these studies provide a framework for correlates of IDU and factors that contribute to the transition to IDU, to our knowledge, no studies to date have investigated the early onset of alcohol, cigarette, marijuana and polysubstance use prior to age 15 as a predictor of IDU in adulthood.
This appears to be a critical omission in the literature when we consider that alcohol is currently the most commonly used substance among adolescents in the United States followed by cigarettes and marijuana (Johnston, O'Malley, Bachman, & Schulenberg, 2009). Previous studies investigating the developmental trajectory of substance use behaviors have established that the early onset of alcohol for males and tobacco for females precedes marijuana use and, subsequently, the use of more deleterious substances such as crack cocaine or injection of heroin (Golub and Johnson, 2001, Kandel and Yamaguchi, 1993, Yamaguchi and Kandel, 1984). In addition, early drug use has been associated with increased odds of cannabis, stimulant, cocaine, opioid, and hallucinogen dependence among individuals who reported treatment for alcoholism (Sintov, Kendler, Walsh, Patterson, & Prescott, 2009). The relationship between early drug use and later drug problems may be particularly viable in cases where adolescents engage in polysubstance use (Weinberg, Rahdert, Colliver, & Glantz, 1998) and is an area of research that needs additional consideration with regard to early onset substance use and specific drug use outcomes in adulthood, such as IDU.
In the substance abuse literature, early onset has been defined and categorized in various ways. Often, the course of substance use is thought to adhere to a developmental trajectory that begins with experimentation in adolescence and evolves into abuse or dependence in adulthood (Chassin et al., 2009, Masten et al., 2008). Research in this domain has highlighted the importance of investigating the onset of substance use in early adolescence as indicator of risk for more illicit substance use later in life. For example, in a study of the progression of drug use among young adults in New York state, Yu and Williford (1992), found that the onset of substance use during the critical developmental period between the ages of 13 and 16, particularly alcohol, had a stronger impact on the current use of alcohol and other drugs than the initiation of substances during any other age period. In addition, adolescents who begin alcohol use before age 14 are more likely to develop alcohol dependence in adulthood than those that begin drinking after 21 years of age (Grant & Dawson, 1997). Furthermore, in an analysis of the Youth Risk Behavior Survey, Lee and Abdel-Ghany (2004) found that the most prevalent age for the onset of drinking alcohol and smoking cigarettes or marijuana is between 13 and 14 years old. Lastly, DeWit, Adlaf, Offord, and Ogborne (2000) found that adolescents who began to drink before age 15 had a 2 to 3 times greater risk of developing alcohol dependence compared to youth who started drinking at age 19 or later. As such, exploring the early onset of substance use at or prior to 15 years of age seems particularly pertinent.
Early onset of substance use is of particular concern during adolescence as research has begun to emerge which shows exposure to alcohol and/or marijuana has detrimental neurotoxic effects on brain chemistry and may interfere with neurodevelopment. This may result in difficulties with higher executive functions such as problem-solving, planning, decision-making, judgment, and selective attention, as well as the development of reward systems and self-control (Brown et al., 2008, Chassin et al., 2009, Lezak, 1995). Further, the early onset of substances may have continuing detriments to executive functioning such as self-regulation which is crucial in later adolescence – particularly for those who have drug-using peers – when they may be more likely to be confronted with having to make decisions in risky situations such as driving while intoxicated, having unsafe sex, or escalating drug use (Brown et al., 2008). Though much literature has been devoted to exploring and understanding the many consequences associated with early initiation of substances and the resulting impact later in life, research has yet to address the consequences of early onset of alcohol, cigarette, marijuana, both individually or in conjunction with one another, as they specifically relate to IDU in adulthood.
As previous work has explored the correlates of early initiation into IDU and the transition among substance users to IDU, to our knowledge, no studies have specifically addressed early onset substance use and polysubstance use as a predictor of IDU among adult substance users. To date the majority of research investigating early onset substance and subsequent illicit drug use has neglected to specify IDU as an outcome. Generally, when discussing outcomes of early onset of substance use, studies in this area have grouped all other substances together as “other illicit drugs.” In doing so, previous research neglects differences between route of administration of illicit drugs and overlooks subtle yet potentially vital nuances of early substance use, singularly and in combination, as predictors of both injection and non-injection drug use. The current study seeks to explore early onset alcohol, cigarette, marijuana, and polysubstance use at or before age 15 and its association with injection drug use, specifically, in adulthood in an effort to begin to address this gap.
Section snippets
Design and sample
Data for this study were obtained from the Baltimore site of the NEURO-HIV Epidemiologic Study and has been described in detail in other publications (Mitchell and Latimer, 2009, Severtson et al., 2009). This study was designed to examine neuropsychological and social–behavioral risk factors of HIV, hepatitis A, hepatitis B, and hepatitis C among both injection and non-injection drug users in Baltimore, Maryland. This study was approved by the Institutional Review Board at the Johns Hopkins
Prevalence of recent drug use
In the full sample slightly more than half (52.5%) of study participants reported IDU in some form in the past 6 months. A summary of past 6 month drug use can be found in Table 1. The majority of the participants drank alcohol (71.1%), smoked cigarettes (89.2%), and/or smoked marijuana (52.4%) in the past 6 months. The prevalence of IDU took several forms including injecting speedball (30.9%), heroin (49%), and cocaine (31.4%). The prevalence of non-injection drug use in the past 6 months included
Discussion
The purpose of this study was to examine the relationship between early onset of alcohol, cigarette, marijuana, and polysubstance use and injection drug use status among a sample of recent substance users. Both early onset of alcohol use and polysubstance use were risk factors for IDU, though polysubstance use was found to have a greater odds ratio of predicting IDU. The early onset of alcohol use is consistent with research that suggests alcohol may promote involvement in other illicit
Role of funding sources
Funding sources for this study had no role in the design of the study, data collection, data analysis, data interpretation, writing of the manuscript, or decision to submit for publication.
Contributors
Rebecca Trenz designed the study, conducted the analysis, and led the writing of the article. Michael Scherer, Paul Harrell, Julia Zur, and Ashish Sinha conducted literature searches, provided summaries of previous research, and collaborated on the final presentation of the article. William Latimer was the principal investigator for this study. All authors contributed to and have approved the final manuscript.
Conflict of interest
None.
Acknowledgments
This study was supported by grants R01DA014498 and T32DA007292 from the National Institute on Drug Abuse.
References (57)
- et al.
Risk for initiation of substance use as a function of age of onset of cigarette, alcohol and cannabis use: Findings in a Midwestern female twin cohort
Preventive Medicine
(2006) - et al.
Early-onset drug use and risk of later drug problems
Drug and Alcohol Dependence
(1995) - et al.
Early-onset and risk for drug dependence problems
Addictive Behaviors
(2009) Self-report among injection drug users: A review
Drug and Alcohol Dependence
(1998)- et al.
The developmental antecedents of illicit drug use: Evidence from a 25-year longitudinal study
Drug and Alcohol Dependence
(2008) - et al.
High-risk behaviors associated with transition from illicit non-injection to injection drug use among adolescent and young adult drug users: A case–control study
Drug and Alcohol Dependence
(2002) Age of smoking onset and its association with alcohol consumption and DSM-IV alcohol abuse and dependence: Results from the national longitudinal alcohol epidemiologic survey
Journal of Substance Abuse
(1998)- et al.
Age at onset of alcohol use and its association with DSM-IV alcohol use and dependence: Results from the national longitudinal alcohol epidemiologic survey
Journal of Substance Abuse
(1997) - et al.
A cotwin-control analysis of drug use and abuse/dependence risk associated with early-onset cannabis use
Addictive Behaviors
(2010) - et al.
Age at onset of alcohol abuse and dependence: A 12-year follow-up
Journal of Substance Abuse
(2001)
Patterns of illegal drug use among an adult alcohol dependent population: Results from the National Survey on Drug Use and Health
Drug and Alcohol Dependence
Epidemiologic trends of alcohol, tobacco, and other drugs
Child and Adolescent Psychiatric Clinics of North America
Predicting early adolescent substance use: Do risk factors differ depending on age of onset?
Journal of Substance Abuse
Alcohol expectancies among adolescent nondrinkers: They may not be drinking now, but they're “thinkin bout it”
Journal of Adolescent Health
Drug dependence among young recently initiated injection drug users
Journal of Drug Issues
A developmental perspective on alcohol and youths 16 to 20 years of age
Pediatrics
Neurocognitive functioning of adolescents: Effects of protracted alcohol use
Alcoholism, Clinical and Experimental Research
Adolescent drug use
Childhood factors that precede drug injection: Is there a link?
Journal of Child and Family Studies
Age at first drink and the first incidence of adult-onset DSM-IV alcohol use disorders
Alcoholism, Clinical and Experimental Research
Does the ‘gateway’ matter? Associations between the order of drug use initiation and the development of drug dependence in the National Comorbidity Study Replication
Psychological Medicine
Age at first alcohol use: A risk factor for the development of alcohol disorders
The American Journal of Psychiatry
Marijuana use and later problems: when frequency of recent use explains age of initiation effects (and when it does not)
Substance Use & Misuse
Effects of race, neighborhood, and social network on age at initiation of injection drug use
American Journal of Public Health
Factors associated with adolescent initiation of injection drug use
Public Health Reports
Variation in youthful risks of progression from alcohol and tobacco to marijuana and to hard drugs across generations
American Journal of Public Health
Sensitive periods for adolescent alcohol use initiation: Predicting the lifetime occurrence and chronicity of alcohol problems in adulthood
Journal of Studies on Alcohol and Drugs
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