Elsevier

Addictive Behaviors

Volume 113, February 2021, 106679
Addictive Behaviors

Adolescent drug use initiation and transition into other drugs: A retrospective longitudinal examination across race/ethnicity

https://doi.org/10.1016/j.addbeh.2020.106679Get rights and content

Highlights

  • 69% adolescent drug users initiated with marijuana and 27% with inhalants.

  • About 40% of inhalant users transitioned to new drugs by year 8.

  • About 70% to 80% other drug users transitioned to new drugs by year 8.

  • There were racial/ethnic discrepancies in both drug use initiation and transition.

Abstract

Background

Understanding adolescent drug use mechanisms is critical for drug use prevention. Although some theories such as the gateway theory suggest that drug users gradually transition into using more addictive drugs, there is no consensus about such a hypothesis. One important factor that hinders the advancement of knowledge in this area is the scarcity of longitudinal studies examining the type of drugs adolescents initially use and the different pathways adolescents take to transition into using other drugs as they grow older.

Methods

Using the pooled sample of adolescent dug users (14–17 years old; n = 10,644) from the National Survey on Drug Use and Health (2015–2018), we constructed longitudinal data on adolescents’ illicit drug use history other than the use of tobacco and alcohol based on the age of drug initiation. This allowed us to investigate what drugs were initially used by adolescents, how the use of these drugs may have progressed into a new drug, and whether there were racial/ethnic differences in the initiation and progression. The retrospective longitudinal data analyses applied life table method and Cox regression models.

Results

Two thirds of the adolescent drug users initiated their drug use trajectories with marijuana, one quarter with inhalants, and the remaining with hallucinogens, prescription drugs, and hard drugs. Adolescent drug users who initiated with different drugs showed unique trajectories to the use of a new drug. By year 8, the probability of using a new drug was about 40% and 70% to 80% for adolescents who initiated with inhalants and other drugs, respectively. The probability of using a new drug for adolescents who initiated with marijuana and inhalants accumulated stably over time, and its difference with that of other drug users diminished over time. The multivariate Cox regression models suggest the observed discrepancies generally held after controlling for covariates. There were also racial/ethnic differences in adolescent drug use initiation and progression, with Black/African American adolescents being the least likely to switch to the use of a new drug.

Conclusion

Adolescents’ initial use of marijuana and inhalants may lead to substantial risks of using other drugs over time. It is therefore important to screen adolescent drug use comprehensively and provide early interventions to prevent an escalation to more detrimental drugs. The findings provide new evidence to support aspects of both the gateway and generalized risk drug use theories.

Introduction

Substance use among adolescents is a significant public health concern in the United States. Although adolescents’ use of alcohol and tobacco has dropped by about half and more than three quarters respectively in the past two decades (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019), their use of illicit drugs has remained largely stable (Vaughn, Salas-Wright, Cordova, Nelson, & Jaegers, 2018). Of the illicit drugs used by adolescents in the past year, marijuana (12.5%) was the most commonly used, followed by misused prescriptions (4.8%), opioids (2.8%), inhalants (2.7%), hallucinogens (1.5%), and hard drugs (e.g., cocaine, methamphetamine and heroin, <1%; SAMHSA, 2019). In addition, substance use co-occurrence is common among adolescent substance users. About two thirds of adolescent drug users use both alcohol and marijuana and about one fifth of them are using three and more drugs (Choi, Lu, Schulte, & Temple, 2018).

Substances use impairs adolescent wellbeing in a extensive way, leading to poor academic performance, aggravated physical and mental health problems, disruptions in family functioning, unhealthy peer relationships, and accidental deaths in childhood and throughout their lifetime (Brière et al., 2014, Hawkins et al., 1992, Pei et al., 2020, Marsiglia et al., 2019, Spooner and Hetherington, 2004). The devastating consequences of substance use and misuse are exemplified in the current opioid epidemic, which has claimed nearly 43,000 lives and incurred $95.8 billion in societal costs in 2016 alone (Normile, Hanlon, & Eichner, 2018).

Understanding the mechanism of adolescent drug use is critical for effective prevention strategy development and implementation. Gateway drug theory is often used to explain adolescent’s drug use initiation and progression (Golub and Johnson, 2002, Kandel, 2002). The theory hypothesizes that drug users tend to start with soft drugs such as tobacco, alcohol, and marijuana and then progress to hard drugs such as heroine and crack (Fairman et al., 2018, Maldonado-Molina and Lanza, 2010, Nkansah-Amankra and Minelli, 2016). For example, Nkansah-Amankra and Minelli (2016) longitudinal study based on national data shows that early adolescence gateway drug (e.g., tobacco and alcohol) use was significantly associated with the use of marijuana, cocaine, and other illicit drugs in older adolescence. The theory has also been supported by evidence from prevention practices, in which the reduction of tobacco, alcohol, and marijuana use has lowered the probability of other illicit drug use (Botvin et al., 2001, Maldonado-Molina and Lanza, 2010).

On the other hand, generalized risk theory argues that there are common risks underlying individuals ’drug use behavior, especially drug use disorders. Common risks such as individual genetic and psychological traits and environmental factors like familial and peer influence render a sequential order in drug use unlikely (DuPont et al., 2018, Palmer et al., 2014, Xian et al., 2008). The theory has been supported by studies that do not find a sequential order in drug use (Rebellon and Van Gundy, 2006, Wu et al., 2020), and studies that suggest that genetic and environmental factors are linked to drug use and use disorders (Degenhardt et al., 2010, DuPont et al., 2018). In addition, studies have found racial/ethnic differences in drug use initiation and progression between and within groups (Park et al., 2018, Vaughn et al., 2008). For example, Vaughn et al. (2008) found that Black adolescents were more likely to use marijuana before tobacco than Caucasian adolescents.

There are limitations in existing studies examining adolescent drug use initiation and progression. First, most studies used cross-sectional data and thus can only assess the co-occurrence rather than sequence of drug use (Nguyen et al., 2019, Winstanley et al., 2020, Zuckermann et al., 2020). For example, Nguyen et al. (2019) found that the joint use of both tobacco and marijuana was most common among adolescents, but the cross-sectional data prevented investigating whether adolescents started from using tobacco or marijuana. Second, among a limited number of longitudinal studies that examined the drug use sequence, the focus was often to identify a gateway drug among tobacco, alcohol, and marijuana (Castaldelli-Maia et al., 2018, Cleveland and Wiebe, 2008, Park et al., 2020, Vaughn et al., 2008). However, some adolescents may initiate drug use with a different type such as inhalants (Castaldelli-Maia et al., 2014, Compton and Volkow, 2006, Kelly et al., 2013, Lankenau et al., 2012, Wu et al., 2020). There is a lack of in-depth investigation about drug use initiation and progression among a broad range of illicit drugs. A unique study examining a comprehensive list of illicit drugs, found that about one quarter of Brazil’s college students initiated illicit drug use with inhalants (Castaldelli-Maia et al., 2014). Many previous studies primarily focused on the use of alcohol, tobacco, and marijuana, while there are less specifics about the initiation and progression of other illicit drugs. Third, for adolescents who initiated drug use with different types of drugs, few studies have examined whether their trajectories into using a new drug vary. Finally, there may be racial/ethnic and related socioeconomic differences in adolescent drug use initiation and transition that deserve exploration (Park et al., 2018, Vaughn et al., 2008). The lack of a suitable longitudinal dataset with national representativeness may be a major barrier to overcome the aforementioned knowledge gaps.

Using adolescents’ reported ages of initiation into different illicit drug use, the current study constructed a retrospective national longitudinal dataset to trace adolescents’ initiation of a comprehensive list of illicit drugs and subsequent transition into using a new drug. We did not include adolescents’ use of alcohol and tobacco in the current study because their use and relations with other drugs have been extensively studied (e.g., Fairman et al., 2018, Nguyen et al., 2019), and the social contexts related to their use may be somewhat different from that related to the use of other illicit drugs (Jackson et al., 1997, Wenzel et al., 2010). The exclusion of these two types of drugs allows to investigate the initiation and transition among other illicit drugs with more depth and specificity (Castaldelli-Maia et al., 2014). The current study contributes to the literature by examining three questions related to drug use initiation and transition:

  • a)

    When and what type of illicit drugs adolescents initially use?

  • b)

    How does the initial drug type relate to the trajectory of using a new illicit drug?

  • c)

    Are there any racial/ethnic differences in those drug use initiations and transitions?

When examining how adolescent drug users’ initial drug types may contribute to the trajectory of using a new drug, factors that are commonly associated with adolescent drug use may confound the process, and thus it is important to control for these variables. Based on the existing literature and available data, we took into account multi-dimension covariates, including adolescent characteristics as indicated by race/ethnicity, age, gender, school attendance, health status, sensation seeking, depression, disability, peer substance use, and antisocial behavior (Donaldson et al., 2015, Nkansah-Amankra and Minelli, 2016, Siegel et al., 2014, Vaughn et al., 2018, Zimmerman and Farrell, 2017, Zuckermann et al., 2020); family characteristics as indicated by family structure, parenting, family income, and youth health insurance coverage (Donaldson et al., 2015, Hemovich et al., 2012, Hemovich and Crano, 2009, Zimmerman and Farrell, 2017, Zuckermann et al., 2020); and place of residence.

Section snippets

Sample and data

The sample consisted of four years of pooled data (2015–2018) derived from the National Survey on Drug Use and Health (NSDUH), a nationally representative study which annually surveys about 70,000 noninstitutionalized individuals 12 years and older in the U.S. civilian population across all 50 states and the District of Columbia (Center for Behavioral Health Statistics and Quality, 2019). About one-fifth of the annual NSDUH survey respondents were adolescents of 12 to 17 years old (N = 54,866).

Sample characteristics

Among the initially used illicit drugs by adolescents, marijuana accounted for more than two thirds (68.72%), followed by inhalants (26.76%), misused prescription drugs (2.80%), hallucinogens (1.25%), and hard drugs (0.47%). More than one third (37.44%) of the adolescents were 14 to 15 years old, and the remaining were 16 to 17 years old. Half were boys (50.49%). Most of the adolescents were in school (88.23%), and most (93.51%) rated their health status as good to excellent. Less than half of

Discussion

Based on retrospective data of adolescent illicit drug use history, this study conducted longitudinal analyses to examine the trajectory of initial adolescent drug users’ transition into a new drug. This is the first study based on the U.S. adolescent population data to examine the pathways from drug use initiation into using other drugs. The findings show that adolescents are most likely to initiate illicit drug use with marijuana and inhalants and the initial drug types are related to

Conclusion

This study demonstrates that more than two thirds of adolescent drug users initiated with marijuana, one quarter with inhalants, and the remaining with hallucinogens, prescriptions, and hard drugs. Adolescent drug users who initiated with different drugs showed different trajectories to the use of new drugs. By the end of the observation period (year 8), about 40% of those who initiated with inhalants would use a new drug and about 70% to 80% of those who initiated with marijuana and other

Author declaration

The study has not been published previously (except in the form of an abstract and academic conference presentation), is not under consideration for publication elsewhere, is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and, if accepted, will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder.

Funding

The study was partially funded by a research grant through the Community and Research Investment Engagement Program (CRIE) from the University of Mississippi School of Applied Sciences (UM SAS). The views and opinions expressed in this article are those of the authors and do not necessarily reflect that of the UM SAS or UM.

CRediT authorship contribution statement

Saijun Zhang: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing. Shiyou Wu: Writing - original draft, Writing - review & editing. Qi Wu: Writing - original draft, Writing - review & editing. Daniel W. Durkin: Writing - review & editing. Flavio F. Marsiglia: Conceptualization, Writing - review & editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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