Elsevier

Addictive Behaviors

Volume 37, Issue 4, April 2012, Pages 367-372
Addictive Behaviors

Early onset of drug and polysubstance use as predictors of injection drug use among adult drug users

https://doi.org/10.1016/j.addbeh.2011.11.011Get rights and content

Abstract

Early onset of alcohol, marijuana, and cigarette use is an indicator of later substance use problems in adulthood such as alcohol or other drug dependence. This paper seeks to address the association between early onset alcohol, marijuana, cigarette, and polysubstance use with injection drug use among recent illicit drug users. The current study used baseline data from the Baltimore site of the NEURO-HIV Epidemiologic Study, an investigation of 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. The present study used a subset (N = 651) of the larger parent study that identified as White or Black, and reported any drug use in the past 6 months. In the full sample slightly more than half (52.5%) of study participants were IDUs. IDUs differed from non-IDUs on age of initiation for cigarettes, marijuana, and alcohol, with IDUs initiating the use of all three substances significantly earlier than non-IDUs. IDUs also had significantly greater proportions of early onset of alcohol (χ2 = 19.71, p < .01), cigarette (χ2 = 11.05, p < .01), marijuana (χ2 = 10.83, p < .01), and polysubstance use (χ2 = 23.48, p < .01) than non-IDUs. After adjusting for age, gender, and race/ethnicity, only participants identified as early onset alcohol users (AOR = 1.47, 95% CI: 1.00–2.18) and early onset polysubstance users (AOR = 1.62, 95% CI: 1.10–2.38) were more likely to have IDU status than those who reported initiating substance use later. IDU status was then stratified by race/ethnicity. After controlling for age and gender, only early polysubstance use was a significant predictor of IDU status for Whites (AOR = 2.06, 95% CI: 1.07–3.93). Consistent with literature on early substance initiation and later illicit substance use, early onset of alcohol and polysubstance use is an important risk factor for IDU in adulthood.

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.

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