TOPIC

3: EPIDIMIOLOGY – POPULATION ENTRY AND EXIT FROM DRUG USE

PREVALENCE
• 2013: 5.2% of global population used an illicit drug in the past year
o 0.59% are considered problem drug users
o Relatively stable since 2006 (World Drug Report 2015)
o Only a small proportion of people who have used drugs in the past year are problem
users – issues with self-reported use collected from survey data
• 2011: 20.4% of Australian population have used illicit drugs once in their lifetime
o 5.4% used recently (AIHW, 2011)
o Household Drug Survey 2013
o NDARC Trends in Drug Use 2013
o Only a small proportion of people who every try dugs become frequent users
• US National Comorbidity Survey:
o Left column: percentage of respondents who reported ever using drugs of different
classes – range from 91.5% and 75.6% for alcohol and tobacco respectively, down
to 6.8% and 1.5% for inhalants and heroin respectively
o Middle column: percentage of respondents who responded every meeting clinical
criteria for drug dependence – NB: is less than the number who ever used
o Key point: only a proportion of people who ever try drugs become dependent, which
is shown in the right column - averaging the column gives an estimated 13.4% risk
that trying a drug will subsequently lead to dependence
§ Probably an underestimation
§ It is commonly assumed as a rule of thumb that there is an approximately
20% risk of drug experimentation leading to dependence

FIRST CONTACT AND EXPERIENCE
ADOLESCENT ONSET – ILLICIT DRUGS
• Use in the past year (Household Drug Survey Report 2013)
o Peak between age 14-29
o Decline from 30 onwards
o Prevalence of drug use is greatest around early adulthood

ADOLESCENT ONSET – ALCOHOL
• Recent alcohol use commences in late adolescents/early adulthood
• Remains prevalent amongst the older age groups (Household Drug Survey Report 2013)
• Binge use and heave use do show an age dependent decline
o Heavy alcohol use carries similar health consequences to illicit drug use, which
becomes an increasingly important consideration with age

 TOPIC 3: EPIDIMIOLOGY – POPULATION ENTRY AND EXIT FROM DRUG USE

ADOLESCENT ONSET – TOBACCO

• (Household Drug Survey Report 2013)
• Smoking again shows the same initiation peak in late adolescents/early adulthood
o Shallow decline with age – comparable to alcohol use and contrast to illicit drug use
• Why does illicit drug use decline more steeply with age compared to alcohol and tobacco?
o Changing addictive potential of various drugs?
o Health impairment in illicit users?
o Criminal sanctions?
o Price?
o More compatible with the responsibilities of adulthood than smoking and drinking?

DEMOGRAPHIC PREDICTORS OF DRUG USE
• Family
o Association with drug using peer group, parent or sibling
o Accepting drug attitudes among peers, parents or siblings
o Criminality in the family
o Extreme parental poverty
o Poor parenting style/broken home (abuse, negative communication, authoritativeness,
inconsistency)
o Psychiatric illness in the parents
o Low parent-child attachment
o Failure at school or low commitment to school
• Community: drug availability, neighbourhood disorganisation (density, permanence, crime
rate), prevalence of drug use in community
• Society: level of law enforcement, tax levels, regulation, price, criminal law
• Relative risk of DA is the probability of initiating drug use if you have a drug using sibling
compared to if you do not
o A relative risk score of 7 indicates that you have a 7 times higher probability of drug
use if you have a drug-using sibling
o The relative risk of DA is increased if the drug-using sibling is within 0-4 years,
remains stable between 4-10 years and then drops again with an age gap greater
than 10 years
o Relative risk is also higher with same sex compared to different sex siblings
o The increased risk of DA resulting from a DA sibling may stem from a transfer of
knowledge between siblings or siblings’ shared experience of a common risky
environment
o Risk of DA is higher if you have an older drug-using sibling, compared to a younger
drug-using sibling – suggests that shared experience of a common risk environment
is less important (the data fits with an age dependent transfer of knowledge from the
older to younger sibling)
o Vygotsky: zone of proximal development – a child learns most from older children
who are operating within the upper limit of the child’s intellectual ability

SOCIAL MODELING AND EXPECTANCIES
EXPECTANCIES
• It has been argued that all the risk factors function to increase positive drug expectances
and decrease negative drug expectances
o Siblings, parents and peers o Bad parenting
o Poverty o Local drug use
o Mental illness o Price levels and marketing
o Low education o Legal Sanction
 TOPIC 3: EPIDIMIOLOGY – POPULATION ENTRY AND EXIT FROM DRUG USE

• Expectancies may explain the strong intergenerational transfer of addictive behaviour

• Shen et al. (2001) interviews children/adolescents aged 8 to 18
o Either from heavy alcohol-using families (high-risk families) or from low alcohol-using
families (low-risk families)
o Alcohol expectancies and alcohol use behaviour of these families was measured at
two time points approximately 3 years apart
§ High-risk offspring reported greater expectations that alcohol would improve
social behaviour and relaxation, drank more frequently and initiated alcohol
drinking at an earlier age than low-risk offspring
§ The alcohol expectations at time 1 predicted both the age of onset of
regular drinking and the frequency of alcohol consumption
o These results suggest that transmission of parental beliefs about alcohol to young
adolescents confers a risk for the early onset of alcohol use and higher drinking
frequency, which may confer a risk for the subsequent formation of alcohol
dependence in adulthood

EARLY ONSET
• Earlier age of drug use onset is associated with an increased risk of becoming drug
dependent
o Unclear if this association is due to increased number of years spent taking the drug,
or whether young people are more sensitive to the dependence forming effect of
drugs
• Anthony et al. (1995) tried to separate between these two explanations
o Interviewed 1525, 14-24-year-olds – age of onset, age drug dependence
o Results:
§ Probability of dependence increase with number of years spent using
§ Young users more sensitive to developing dependence than older users
§ Early age of onset increases risk for dependence

DRUG LIKING
• Drug liking is another predictor of whether drug use is adopted
• Haertzen et al. (1983)
o Clinical sample of male opiate addicts
o Interviewed about their liking of the initial experience of different drug classes and
subsequent lifetime dependence
o There were significant positive correlations between first liking and lifetime
dependence, in the region of 0.4-0.8
o For those drugs that showed no significant correlation between first liking and
dependence, once may assume that the initial aversive experience disappeared with
time allowing liking to emerge and determine uptake
• Prospective design: initial drug liking is recorded closer to its time of occurrence in a young
sample – followed up over years to see if liking predicts whether they become dependent
o Experience of early cannabis use was recorded in 198, 14-16-year-olds: 2 years later
they were assessed for cannabis dependence
§ Those who said they did not get really high during initial experience, 12.4%
became dependent two years later
§ 34.1% became dependent from those who said they did get really high in
early experience
§ Similar increased risk of becoming dependent was predicted by other
subjective reactions to early cannabis use – happy, relaxed, silly, laughed
§ Negative experiences: ill/dizzy, frightened or passed out, did not modify risk
of later dependence
 TOPIC 3: EPIDIMIOLOGY – POPULATION ENTRY AND EXIT FROM DRUG USE

DEVELOPMENTAL TRAJECTORIES
• Developmental trajectories chart the progress of uptake and exit from drug use in different
groups
• Chassin et al. (2000): 2711 smokers reported their level of smoking at different ages
o There were four groups with different trajectories: early stable smokers, late stable
smokers, experimenters, quitters
o Early stable trajectory was associated with parents and peers who smoked,
highlighting the role of knowledge transfer
o Note that the asymptotic level of smoking is higher in the early stable compared to
the late stable group, indicating the importance of early onset in determining the final
frequency of drug use
o The existence of quitter and experimenter groups confirms earlier evidence that only
a sub-group of people who try drugs become dependent

CHIPPERS
• People who maintain a low level of drug use over an extended period of time (Zinberg &
Jacobson, 1976)
o Contradicts the notion that extended drug use leads to an escalation of drug
consumption
o Suggests that ‘controlled’ drug use can be maintained over protracted period of
time.

• Some argue that chippers are defined by having
established proscribed rituals of drug use,
which prevent escalation of dose, e.g. I only do MDMA at Raves
• Others have argued that chippers do not represent a different group, they are simply stable
drug users whose favoured dose range is at the low end of the continuum, e.g. I only smoke
one pipe per night, never more (Brauer et al 1996)
• Chippers are an understudied group, because they are uncommon and there is no accepted
metric upon which to distinguish them from other drug users, so their oft vaunted importance
in discovering a solution to drug dependence formation remains unclear.

LIFE HISTORY
• Stable patterns of drug use may be more common with the legal drugs 

• Patterns of illicit drug use tend to be more unstable over time. 

• Life history of 10 opiate addicts as they transition between occasional use, daily use &
abstinence. 

• No individual shows a simple pattern of occasional use followed by daily use followed by
abstinence. Instead, we see bouts of use followed by abstinence, then relapse, then
abstinence, sometimes broken up by institutionalization or methadone maintenance. 

• Note the frequency with which sometimes protracted abstinence is followed by relapse to
use
o Such observations support the view that addiction is a chronically relapsing disorder.
However, such chronic relapsing must be overlaid on the progressive increase in
permanent abstinence as individuals age from 30-65 years

GATEWAY HYPOTHESIS
• Substantial evidence for the gateway hypothesis 

• Experimentation with alcohol and/or tobacco normally proceeds the use of marijuana, which
proceeds pills,
then the ‘harder’ routes of administration, snorting then injecting (Kandel &
Logan 1984; Welte & Barnes 1985). 

• An atypical order of entry into drug use may be seen in very serious adolescent drug users,
perhaps due to 
peer or family introduction (Mackesy-Amiti et al. 1997). 

 TOPIC 3: EPIDIMIOLOGY – POPULATION ENTRY AND EXIT FROM DRUG USE

• Early onset of initial alcohol or tobacco use is associated with a higher risk of progressing to
polydrug use (Stein et al. 1987). 

• Why would taking one drug increase the probability of progressing to another?
o Different drugs might compliment one another (e.g. smoking & alcohol; heroin &
cocaine)
o A drug may be used to counteract the withdrawal phase of another drug (e.g.
benzodiazepines & 
cocaine)
o Substitution of one drug (e.g. meth) might occur when the primary drug (e.g. heroin) is
unavailable
o There may be cross-sensitization wherein experience of one drug renders other
drugs more 
rewarding by sensitizing brain reward systems
o ‘Common syndrome’ wherein drug use renders individuals more prone to sensation
seeking which 
predisposes them to try other drugs as well as risky sex, criminality,
violence etc. (Donovan & Jessor 1985) 

• Probably all these factors contribute to the progression from one drug to another. 


QUIT RATES AND EXIT FORM DRUG USE
• “Natural recovery” is where the individual chooses to undertake a quit attempt without formal
help or treatment
o The bulk of quitting across drug classes (≈80%)
o Largely undertaken by individuals aged 30-40, 
following about 5-15 years of use
(Sobell et al. 
2000; Price et al. 2001). 

• Chen & Kandel (1995)
o 1160 New Yorkers
o Information on frequency of drug use during 
adolescence & early adulthood
o Individuals who had initiated use of various 
drugs, alcohol, cigarettes & marijuana
peaked around 19-22, prior to the peak of cocaine around 24 consistent with a
gateway hypothesis
o Cigarette usage was unique in remaining stable into adulthood. This is consistent
with the shallower age dependent decline in smoking & compared to illicit drugs
o NB: this is heavy alcohol use, not regular use seen at the start of this lecture. 

• A smaller proportion of quit attempts occur within a treatment setting (≈10-20%)
• Key factors: availability & acceptability of the treatment service (Babor et al. 2008), legal
referral from courts or criminal sanctions, & prior experience of treatment (Siegal 2002)
• Treatment-seekers are also characterised by a higher incidence of psychiatric symptoms
(Rounsaville 1985; Carroll & Rounsaville 1992; Regier et al. 1990)