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Substance Use and Associated Health Conditions throughout the Lifespan

Substance Use and Associated Health Conditions throughout the Lifespan 1 Public Health Reviews, Vol. 35, No 2 Substance Use and Associated Health Conditions throughout the Lifespan Marya T. Schulte, PhD, Yih-Ing Hser, PhD ABSTRACT A life stage perspective is necessary for development of age-appropriate strategies to address substance use disorders (SUDs) and related health conditions in order to produce better overall health and well-being. The current review evaluated the literature across three major life stages: adolescence, adulthood, and older adulthood. Findings: 1) Substance use is often initiated in adolescence, but it is during adulthood that prevalence rates for SUDs peak; and while substance involvement is less common among older adults, the risk for health complications associated with use increases. 2) Alcohol, tobacco, marijuana, and, increasingly, prescription medications, are the most commonly misused substances across age groups; however, the use pattern of these and other drugs and the salient impact vary depending on life stage. 3) In terms of health outcomes, all ages are at risk for overdose, accidental injury, and attempted suicide. Adolescents are more likely to be in vehicular accidents while older adults are at greater risk for damaging falls. Adulthood has the highest rates of associated medical conditions (e.g., cancer, sexually transmitted disease, heart disease) and mental health conditions (e.g., bipolar disorder, anxiety disorders, antisocial personality disorder). Conclusion: Prolonged heavy use of drugs and/or alcohol results in an array of serious health conditions. Addressing SUDs from a life stage perspective with assessment and treatment approaches incorporating co-occurring disorders are necessary to successfully impact overall health. Key Words: Substance use disorder, psychiatric disorder, medical condition, comorbidity Recommended Citation: Schulte MT, Hser Y-I. Substance use and associated health conditions throughout the lifespan. Public Health Reviews. 2014;35: epub ahead of print. UCLA Integrated Substance Abuse Programs, University of California, Los Angeles, CA, USA. Corresponding Author Contact Information: Marya T. Schulte at mtschulte@ucla.edu; UCLA Integrated Substance Abuse Programs 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA 90025, USA. 2 Public Health Reviews, Vol. 35, No 2 INTRODUCTION Substance use is a major public health concern that affects every level of society. Individuals, families, communities, and overall government spending is impacted by the use of licit and illicit substances. Recent reports estimated that annual costs in the United States are approximately USD $193 billion for illicit drug use, USD $223 billion for excessive 2 3 alcohol use, and USD $193 billion for tobacco use. These costs include lost wages and productivity, criminal activity, and healthcare expenses. The economic burden aside, public health efforts can benefit from a better understanding of the impact of substance use disorder (SUD) on physical and mental health. Particularly, examining SUDs and the constellation of associated health and mental health problems throughout the lifespan provides a full picture of how variations in drug use patterns and outcomes shift with age, on which the present article will focus. Adolescence represents a time in biological and social development that is associated with increased risk-taking behaviors; as such, experi- mentation with drugs and alcohol often begins in adolescence. Young brains are still changing as synaptic pruning continues into early adult- hood, making the possibility for long-term negative effects of substance involvement even more profound. On the other end of the age spectrum, older adults also represent an extremely vulnerable group. The physiological changes that occur as a result of the natural aging process result in an increased use of multiple medications, drug and alcohol sensitivity, and the likelihood of co-occurring health conditions; thus, the risk for and con- 6-8 sequences of SUDs are magnified. The purpose of the current review is to synthesize the research findings to date that examine physical and mental health problems associated with substance use at different stages of life. The goal is not to provide an exhaustive list of studies, but to emphasize the changing needs across the lifespan of those suffering from comorbidities in order to inform development of care and future research. In addition to presenting general patterns of alcohol, tobacco, and licit/illicit drug use, common and troublesome medical and psychiatric conditions associated with SUDs among adolescents, adults, and older adults are discussed. While some substances can result in significant consequences that are both acute and chronic (e.g., alcohol), the negative impact of others (e.g., tobacco) are primarily observed only after prolonged use. Finally, recommendations regarding clinical implications and areas for future research are presented. Substance Use and Health 3 Table 1 Major domains of developmental transitions influencing substance use and physical and mental health conditions Achievement Biological and Cognitive Identity and Relationships and Responsibility Adolescence -Pubertal development/ -Increased autonomy from -Increased personal hormonal changes family responsibility in school -physical appearance -less parental control & (i.e., less individualized begins to look more more independence (e.g., instructor attention in high adult-like driving, moving away from school & college) home) -Axon myelination & -Increased financial synaptic pruning -Greater influence from peer autonomy (e.g., more -increased ability to groups likely to have part-time perform executive job, pay some bills) -Increased interest & functioning tasks (e.g., involvement in sexual & increased ability to romantic relationships think abstractly & -Increased awareness & decision-making) adherence to gender roles & norms Adulthood -Sexual maturation & -Greater stability in romantic -Full-time work with greater hormonal stability relationship, such as marriage financial independence & responsibility (i.e., pay -Neurocognitive brain -Formation & commitment to bills for self & family) maturation, specifically one’s own family (i.e., spouse prefrontal cortex & children) -Intergenerational -optimal organization & responsibility -Legal maturity regulation of cognition -parenting children -social decisions based on & goal-directed while caring for aging one’s own beliefs & values behavior parents rather than legal restriction (e.g., voting, drinking) Older Adulthood -Hormonal decline (i.e., -Decreased autonomy due to -Reduced employment or menopause & decreased physical &/or cognitive retirement testosterone) leading to limitations -increased financial decreased reproductive restrictions from fixed -Lessened connection to capabilities income extended family (e.g., possible -Decrease in neurocognitive death of spouse and/or family -Increased reliance on functioning in speed of members, children move from public assistance (e.g., processing, working home) medicare, social security) 4 Public Health Reviews, Vol. 35, No 2 Developmental Framework and Life Stages Focal to the current review is the integration of studies across developmental periods which link substance use and health conditions. Biogenetic, psycho- logical, and sociocultural factors vary in influence depending upon proximal (e.g., family, peer group, work setting) and distal (e.g., broader cultural, sociohistorical events such as wars or economic recession) contextual events 9-12 over the lifespan. By placing the current literature within a developmental- contextual framework, we highlight what Bronfenbrenner terms “ecological transitions.” These transitions are characterized as “whenever a person’s position in the ecological environment is altered as a result of change in role, setting, or both.” We have organized the reviewed studies based on life stages marked by major developmental transitions. While specific age groupings may vary somewhat from study to study, the majority of research investigates substance involvement within one of three seminal life stages: adolescence, adulthood, and older adulthood. Table 1 summarizes examples from principal domains of developmental transitions relevant to each of the three life stages. Substance Use Patterns Large epidemiological surveys have shown alcohol, tobacco (i.e., cigarettes), and marijuana have the highest prevalence rates across all age groups. Figure 1 shows the percentage of people endorsing use in the past year (2011) for alcohol, tobacco, marijuana, cocaine, methamphetamine, heroin, and prescription drug misuse (i.e., pain relievers, tranquilizers, stimulants, sedatives). In early adolescence, prevalence rates of marijuana use were higher than tobacco; however, this appears to change in later teen years. Early adulthood shows the greatest amount of substance involvement, especially alcohol use. And while older adults are less likely to report past year substance use than most of their younger counterparts, prevalence rates for alcohol use remain relatively high. The Treatment Episode Data Set (TEDS) presents US national-level data on demographic and substance abuse characteristics of admissions to treatment for abuse of alcohol and/or drugs. Figure 2 shows the distribution of primary substance of abuse reported at admission by age groups for treatment admissions in 2010. The majority of admissions are accounted for by four major substance groups: alcohol, marijuana, opiates, and cocaine. The remaining substances classified as “other” (methamphetamine, tran quilizers, sedatives, hallucinogens, PCP, inhalants, and “none specified”) are grouped due to low prevalence rates, particularly among youths and older adults. Adolescents largely seek treatment for marijuana Substance Use and Health 5 use disorders, while older adults are largely in treatment for alcohol use disorders. The proportion of treatment admissions by drug group is most evenly distributed during adulthood. Fig. 1. Past-year substance use by age. Source: Data from National Survey on Drug Use and Health 2011, N=58,397. Fig. 2. Treatment admissions by age at admission and according to primary substance of abuse. Source: Results from Treatment Episode Data Set (TEDS) 2010, N=1,820,737. 6 Public Health Reviews, Vol. 35, No 2 Of the almost two million treatment admissions reported by TEDS, less than 40,000 were accounted for by those 60 or over. While many adults “mature out” of heavy drinking and illicit drug use during the second half of life, prevalence rates among older adults are also affected by higher mortality rates among drug users. Epidemiological surveys are not based on longitudinal data sets and therefore do not track the course of drug involvement over time. Hser and colleagues’ 33-year follow-up study of narcotics addicts showed high rates of mortality among drug users, most commonly attributed to accidental poisoning or overdose. Premature mortality is believed to be a function of substance use and lifestyle. DISCUSSION Table 2 summarizes the substances and associated health conditions that are most prominently featured in the literature. Again, while not exhaustive lists, the mental and physical health problems highlighted here represent areas we believe are of great public health importance. Adolescence Although legal and practical barriers are most restrictive for teen users, substance use remains an area of concern due to the potentially hazardous short- and long-term consequences. The leading cause of accidental injury and death (e.g., automobile accidents, suicide) among adolescents is precipitated by substance use. Maladaptive behavioral patterns associated with later physical and mental health problems are formed and consolidated 18-20 during this time. Thus, examination of substance use and outcomes among adolescents can help tailor interventions and maximize long-term benefits. Physical Health/Medical Conditions Adolescence is a period marked by significant developmental changes. As such, even moderate substance use can cause harm. Behaviors associated with drinking and drug use in teens contribute to increased risk for injury and violence. US national survey results indicate that within the month prior to survey, 24.1 percent of high school students reported being a passenger in a car when the driver had been drinking and 8.2 percent reported having driven a car themselves after consuming alcohol. An examination of older adolescents revealed that one in six college students reported drugged driving (i.e., illicit drugs or prescription drugs used non-medically) in the past year. The combination of limited driving experience and impaired motor skills results in increased rates of injuries and fatalities from traffic accidents. Substance Use and Health 7 Table 2 Summary substance use patterns and associated mental and physical health conditions by life stage Physical/ Mental Health/ Substance Use Medical Conditions Psychiatric Disorders Adolescence Alcohol Accidental Injury Suicidal Ideation/Behaviors Automobile Accidents Marijuana Internalizing Disorders Physical/Sexual Violence Depression Tobacco Anxiety Poisoning/Overdose Inhalants Externalizing Disorders Sexually Transmitted Psychotherapeutic Drugs Oppositional Defiant Disorder Diseases Amphetamines Attention Deficit/ Opioids/Pain Relievers Respiratory Problems Hyperactivity Disorder Asthma Conduct Disorder Pain-Related Diagnoses Adulthood Alcohol Poisoning/Overdose Suicidal Ideation/Behaviors Marijuana Sexually Transmitted Mood Disorders Diseases Depression Tobacco Bipolar I & II Cancers Psychotherapeutic Drugs Anxiety Disorders Opioids/Pain Relievers Heart Disease/ Panic Disorder Tranquilizers/ Hypertension/Stroke Post-traumatic Stress Disorder Benzodiazepines Reproductive Morbidity/ Social & Specific Phobias Cocaine/Crack Fetal Damage Generalized Anxiety Disorder Heroin Diabetes Antisocial Personality Disorder Methamphetamine Respiratory Problems Asthma Infection Liver Damage/Disease Older Adulthood Alcohol Accidental Injury Suicidal Ideation/Behaviors Psychotherapeutic Drugs Cirrhosis Depression/Bereavement Opioids/Pain Relievers Heart Attack/Stroke Anxiety Disorders Sedatives/ Social & Specific Phobias Insomnia Benzodiazepines Generalized Anxiety Disorder Cancers Amphetamines Dementia/Wernicke-Korsakoff Diabetes Marijuana Syndrome Tobacco Insomnia 8 Public Health Reviews, Vol. 35, No 2 Substance using adolescents also frequently engage in risky sexual 23,24 behaviors. Among sexually active high school students, 22.1 percent report having used drugs or alcohol prior to their most recent sexual inter- course. Consequently, substance use and corresponding risky sexual behaviors have shown consistently strong associations with sexually trans- 23,25,26 mitted diseases (STDs) among teens. Unprotected sex and history of sex with multiple partners is more likely among both social and chronic 27-29 substance users well into late adolescence. Recent Centers for Disease Control and Prevention (CDC) data show the magnitude of this risk, with young people accounting for over a quarter of new HIV infection cases; almost 60 percent of those infected did not know their HIV status. Yan and colleagues examined the relationship between substance use and HIV/ STD-related sexual risk behaviors more closely. In their national sample of sexually active teens living in rural US settings, they found that smoking three or more days in the past month was significantly associated with not using condoms. Recent and lifetime drug and alcohol use were related to having multiple sexual partners. It appears that substance use and risky sexual behavior represent part of a constellation of reckless behaviors, 30,31 some of which are normative while others are the result of social deficits. Adolescents diagnosed with an SUD show more acute and potentially chronic health problems than teens without SUD. Nonmedical use of prescription drugs and over-the-counter medications accounted for approximately half of emergency department (ED) visits for drug abuse or misuse in the US in 2011; among youth aged 12-17, the proportion of those seeking emergency medical care due to pharmaceutical misuse exceeds that of alcohol (301 ED visits versus 160 ED visits per 100,000 population). The risk for substantial harm is increased when medications are abused with one another and/or alcohol. Specific, chronic health problems can be difficult to detect in a younger population; however, Mertens, Flisher, Fleming and Weisner found that prevalence rates for one-fourth of the comorbid medical conditions examined were greater among substance-using teens. In particular, asthma and pain-related diagnoses surfaced as common and costly health conditions 34,35 among the patient group. Myers and Brown found that independent of other drug involvement, respiratory problems continued from two to four years after substance abuse treatment for adolescent smokers. Although definitive causal relationships across medical conditions are difficult to discern, continued substance involvement can exacerbate symptoms, and for some, lead to more severe, life-threatening disorders. Substance Use and Health 9 Mental Health/Psychiatric Disorders Suicidal thoughts and behaviors directly link mental health to physical well-being. Suicide is the third leading cause of death among American 36,37 youth age 10-19. Although substance use is not always the “cause” of suicidal ideation or attempts, it is a significant risk factor. Teens with SUDs have been found to be about three times more likely to make a suicide attempt as compared to non-drug-using adolescents. In a study examining data from a community sample of youth, suicide attempts were strongly associated with alcohol abuse and dependence, even after controlling for depression. These findings highlight the need to better understand the role that substance use and abuse plays in suicidal thoughts and actions, both in the presence and absence of mental health conditions. Among clinical samples, high rates of comorbidity exist during adolescence. Approximately 70-80 percent of youths presenting to treatment are dually diagnosed. Comorbidity patterns, however, vary by substance type, severity of SUD, and psychiatric disorder. For instance, while internalizing disorders (e.g., anxiety, depression) are prevalent in 44,45 both clinical and general adolescent populations, many studies indicate gender differences in co-occurrence for mood disorders. Specifically, rates 43,46-48 of depression are higher for girls than boys with SUDs. Shrier and colleagues examined this further by assessing psychiatric symptoms among youth with sub-diagnostic substance use problems within a primary care setting. They found that girls exhibiting substance use problems were more likely to report symptoms of mood disturbance. Anxiety symptomology has been found to be highly prevalent for both adolescent boys and girls 43,49 with diagnostic or problematic use, with about seven percent of youths with an SUD meeting criteria for any anxiety disorder within the past year. While the exact sequencing of psychiatric symptoms and substance use can vary by individual, there is some evidence that externalizing disorders 50-53 typically precede SUDs. Disorders such as Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Attention Deficit/ Hyperactivity Disorder (ADHD) are characterized by their childhood or adolescent onset and constellation of disruptive and maladaptive behaviors. Externalizing symptoms have been associated with sub-diagnostic drug 49,51 and alcohol use for both male and female adolescents, suggesting an association between behavioral disturbance and problematic use prior to full SUD criteria. However, epidemiologic data indicate that SUDs are associated with greater odds of comorbid CD and ODD. Taken together, the evidence suggests the co-occurrence of substance use, problematic or diagnostic, and socially harmful behaviors may be interacting and possibly 10 Public Health Reviews, Vol. 35, No 2 43,55 exacerbating one another. While limited social responsibilities during adolescence may restrict the impact of these behaviors, the combination of ongoing substance involvement and maladaptive behavior can set the stage for greater impairment as youth move into adulthood. Adulthood Referring once again to Bronfenbrenner’s developmental framework, the ecological transition from adolescence to adulthood is marked by profound changes. Prevalence rates for drugs and alcohol increase during late adolescence; however, most individuals transition out of this drinking and 56,57 drug use pattern. The multilevel developmental contextual approach recognizes that a move into SUD is influenced by multiple factors within a dynamic, probabilistic process. Physical Health/Medical Conditions The impact of SUDs on physical health is most easily seen in terms of acute effects. Intoxication, misuse, and overdose can be life-threatening and result in medical emergencies. In 2011, the majority of ED visits in the US related to illicit drugs was accounted for by adults (21-64 years). Young adults had the highest rates of medical emergencies involving marijuana, heroin, and amphetamine/methamphetamines in comparison to other age groups. However, a recent morbidity and mortality report reveals that opioid analgesic poisoning was related to more deaths than heroin or cocaine, the majority of which were aged 35-54. Prescription medication misuse poses as much of a threat to health as traditional street drugs. Unfortunately, the consequences of non-medical use of prescription drugs may continue to rise as the younger generations with access to pharma- ceuticals ages and social acceptance of medication sharing continues. In addition to acute problems, SUDs can result in general health deterioration and specific, ongoing conditions. In a 14-year prospective study of young adults reporting “good” or better health at intake, baseline hard drug use was significantly associated with subsequent self-rated health decline as compared to never using. They found even if drug use stopped, the decline continued. The authors identified tobacco use as a significant factor for lack of restored health. These results are consistent with national studies in which 77-93 percent of clients in SUD treatment settings use 61 62 tobacco products and over 50 percent die of tobacco-related causes. The combination of multiple substances substantially increases the risk for health problems. For instance, while cancers of the mouth and throat are seven and six times greater for tobacco and alcohol users respectively, the Substance Use and Health 11 risk is 38 times more for those who use both substances. Cigarette smoking in particular has been linked to 90 percent of all cases of lung cancer and accounts for approximately one-third of all cancer deaths. While the research regarding marijuana smoking and lung cancer remains inconclusive, there is evidence for increased risk of respiratory illnesses 66,67 among regular marijuana smokers. Several substances (e.g., alcohol, tobacco, heroin, prescription stimulants, methamphetamine) have been linked to increased risk for cardiovascular problems and heart disease. As a stimulant, cocaine immediately and directly impacts blood pressure; thus, the resulting increased risk for heart 64,68 attack and cardiac arrest seems an obvious one. There is, however, a strong and consistent relationship between long-term alcohol use and 69-71 hypertension as well. In fact, heavy drinking is purported to be the most 72,73 common cause of secondary hypertension. Although it appears these effects are often reversible with sustained abstinence, blood pressure quickly 73,74 returns to elevated levels upon relapse. Over time, continued use and hypertension increase the risk for cereborvascular accidents, with binge drinking being a significant risk factor for all subtypes of stroke. The physical and mental impairment from stroke is potentially large and irreversible; thus, cardiovascular health is an important issue in individual and public health. Substance use also increases risk for infectious disease. Drug and needle sharing practices can lead to infection of HIV, hepatitis C (HCV), and other blood-borne pathogens. Injection drug users (IDUs) are the highest risk group for acquiring HCV; approximately 70 to 80 percent of 76-78 new HCV cases in the US each year are among IDUs. Similarly, injection drug use, both directly and indirectly, is a significant contributor to the spread of HIV. More than one-third of AIDS cases in the US are due to IDUs, people who have sex with IDUs, and children born to mothers who have contracted HIV through drug use practices. HIV and HCV infection rates specifically among crack cocaine users is also accounted for by sharing of pipes among users with open mouth sores, increased risky 80-82 sexual behavior, and sex work (i.e., trading sex for crack or money). Similarly, methamphetamine use, whether injected, snorted, or smoked, is associated with increased risk for HIV and other STDs, particularly among men who have sex with men. Regardless of sexual orientation, however, sexual risk practices such as reduced condom use, being high during sex, and having multiple sexual partners is prevalent among methamphetamine 84,85 users. Once contracted, the course of sexually transmitted infectious disease carries with it a long-term, cost-heavy burden for treatment. 12 Public Health Reviews, Vol. 35, No 2 Mental Health/Psychiatric Disorders Adults diagnosed with an SUD and comorbid mental health disorder are at increased risk for poor health, social dysfunction, incarceration, poverty, 86,87 and homelessness. Anxiety disorders represent some of the most commonly co-occurring disorders, with significant associations between 88-90 any anxiety disorder and any drug dependence. Among the general US population, 30 percent of those meeting criteria for any lifetime drug use disorder had at least one anxiety disorder. In particular, sedative, opioid, and tranquilizer use disorders have shown a strong association with anxiety 90,91 disorders. Women have demonstrated greater comorbidity between these specific SUDs and anxiety disorders, especially social and specific 88,91 phobias. Although epidemiologic surveys cannot definitively support the self-medication hypothesis, some speculate that the calming effects of these drugs play a role in their link to comorbid anxiety. Although post-traumatic stress disorder (PTSD) is also classified as an anxiety disorder, its fundamental component of resulting from a traumatic event sets it apart. The lifetime prevalence of PTSD in the general population 92,93 is estimated to be less than eight percent; however, the lifetime pre- valence rate of PTSD among adults with a drug or alcohol use disorder 94,95 ranges from a quarter to a half in clinical samples. The relationship between trauma and SUDs is believed to be bidirectional. Heavy drug and alcohol use places individuals at risk for victimization; and conversely, those who have experienced a traumatic event often cope with the symptoms (e.g., insomnia, hyperarousal, intrusive thoughts) by using drugs and 90,96,97 97 alcohol. Ouimette and colleagues demonstrated the impact that PTSD symptoms and substance use have on one another by monitoring dually diagnosed out-patients for 26 weeks. Results indicated that PTSD symptoms and alcohol and cocaine symptoms fluctuated concurrently week to week. These findings and high rates of comorbidity speak to the need for assessments and treatments that address both. Mood disorders, including major depressive disorder (MDD) and bipolar I and II, have consistently demonstrated most common co-occurrence 88,90,98,99 with SUDs among adults. Individuals meeting criteria for MDD are approximately twice as likely to have SUD as those with no mood disorder 90,98,100,101 diagnosis. The risk of a comorbid SUD is even greater among those with bipolar disorder, with estimates indicating a seven times greater 90 102 likelihood. In a 20-year prospective study by Merikangas and colleagues, results indicated that people who reported symptoms of mania, but did not meet full diagnostic criteria for bipolar I or II, were at an increased risk for developing an alcohol use disorder. Furthermore, those diagnosed as Substance Use and Health 13 bipolar II showed even greater risk for developing an alcohol use disorder or benzodiazepine use problem. Of particular concern is the increased risk for suicide attempts and completion within this population. The stronger association between mood disorders and SUDs among women has potentially grave implications beyond the individual. Mental health status and associated impairment can affect child rearing and the family environment when mothers suffer from comorbidity. Antisocial personality disorder (ASPD) is commonly discussed in the literature because of its significant and consistent relationship with 88,105 SUDs. ASPD is more often diagnosed in men and is defined by a failure to conform to social norms and a persistent disregard for the rights of others. Compared to the general public, prevalence rates of ASPD are 106,107 higher among prisoners and those in drug and alcohol treatment settings. The co-occurrence of these disorders is associated with greater severity and poorer prognosis; substance use is initiated earlier and the progression into dependence occurs more quickly. Substance use combined with the pervasive impulsivity and aggression characteristic of ASPD can result in problematic family relationships and increased recidivism among those 106,109 who have been criminally convicted. Treating ASPD patients is often challenging. Establishing a good therapeutic alliance is difficult and many refuse services or terminate early unless required by an external source (e.g., condition of parole). The transition into later adulthood for these individuals is likely to be a difficult one, with little positive social support and poor health. Older Adulthood Although Bronfenbrenner’s developmental framework focuses more on understanding how a child’s interaction with the external world shapes internal processes and behaviors, ecological systems continue to influence functioning as adults age. Older adults tend to experience fewer traditional responsibilities, such as full-time employment or parenthood; however, the natural aging process brings other notable social, cognitive, and physiological challenges. And while substance use generally declines in later adulthood, even small amounts of drug and alcohol use can have serious consequences. Physical aging and commonly used medications can 8,111 result in increased sensitivity to the effects of substance use, elevating the risk for impairment and accidental death. 14 Public Health Reviews, Vol. 35, No 2 Physical Health/Medical Conditions Substance use disorders in older adults may be a continuation of excessive drug and alcohol use initiated while younger, but for some, substance use begins during times of transition or loss. For instance, health declines that accompany older age may lead to reduced independence or associated pain; drug and alcohol use therefore provides an emotional escape from boredom and loneliness. Unfortunately, the combination of existing chronic conditions and substance use or misuse can result in exponentially negative 113,114 effects on physical health. Older adults are more likely to experience adverse events from psychoactive medications, and due to the increased likelihood of older adults being prescribed multiple medications, the risk for serious drug interactions is high and often requires emergency medical 115-117 care. Additionally, prescription medication use, such as regular use or misuse of sedatives and benzodiazepines, has been associated with 116,118 increased risk for falls in older populations. When alcohol is combined with prescription medications, the effects appear even more detrimental. In a national study of Medicare beneficiaries, heavy drinking more than doubled the risk for hip fractures. All of these can lead to costly hospital admissions and lengthy stays. The impact of drugs and alcohol on blood pressure and insulin production can greatly increase the risk for heart attack and stroke. In a population-based cohort study of cardiovascular health among older adults, nine-year follow-up data demonstrated modestly lowered risk for stroke among light drinkers; however, alcohol consumption greater than six drinks per week was associated with increased risk. Although the relationship between cardiovascular health risks and alcohol use may be somewhat inconsistent, the link between tobacco use and heart and cerebrovascular disease is very clear, with smoking being a major risk factor in these leading 120,121 causes of death among those 60 and over. The increased prevalence of smoking and non-medical use of prescription drugs among older adults who drink more heavily places this group at high risk for premature death. Unfortunately, however, few interventions are tailored to older adults and may fail to address their specific needs and concerns. Substance-using older adults are at increased risk for organ damage and various cancers. In particular, the ten-year risk for developing breast cancer among women age 60 and over is more than double than that of their 40-year-old counterparts; regular alcohol consumption and cigarette smoking are considered significant and controllable risk factors for the disease. Similarly for men, risk for colorectal and prostate cancer quickly 120,122 increases with age, with substance involvement amplifying risk. Substance Use and Health 15 Additionally, although women are more sensitive to the effects of long-term alcohol use, alcoholic men are approximately two to six times more likely to 123,124 be diagnosed with cirrhosis in comparison with alcoholic women. Thus, gender appears to be an important factor in determining the health needs of older adults. Mental Health/Psychiatric Disorders Mental health disorders are associated with significant disability in older adults. Mental capacity can compromise quality of life, increase mortality, and decay physical health. Multiple cognitive deficits, most prominently memory difficulties, that are severe enough to cause significant impairment in functioning are classified as dementia. While chronic alcohol use can be detrimental to memory function and at times result in Wernicke- 126,127 Korsakoff syndrome, some evidence indicates limited alcohol intake may be protective against developing dementia as adults age. A recent meta-analysis on alcohol consumption and cognitive decline in older adults showed moderate drinking was associated with a reduced risk for dementia. Conversely, even small amounts of alcohol can potentially intensify the effects of many commonly used prescription (e.g., benzo- 129,130 diazepines) and over-the-counter medications (e.g., anti histamines). Resulting confusion can impact even simple tasks like personal hygiene 129-131 and self-grooming, making independent living less possible. Since individual differences appear to be even greater among older adults, physician-monitoring of substance use and misuse is of increased importance for overall safety. Like all stages of life, older adults are at risk for depression and anxiety. Among older adults meeting criteria for panic disorder, approximately 36.7 percent are comorbid for current MDD. In a survey among older adults admitted for SUD treatment, anxiety and depression were cited as the top reasons for misusing substances. Older women are particularly high risk for comorbidity; they receive twice the number of prescription medications 130,134 as men, making them vulnerable to drug misuse. More severe depressive symptoms, especially those caused by bereavement, can result in suicide attempts. Rates of completed suicide are most prevalent among older white men who drink heavily after the loss of their spouse. In terms of ecological transitions, the loss of loved ones and erosion of independence are the hallmarks of older adulthood. Both can have significant impacts on mood and functioning. 16 Public Health Reviews, Vol. 35, No 2 RECOMMENDATIONS Adolescents may only see the beginnings of emerging medical and psychiatric complications, either resulting from or exacerbating their substance use, and therefore issues of comorbidity may not be adequately assessed or addressed in treatment. Further, substance use or psycho- therapeutic misuse may not be identified as a primary problem among older adults during doctor visits. Physicians and patients may assume medical and mental health symptoms are the result of normal aging and therefore not assess substance involvement. Despite the prevalence of SUDs among adult men and women, most never receive formal treatment. The majority of those who do seek out services do so through self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous); they report lack of health care coverage and not being ready to stop using as the top reasons for not receiving treatment. In order to address this gap in care, healthcare systems should have improved integrated care for mental health, medical conditions, and SUDs. Increased training for physicians in how to assess for SUDs and mental health disorders could help them better identify and refer patients in need of specialized services. Patients’ reluctance to reduce or stop using may be better combated if physicians were able to adequately identify and communicate how substance use was impacting specific health conditions. Personal relevance along with a more complete picture of how behaviors affect well-being may assist in promoting and sustaining behavioral change. Additionally, integrated care for SUDs and health conditions will require ongoing assessment and support. Just as medication adherence is monitored through the use of self-management tools (e.g., pill boxes, alarms), frequency and quantity of drug, alcohol, and tobacco use must also be regularly assessed by the individual as well as during doctor visits. As technology advances, self-regulation tools are being increasingly adapted into smartphone applications and web-based formats. These can range from simple recordings of daily or weekly use and mental or physical health symptoms, to interactive phone apps or websites that patients can access if in need of support or information. Both are useful and economical adjuncts to help healthcare professionals and individuals monitor health behaviors and symptoms over the long-term. Drug and alcohol use and misuse can occur at any age with negative consequences; therefore, ways to provide empirically supported treatments and individualized care are necessary across all life stages. In order to achieve these goals, future research would benefit from longitudinal studies to monitor relapse and remission, and explore the Substance Use and Health 17 changes in risk and protective factors as people age. Teens have parental monitoring to help deter them from using drugs and alcohol, but older adults are likely to have fewer social contacts so variations in their substance use patterns may go unnoticed. Additional studies are needed to explore differences in drug and alcohol use among other populations and diverse settings, such as third-world countries, assisted living/nursing facilities, and women. Finally, it is important that SUDs research utilizes a developmental- contextual framework in order to acknowledge and understand how external variables (e.g., war, economic recession, information/technology age, social media) influence drug and alcohol use, perceptions of substance use, and mental and physical well-being. SUMMARY The physical, emotional, and social needs and resources of individuals change as they grow older. Internal (e.g., neurocognitive, hormonal) and external (e.g., parenthood, occupational responsibilities) factors influence shifts in substance involvement over time and subsequently, wield great influence over health status. For many adolescents, the developmental move into adulthood results in a natural decrease in substance use; however, for some, adulthood moves them from “gateway” drugs into more dis ordered use of illicit drugs. While older adults may appear to be the least likely to misuse substances, our large aging population, combined with increased physical vulnerability and the common use of multiple pharmaceuticals, makes them a group with rising needs for intervention services. In fact, tracking developmental changes over the lifespan high lights the need for specialized services not only for SUDs, but for coordinated care attending to the associated mental and physical health problems. As described within this review, these issues do not exist in isolation. Older adults may experience decreased medication effectiveness or risk for hip fracture because of alcohol use; and among adults, stopping substance use may be hindered by unmanaged PTSD or depression symptoms. Although health consequences of use may be mild or not immediate for many teens, the initiation of regular substance involvement during adolescence can greatly impact neurological development and lead to more disordered use in adulthood. Regardless of whether the psychiatric or medical condition preceded or resulted from substance use, it appears that continued involvement in drinking, smoking, and/or using drugs exacerbates symptoms and potentially strains healthcare services. 18 Public Health Reviews, Vol. 35, No 2 Acronyms List: ASPD = Antisocial personality disorder CD = Conduct disorder ED = Emergency department HCV = Hepatitis C IDU = Injection drug user MDD = Major depressive disorder ODD = Oppositional defiant disorder PTSD = Post-traumatic stress disorder STD = Sexually transmitted diseases SUD = Substance use disorder TEDS = Treatment Episode Data Set Conflicts of Interest: None declared. Acknowledgements: Grant Support from Center for Advancing Longitudinal Drug Abuse Research (P30DA016383 from NIDA; PI: Hser). REFERENCES 1. U.S. Department of Justice, National Drug Intelligence Center. The economic impact of illicit drugs use on American society. Washington (DC): U.S. Department of Justice; April 2011. 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Substance Use and Associated Health Conditions throughout the Lifespan

Public Health Reviews , Volume 35 (2) – Dec 13, 2013

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Springer Journals
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Copyright © 2013 by BioMed Central London
Subject
Medicine & Public Health; Public Health
eISSN
2107-6952
DOI
10.1007/BF03391702
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Abstract

1 Public Health Reviews, Vol. 35, No 2 Substance Use and Associated Health Conditions throughout the Lifespan Marya T. Schulte, PhD, Yih-Ing Hser, PhD ABSTRACT A life stage perspective is necessary for development of age-appropriate strategies to address substance use disorders (SUDs) and related health conditions in order to produce better overall health and well-being. The current review evaluated the literature across three major life stages: adolescence, adulthood, and older adulthood. Findings: 1) Substance use is often initiated in adolescence, but it is during adulthood that prevalence rates for SUDs peak; and while substance involvement is less common among older adults, the risk for health complications associated with use increases. 2) Alcohol, tobacco, marijuana, and, increasingly, prescription medications, are the most commonly misused substances across age groups; however, the use pattern of these and other drugs and the salient impact vary depending on life stage. 3) In terms of health outcomes, all ages are at risk for overdose, accidental injury, and attempted suicide. Adolescents are more likely to be in vehicular accidents while older adults are at greater risk for damaging falls. Adulthood has the highest rates of associated medical conditions (e.g., cancer, sexually transmitted disease, heart disease) and mental health conditions (e.g., bipolar disorder, anxiety disorders, antisocial personality disorder). Conclusion: Prolonged heavy use of drugs and/or alcohol results in an array of serious health conditions. Addressing SUDs from a life stage perspective with assessment and treatment approaches incorporating co-occurring disorders are necessary to successfully impact overall health. Key Words: Substance use disorder, psychiatric disorder, medical condition, comorbidity Recommended Citation: Schulte MT, Hser Y-I. Substance use and associated health conditions throughout the lifespan. Public Health Reviews. 2014;35: epub ahead of print. UCLA Integrated Substance Abuse Programs, University of California, Los Angeles, CA, USA. Corresponding Author Contact Information: Marya T. Schulte at mtschulte@ucla.edu; UCLA Integrated Substance Abuse Programs 11075 Santa Monica Blvd., Suite 200, Los Angeles, CA 90025, USA. 2 Public Health Reviews, Vol. 35, No 2 INTRODUCTION Substance use is a major public health concern that affects every level of society. Individuals, families, communities, and overall government spending is impacted by the use of licit and illicit substances. Recent reports estimated that annual costs in the United States are approximately USD $193 billion for illicit drug use, USD $223 billion for excessive 2 3 alcohol use, and USD $193 billion for tobacco use. These costs include lost wages and productivity, criminal activity, and healthcare expenses. The economic burden aside, public health efforts can benefit from a better understanding of the impact of substance use disorder (SUD) on physical and mental health. Particularly, examining SUDs and the constellation of associated health and mental health problems throughout the lifespan provides a full picture of how variations in drug use patterns and outcomes shift with age, on which the present article will focus. Adolescence represents a time in biological and social development that is associated with increased risk-taking behaviors; as such, experi- mentation with drugs and alcohol often begins in adolescence. Young brains are still changing as synaptic pruning continues into early adult- hood, making the possibility for long-term negative effects of substance involvement even more profound. On the other end of the age spectrum, older adults also represent an extremely vulnerable group. The physiological changes that occur as a result of the natural aging process result in an increased use of multiple medications, drug and alcohol sensitivity, and the likelihood of co-occurring health conditions; thus, the risk for and con- 6-8 sequences of SUDs are magnified. The purpose of the current review is to synthesize the research findings to date that examine physical and mental health problems associated with substance use at different stages of life. The goal is not to provide an exhaustive list of studies, but to emphasize the changing needs across the lifespan of those suffering from comorbidities in order to inform development of care and future research. In addition to presenting general patterns of alcohol, tobacco, and licit/illicit drug use, common and troublesome medical and psychiatric conditions associated with SUDs among adolescents, adults, and older adults are discussed. While some substances can result in significant consequences that are both acute and chronic (e.g., alcohol), the negative impact of others (e.g., tobacco) are primarily observed only after prolonged use. Finally, recommendations regarding clinical implications and areas for future research are presented. Substance Use and Health 3 Table 1 Major domains of developmental transitions influencing substance use and physical and mental health conditions Achievement Biological and Cognitive Identity and Relationships and Responsibility Adolescence -Pubertal development/ -Increased autonomy from -Increased personal hormonal changes family responsibility in school -physical appearance -less parental control & (i.e., less individualized begins to look more more independence (e.g., instructor attention in high adult-like driving, moving away from school & college) home) -Axon myelination & -Increased financial synaptic pruning -Greater influence from peer autonomy (e.g., more -increased ability to groups likely to have part-time perform executive job, pay some bills) -Increased interest & functioning tasks (e.g., involvement in sexual & increased ability to romantic relationships think abstractly & -Increased awareness & decision-making) adherence to gender roles & norms Adulthood -Sexual maturation & -Greater stability in romantic -Full-time work with greater hormonal stability relationship, such as marriage financial independence & responsibility (i.e., pay -Neurocognitive brain -Formation & commitment to bills for self & family) maturation, specifically one’s own family (i.e., spouse prefrontal cortex & children) -Intergenerational -optimal organization & responsibility -Legal maturity regulation of cognition -parenting children -social decisions based on & goal-directed while caring for aging one’s own beliefs & values behavior parents rather than legal restriction (e.g., voting, drinking) Older Adulthood -Hormonal decline (i.e., -Decreased autonomy due to -Reduced employment or menopause & decreased physical &/or cognitive retirement testosterone) leading to limitations -increased financial decreased reproductive restrictions from fixed -Lessened connection to capabilities income extended family (e.g., possible -Decrease in neurocognitive death of spouse and/or family -Increased reliance on functioning in speed of members, children move from public assistance (e.g., processing, working home) medicare, social security) 4 Public Health Reviews, Vol. 35, No 2 Developmental Framework and Life Stages Focal to the current review is the integration of studies across developmental periods which link substance use and health conditions. Biogenetic, psycho- logical, and sociocultural factors vary in influence depending upon proximal (e.g., family, peer group, work setting) and distal (e.g., broader cultural, sociohistorical events such as wars or economic recession) contextual events 9-12 over the lifespan. By placing the current literature within a developmental- contextual framework, we highlight what Bronfenbrenner terms “ecological transitions.” These transitions are characterized as “whenever a person’s position in the ecological environment is altered as a result of change in role, setting, or both.” We have organized the reviewed studies based on life stages marked by major developmental transitions. While specific age groupings may vary somewhat from study to study, the majority of research investigates substance involvement within one of three seminal life stages: adolescence, adulthood, and older adulthood. Table 1 summarizes examples from principal domains of developmental transitions relevant to each of the three life stages. Substance Use Patterns Large epidemiological surveys have shown alcohol, tobacco (i.e., cigarettes), and marijuana have the highest prevalence rates across all age groups. Figure 1 shows the percentage of people endorsing use in the past year (2011) for alcohol, tobacco, marijuana, cocaine, methamphetamine, heroin, and prescription drug misuse (i.e., pain relievers, tranquilizers, stimulants, sedatives). In early adolescence, prevalence rates of marijuana use were higher than tobacco; however, this appears to change in later teen years. Early adulthood shows the greatest amount of substance involvement, especially alcohol use. And while older adults are less likely to report past year substance use than most of their younger counterparts, prevalence rates for alcohol use remain relatively high. The Treatment Episode Data Set (TEDS) presents US national-level data on demographic and substance abuse characteristics of admissions to treatment for abuse of alcohol and/or drugs. Figure 2 shows the distribution of primary substance of abuse reported at admission by age groups for treatment admissions in 2010. The majority of admissions are accounted for by four major substance groups: alcohol, marijuana, opiates, and cocaine. The remaining substances classified as “other” (methamphetamine, tran quilizers, sedatives, hallucinogens, PCP, inhalants, and “none specified”) are grouped due to low prevalence rates, particularly among youths and older adults. Adolescents largely seek treatment for marijuana Substance Use and Health 5 use disorders, while older adults are largely in treatment for alcohol use disorders. The proportion of treatment admissions by drug group is most evenly distributed during adulthood. Fig. 1. Past-year substance use by age. Source: Data from National Survey on Drug Use and Health 2011, N=58,397. Fig. 2. Treatment admissions by age at admission and according to primary substance of abuse. Source: Results from Treatment Episode Data Set (TEDS) 2010, N=1,820,737. 6 Public Health Reviews, Vol. 35, No 2 Of the almost two million treatment admissions reported by TEDS, less than 40,000 were accounted for by those 60 or over. While many adults “mature out” of heavy drinking and illicit drug use during the second half of life, prevalence rates among older adults are also affected by higher mortality rates among drug users. Epidemiological surveys are not based on longitudinal data sets and therefore do not track the course of drug involvement over time. Hser and colleagues’ 33-year follow-up study of narcotics addicts showed high rates of mortality among drug users, most commonly attributed to accidental poisoning or overdose. Premature mortality is believed to be a function of substance use and lifestyle. DISCUSSION Table 2 summarizes the substances and associated health conditions that are most prominently featured in the literature. Again, while not exhaustive lists, the mental and physical health problems highlighted here represent areas we believe are of great public health importance. Adolescence Although legal and practical barriers are most restrictive for teen users, substance use remains an area of concern due to the potentially hazardous short- and long-term consequences. The leading cause of accidental injury and death (e.g., automobile accidents, suicide) among adolescents is precipitated by substance use. Maladaptive behavioral patterns associated with later physical and mental health problems are formed and consolidated 18-20 during this time. Thus, examination of substance use and outcomes among adolescents can help tailor interventions and maximize long-term benefits. Physical Health/Medical Conditions Adolescence is a period marked by significant developmental changes. As such, even moderate substance use can cause harm. Behaviors associated with drinking and drug use in teens contribute to increased risk for injury and violence. US national survey results indicate that within the month prior to survey, 24.1 percent of high school students reported being a passenger in a car when the driver had been drinking and 8.2 percent reported having driven a car themselves after consuming alcohol. An examination of older adolescents revealed that one in six college students reported drugged driving (i.e., illicit drugs or prescription drugs used non-medically) in the past year. The combination of limited driving experience and impaired motor skills results in increased rates of injuries and fatalities from traffic accidents. Substance Use and Health 7 Table 2 Summary substance use patterns and associated mental and physical health conditions by life stage Physical/ Mental Health/ Substance Use Medical Conditions Psychiatric Disorders Adolescence Alcohol Accidental Injury Suicidal Ideation/Behaviors Automobile Accidents Marijuana Internalizing Disorders Physical/Sexual Violence Depression Tobacco Anxiety Poisoning/Overdose Inhalants Externalizing Disorders Sexually Transmitted Psychotherapeutic Drugs Oppositional Defiant Disorder Diseases Amphetamines Attention Deficit/ Opioids/Pain Relievers Respiratory Problems Hyperactivity Disorder Asthma Conduct Disorder Pain-Related Diagnoses Adulthood Alcohol Poisoning/Overdose Suicidal Ideation/Behaviors Marijuana Sexually Transmitted Mood Disorders Diseases Depression Tobacco Bipolar I & II Cancers Psychotherapeutic Drugs Anxiety Disorders Opioids/Pain Relievers Heart Disease/ Panic Disorder Tranquilizers/ Hypertension/Stroke Post-traumatic Stress Disorder Benzodiazepines Reproductive Morbidity/ Social & Specific Phobias Cocaine/Crack Fetal Damage Generalized Anxiety Disorder Heroin Diabetes Antisocial Personality Disorder Methamphetamine Respiratory Problems Asthma Infection Liver Damage/Disease Older Adulthood Alcohol Accidental Injury Suicidal Ideation/Behaviors Psychotherapeutic Drugs Cirrhosis Depression/Bereavement Opioids/Pain Relievers Heart Attack/Stroke Anxiety Disorders Sedatives/ Social & Specific Phobias Insomnia Benzodiazepines Generalized Anxiety Disorder Cancers Amphetamines Dementia/Wernicke-Korsakoff Diabetes Marijuana Syndrome Tobacco Insomnia 8 Public Health Reviews, Vol. 35, No 2 Substance using adolescents also frequently engage in risky sexual 23,24 behaviors. Among sexually active high school students, 22.1 percent report having used drugs or alcohol prior to their most recent sexual inter- course. Consequently, substance use and corresponding risky sexual behaviors have shown consistently strong associations with sexually trans- 23,25,26 mitted diseases (STDs) among teens. Unprotected sex and history of sex with multiple partners is more likely among both social and chronic 27-29 substance users well into late adolescence. Recent Centers for Disease Control and Prevention (CDC) data show the magnitude of this risk, with young people accounting for over a quarter of new HIV infection cases; almost 60 percent of those infected did not know their HIV status. Yan and colleagues examined the relationship between substance use and HIV/ STD-related sexual risk behaviors more closely. In their national sample of sexually active teens living in rural US settings, they found that smoking three or more days in the past month was significantly associated with not using condoms. Recent and lifetime drug and alcohol use were related to having multiple sexual partners. It appears that substance use and risky sexual behavior represent part of a constellation of reckless behaviors, 30,31 some of which are normative while others are the result of social deficits. Adolescents diagnosed with an SUD show more acute and potentially chronic health problems than teens without SUD. Nonmedical use of prescription drugs and over-the-counter medications accounted for approximately half of emergency department (ED) visits for drug abuse or misuse in the US in 2011; among youth aged 12-17, the proportion of those seeking emergency medical care due to pharmaceutical misuse exceeds that of alcohol (301 ED visits versus 160 ED visits per 100,000 population). The risk for substantial harm is increased when medications are abused with one another and/or alcohol. Specific, chronic health problems can be difficult to detect in a younger population; however, Mertens, Flisher, Fleming and Weisner found that prevalence rates for one-fourth of the comorbid medical conditions examined were greater among substance-using teens. In particular, asthma and pain-related diagnoses surfaced as common and costly health conditions 34,35 among the patient group. Myers and Brown found that independent of other drug involvement, respiratory problems continued from two to four years after substance abuse treatment for adolescent smokers. Although definitive causal relationships across medical conditions are difficult to discern, continued substance involvement can exacerbate symptoms, and for some, lead to more severe, life-threatening disorders. Substance Use and Health 9 Mental Health/Psychiatric Disorders Suicidal thoughts and behaviors directly link mental health to physical well-being. Suicide is the third leading cause of death among American 36,37 youth age 10-19. Although substance use is not always the “cause” of suicidal ideation or attempts, it is a significant risk factor. Teens with SUDs have been found to be about three times more likely to make a suicide attempt as compared to non-drug-using adolescents. In a study examining data from a community sample of youth, suicide attempts were strongly associated with alcohol abuse and dependence, even after controlling for depression. These findings highlight the need to better understand the role that substance use and abuse plays in suicidal thoughts and actions, both in the presence and absence of mental health conditions. Among clinical samples, high rates of comorbidity exist during adolescence. Approximately 70-80 percent of youths presenting to treatment are dually diagnosed. Comorbidity patterns, however, vary by substance type, severity of SUD, and psychiatric disorder. For instance, while internalizing disorders (e.g., anxiety, depression) are prevalent in 44,45 both clinical and general adolescent populations, many studies indicate gender differences in co-occurrence for mood disorders. Specifically, rates 43,46-48 of depression are higher for girls than boys with SUDs. Shrier and colleagues examined this further by assessing psychiatric symptoms among youth with sub-diagnostic substance use problems within a primary care setting. They found that girls exhibiting substance use problems were more likely to report symptoms of mood disturbance. Anxiety symptomology has been found to be highly prevalent for both adolescent boys and girls 43,49 with diagnostic or problematic use, with about seven percent of youths with an SUD meeting criteria for any anxiety disorder within the past year. While the exact sequencing of psychiatric symptoms and substance use can vary by individual, there is some evidence that externalizing disorders 50-53 typically precede SUDs. Disorders such as Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Attention Deficit/ Hyperactivity Disorder (ADHD) are characterized by their childhood or adolescent onset and constellation of disruptive and maladaptive behaviors. Externalizing symptoms have been associated with sub-diagnostic drug 49,51 and alcohol use for both male and female adolescents, suggesting an association between behavioral disturbance and problematic use prior to full SUD criteria. However, epidemiologic data indicate that SUDs are associated with greater odds of comorbid CD and ODD. Taken together, the evidence suggests the co-occurrence of substance use, problematic or diagnostic, and socially harmful behaviors may be interacting and possibly 10 Public Health Reviews, Vol. 35, No 2 43,55 exacerbating one another. While limited social responsibilities during adolescence may restrict the impact of these behaviors, the combination of ongoing substance involvement and maladaptive behavior can set the stage for greater impairment as youth move into adulthood. Adulthood Referring once again to Bronfenbrenner’s developmental framework, the ecological transition from adolescence to adulthood is marked by profound changes. Prevalence rates for drugs and alcohol increase during late adolescence; however, most individuals transition out of this drinking and 56,57 drug use pattern. The multilevel developmental contextual approach recognizes that a move into SUD is influenced by multiple factors within a dynamic, probabilistic process. Physical Health/Medical Conditions The impact of SUDs on physical health is most easily seen in terms of acute effects. Intoxication, misuse, and overdose can be life-threatening and result in medical emergencies. In 2011, the majority of ED visits in the US related to illicit drugs was accounted for by adults (21-64 years). Young adults had the highest rates of medical emergencies involving marijuana, heroin, and amphetamine/methamphetamines in comparison to other age groups. However, a recent morbidity and mortality report reveals that opioid analgesic poisoning was related to more deaths than heroin or cocaine, the majority of which were aged 35-54. Prescription medication misuse poses as much of a threat to health as traditional street drugs. Unfortunately, the consequences of non-medical use of prescription drugs may continue to rise as the younger generations with access to pharma- ceuticals ages and social acceptance of medication sharing continues. In addition to acute problems, SUDs can result in general health deterioration and specific, ongoing conditions. In a 14-year prospective study of young adults reporting “good” or better health at intake, baseline hard drug use was significantly associated with subsequent self-rated health decline as compared to never using. They found even if drug use stopped, the decline continued. The authors identified tobacco use as a significant factor for lack of restored health. These results are consistent with national studies in which 77-93 percent of clients in SUD treatment settings use 61 62 tobacco products and over 50 percent die of tobacco-related causes. The combination of multiple substances substantially increases the risk for health problems. For instance, while cancers of the mouth and throat are seven and six times greater for tobacco and alcohol users respectively, the Substance Use and Health 11 risk is 38 times more for those who use both substances. Cigarette smoking in particular has been linked to 90 percent of all cases of lung cancer and accounts for approximately one-third of all cancer deaths. While the research regarding marijuana smoking and lung cancer remains inconclusive, there is evidence for increased risk of respiratory illnesses 66,67 among regular marijuana smokers. Several substances (e.g., alcohol, tobacco, heroin, prescription stimulants, methamphetamine) have been linked to increased risk for cardiovascular problems and heart disease. As a stimulant, cocaine immediately and directly impacts blood pressure; thus, the resulting increased risk for heart 64,68 attack and cardiac arrest seems an obvious one. There is, however, a strong and consistent relationship between long-term alcohol use and 69-71 hypertension as well. In fact, heavy drinking is purported to be the most 72,73 common cause of secondary hypertension. Although it appears these effects are often reversible with sustained abstinence, blood pressure quickly 73,74 returns to elevated levels upon relapse. Over time, continued use and hypertension increase the risk for cereborvascular accidents, with binge drinking being a significant risk factor for all subtypes of stroke. The physical and mental impairment from stroke is potentially large and irreversible; thus, cardiovascular health is an important issue in individual and public health. Substance use also increases risk for infectious disease. Drug and needle sharing practices can lead to infection of HIV, hepatitis C (HCV), and other blood-borne pathogens. Injection drug users (IDUs) are the highest risk group for acquiring HCV; approximately 70 to 80 percent of 76-78 new HCV cases in the US each year are among IDUs. Similarly, injection drug use, both directly and indirectly, is a significant contributor to the spread of HIV. More than one-third of AIDS cases in the US are due to IDUs, people who have sex with IDUs, and children born to mothers who have contracted HIV through drug use practices. HIV and HCV infection rates specifically among crack cocaine users is also accounted for by sharing of pipes among users with open mouth sores, increased risky 80-82 sexual behavior, and sex work (i.e., trading sex for crack or money). Similarly, methamphetamine use, whether injected, snorted, or smoked, is associated with increased risk for HIV and other STDs, particularly among men who have sex with men. Regardless of sexual orientation, however, sexual risk practices such as reduced condom use, being high during sex, and having multiple sexual partners is prevalent among methamphetamine 84,85 users. Once contracted, the course of sexually transmitted infectious disease carries with it a long-term, cost-heavy burden for treatment. 12 Public Health Reviews, Vol. 35, No 2 Mental Health/Psychiatric Disorders Adults diagnosed with an SUD and comorbid mental health disorder are at increased risk for poor health, social dysfunction, incarceration, poverty, 86,87 and homelessness. Anxiety disorders represent some of the most commonly co-occurring disorders, with significant associations between 88-90 any anxiety disorder and any drug dependence. Among the general US population, 30 percent of those meeting criteria for any lifetime drug use disorder had at least one anxiety disorder. In particular, sedative, opioid, and tranquilizer use disorders have shown a strong association with anxiety 90,91 disorders. Women have demonstrated greater comorbidity between these specific SUDs and anxiety disorders, especially social and specific 88,91 phobias. Although epidemiologic surveys cannot definitively support the self-medication hypothesis, some speculate that the calming effects of these drugs play a role in their link to comorbid anxiety. Although post-traumatic stress disorder (PTSD) is also classified as an anxiety disorder, its fundamental component of resulting from a traumatic event sets it apart. The lifetime prevalence of PTSD in the general population 92,93 is estimated to be less than eight percent; however, the lifetime pre- valence rate of PTSD among adults with a drug or alcohol use disorder 94,95 ranges from a quarter to a half in clinical samples. The relationship between trauma and SUDs is believed to be bidirectional. Heavy drug and alcohol use places individuals at risk for victimization; and conversely, those who have experienced a traumatic event often cope with the symptoms (e.g., insomnia, hyperarousal, intrusive thoughts) by using drugs and 90,96,97 97 alcohol. Ouimette and colleagues demonstrated the impact that PTSD symptoms and substance use have on one another by monitoring dually diagnosed out-patients for 26 weeks. Results indicated that PTSD symptoms and alcohol and cocaine symptoms fluctuated concurrently week to week. These findings and high rates of comorbidity speak to the need for assessments and treatments that address both. Mood disorders, including major depressive disorder (MDD) and bipolar I and II, have consistently demonstrated most common co-occurrence 88,90,98,99 with SUDs among adults. Individuals meeting criteria for MDD are approximately twice as likely to have SUD as those with no mood disorder 90,98,100,101 diagnosis. The risk of a comorbid SUD is even greater among those with bipolar disorder, with estimates indicating a seven times greater 90 102 likelihood. In a 20-year prospective study by Merikangas and colleagues, results indicated that people who reported symptoms of mania, but did not meet full diagnostic criteria for bipolar I or II, were at an increased risk for developing an alcohol use disorder. Furthermore, those diagnosed as Substance Use and Health 13 bipolar II showed even greater risk for developing an alcohol use disorder or benzodiazepine use problem. Of particular concern is the increased risk for suicide attempts and completion within this population. The stronger association between mood disorders and SUDs among women has potentially grave implications beyond the individual. Mental health status and associated impairment can affect child rearing and the family environment when mothers suffer from comorbidity. Antisocial personality disorder (ASPD) is commonly discussed in the literature because of its significant and consistent relationship with 88,105 SUDs. ASPD is more often diagnosed in men and is defined by a failure to conform to social norms and a persistent disregard for the rights of others. Compared to the general public, prevalence rates of ASPD are 106,107 higher among prisoners and those in drug and alcohol treatment settings. The co-occurrence of these disorders is associated with greater severity and poorer prognosis; substance use is initiated earlier and the progression into dependence occurs more quickly. Substance use combined with the pervasive impulsivity and aggression characteristic of ASPD can result in problematic family relationships and increased recidivism among those 106,109 who have been criminally convicted. Treating ASPD patients is often challenging. Establishing a good therapeutic alliance is difficult and many refuse services or terminate early unless required by an external source (e.g., condition of parole). The transition into later adulthood for these individuals is likely to be a difficult one, with little positive social support and poor health. Older Adulthood Although Bronfenbrenner’s developmental framework focuses more on understanding how a child’s interaction with the external world shapes internal processes and behaviors, ecological systems continue to influence functioning as adults age. Older adults tend to experience fewer traditional responsibilities, such as full-time employment or parenthood; however, the natural aging process brings other notable social, cognitive, and physiological challenges. And while substance use generally declines in later adulthood, even small amounts of drug and alcohol use can have serious consequences. Physical aging and commonly used medications can 8,111 result in increased sensitivity to the effects of substance use, elevating the risk for impairment and accidental death. 14 Public Health Reviews, Vol. 35, No 2 Physical Health/Medical Conditions Substance use disorders in older adults may be a continuation of excessive drug and alcohol use initiated while younger, but for some, substance use begins during times of transition or loss. For instance, health declines that accompany older age may lead to reduced independence or associated pain; drug and alcohol use therefore provides an emotional escape from boredom and loneliness. Unfortunately, the combination of existing chronic conditions and substance use or misuse can result in exponentially negative 113,114 effects on physical health. Older adults are more likely to experience adverse events from psychoactive medications, and due to the increased likelihood of older adults being prescribed multiple medications, the risk for serious drug interactions is high and often requires emergency medical 115-117 care. Additionally, prescription medication use, such as regular use or misuse of sedatives and benzodiazepines, has been associated with 116,118 increased risk for falls in older populations. When alcohol is combined with prescription medications, the effects appear even more detrimental. In a national study of Medicare beneficiaries, heavy drinking more than doubled the risk for hip fractures. All of these can lead to costly hospital admissions and lengthy stays. The impact of drugs and alcohol on blood pressure and insulin production can greatly increase the risk for heart attack and stroke. In a population-based cohort study of cardiovascular health among older adults, nine-year follow-up data demonstrated modestly lowered risk for stroke among light drinkers; however, alcohol consumption greater than six drinks per week was associated with increased risk. Although the relationship between cardiovascular health risks and alcohol use may be somewhat inconsistent, the link between tobacco use and heart and cerebrovascular disease is very clear, with smoking being a major risk factor in these leading 120,121 causes of death among those 60 and over. The increased prevalence of smoking and non-medical use of prescription drugs among older adults who drink more heavily places this group at high risk for premature death. Unfortunately, however, few interventions are tailored to older adults and may fail to address their specific needs and concerns. Substance-using older adults are at increased risk for organ damage and various cancers. In particular, the ten-year risk for developing breast cancer among women age 60 and over is more than double than that of their 40-year-old counterparts; regular alcohol consumption and cigarette smoking are considered significant and controllable risk factors for the disease. Similarly for men, risk for colorectal and prostate cancer quickly 120,122 increases with age, with substance involvement amplifying risk. Substance Use and Health 15 Additionally, although women are more sensitive to the effects of long-term alcohol use, alcoholic men are approximately two to six times more likely to 123,124 be diagnosed with cirrhosis in comparison with alcoholic women. Thus, gender appears to be an important factor in determining the health needs of older adults. Mental Health/Psychiatric Disorders Mental health disorders are associated with significant disability in older adults. Mental capacity can compromise quality of life, increase mortality, and decay physical health. Multiple cognitive deficits, most prominently memory difficulties, that are severe enough to cause significant impairment in functioning are classified as dementia. While chronic alcohol use can be detrimental to memory function and at times result in Wernicke- 126,127 Korsakoff syndrome, some evidence indicates limited alcohol intake may be protective against developing dementia as adults age. A recent meta-analysis on alcohol consumption and cognitive decline in older adults showed moderate drinking was associated with a reduced risk for dementia. Conversely, even small amounts of alcohol can potentially intensify the effects of many commonly used prescription (e.g., benzo- 129,130 diazepines) and over-the-counter medications (e.g., anti histamines). Resulting confusion can impact even simple tasks like personal hygiene 129-131 and self-grooming, making independent living less possible. Since individual differences appear to be even greater among older adults, physician-monitoring of substance use and misuse is of increased importance for overall safety. Like all stages of life, older adults are at risk for depression and anxiety. Among older adults meeting criteria for panic disorder, approximately 36.7 percent are comorbid for current MDD. In a survey among older adults admitted for SUD treatment, anxiety and depression were cited as the top reasons for misusing substances. Older women are particularly high risk for comorbidity; they receive twice the number of prescription medications 130,134 as men, making them vulnerable to drug misuse. More severe depressive symptoms, especially those caused by bereavement, can result in suicide attempts. Rates of completed suicide are most prevalent among older white men who drink heavily after the loss of their spouse. In terms of ecological transitions, the loss of loved ones and erosion of independence are the hallmarks of older adulthood. Both can have significant impacts on mood and functioning. 16 Public Health Reviews, Vol. 35, No 2 RECOMMENDATIONS Adolescents may only see the beginnings of emerging medical and psychiatric complications, either resulting from or exacerbating their substance use, and therefore issues of comorbidity may not be adequately assessed or addressed in treatment. Further, substance use or psycho- therapeutic misuse may not be identified as a primary problem among older adults during doctor visits. Physicians and patients may assume medical and mental health symptoms are the result of normal aging and therefore not assess substance involvement. Despite the prevalence of SUDs among adult men and women, most never receive formal treatment. The majority of those who do seek out services do so through self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous); they report lack of health care coverage and not being ready to stop using as the top reasons for not receiving treatment. In order to address this gap in care, healthcare systems should have improved integrated care for mental health, medical conditions, and SUDs. Increased training for physicians in how to assess for SUDs and mental health disorders could help them better identify and refer patients in need of specialized services. Patients’ reluctance to reduce or stop using may be better combated if physicians were able to adequately identify and communicate how substance use was impacting specific health conditions. Personal relevance along with a more complete picture of how behaviors affect well-being may assist in promoting and sustaining behavioral change. Additionally, integrated care for SUDs and health conditions will require ongoing assessment and support. Just as medication adherence is monitored through the use of self-management tools (e.g., pill boxes, alarms), frequency and quantity of drug, alcohol, and tobacco use must also be regularly assessed by the individual as well as during doctor visits. As technology advances, self-regulation tools are being increasingly adapted into smartphone applications and web-based formats. These can range from simple recordings of daily or weekly use and mental or physical health symptoms, to interactive phone apps or websites that patients can access if in need of support or information. Both are useful and economical adjuncts to help healthcare professionals and individuals monitor health behaviors and symptoms over the long-term. Drug and alcohol use and misuse can occur at any age with negative consequences; therefore, ways to provide empirically supported treatments and individualized care are necessary across all life stages. In order to achieve these goals, future research would benefit from longitudinal studies to monitor relapse and remission, and explore the Substance Use and Health 17 changes in risk and protective factors as people age. Teens have parental monitoring to help deter them from using drugs and alcohol, but older adults are likely to have fewer social contacts so variations in their substance use patterns may go unnoticed. Additional studies are needed to explore differences in drug and alcohol use among other populations and diverse settings, such as third-world countries, assisted living/nursing facilities, and women. Finally, it is important that SUDs research utilizes a developmental- contextual framework in order to acknowledge and understand how external variables (e.g., war, economic recession, information/technology age, social media) influence drug and alcohol use, perceptions of substance use, and mental and physical well-being. SUMMARY The physical, emotional, and social needs and resources of individuals change as they grow older. Internal (e.g., neurocognitive, hormonal) and external (e.g., parenthood, occupational responsibilities) factors influence shifts in substance involvement over time and subsequently, wield great influence over health status. For many adolescents, the developmental move into adulthood results in a natural decrease in substance use; however, for some, adulthood moves them from “gateway” drugs into more dis ordered use of illicit drugs. While older adults may appear to be the least likely to misuse substances, our large aging population, combined with increased physical vulnerability and the common use of multiple pharmaceuticals, makes them a group with rising needs for intervention services. In fact, tracking developmental changes over the lifespan high lights the need for specialized services not only for SUDs, but for coordinated care attending to the associated mental and physical health problems. As described within this review, these issues do not exist in isolation. Older adults may experience decreased medication effectiveness or risk for hip fracture because of alcohol use; and among adults, stopping substance use may be hindered by unmanaged PTSD or depression symptoms. Although health consequences of use may be mild or not immediate for many teens, the initiation of regular substance involvement during adolescence can greatly impact neurological development and lead to more disordered use in adulthood. Regardless of whether the psychiatric or medical condition preceded or resulted from substance use, it appears that continued involvement in drinking, smoking, and/or using drugs exacerbates symptoms and potentially strains healthcare services. 18 Public Health Reviews, Vol. 35, No 2 Acronyms List: ASPD = Antisocial personality disorder CD = Conduct disorder ED = Emergency department HCV = Hepatitis C IDU = Injection drug user MDD = Major depressive disorder ODD = Oppositional defiant disorder PTSD = Post-traumatic stress disorder STD = Sexually transmitted diseases SUD = Substance use disorder TEDS = Treatment Episode Data Set Conflicts of Interest: None declared. Acknowledgements: Grant Support from Center for Advancing Longitudinal Drug Abuse Research (P30DA016383 from NIDA; PI: Hser). REFERENCES 1. U.S. Department of Justice, National Drug Intelligence Center. The economic impact of illicit drugs use on American society. Washington (DC): U.S. Department of Justice; April 2011. 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