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A Systematic Literature Review of Substance-Use Prevention Programs Amongst Refugee Youth

• Original Paper
• Open access
• Published: 09 April 2024
• Volume 60 , pages 1151–1170, ( 2024 )

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• Elijah Aleer 1 ,
• Khorshed Alam   ORCID: orcid.org/0000-0003-2232-0745 2 &
• Afzalur Rashid   ORCID: orcid.org/0000-0003-3413-1757 1  

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This paper aims at exploring existing literature on substance use prevention programs, focusing on refugee youth. A comprehensive search for relevant articles was conducted on Scopus, PubMed, and EBSCOhost Megafile databases including Academic Search Ultimate, APA PsycArticles, APA PsycInfo, CINAHL with Full Text, E-Journals, Humanities Source Ultimate, Psychology and Behavioural Sciences Collection, and Sociology Source Ultimate. Initially, a total of 485 studies were retrieved; nine papers were retained for quality assessment after removing duplicates. Of the nine studies that met the inclusion criteria, only three are found to partially addressed substance use prevention programs. The two substance use prevention programs that emerge from the study are Adelante Social and Marketing Campaign (ASMC), and Screening and Brief Intervention (SBI). Six others explored protective factors and strategies for preventing substance use. The study findings show that refugee youth held negative attitudes toward institutions that provide substance use prevention programs. This review concluded that refugee youth often experience persistent substance use as they are not aware of prevention programs that may reduce the prevalence and/or severity of such misuse.

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Introduction

Increasingly, literature suggests that refugee youth face a heightened vulnerability to substance use, coupled with a limited awareness of substance use prevention programs. Refugees’ susceptibility to substance use is linked to adverse living conditions and maladaptive coping mechanisms (Posselt et al., 2015 ; Ramachandran et al., 2019 ; Roberts et al., 2011 ). As a result, research suggests that the prevalence of substance use amongst refugees ranges from 17 to 37% in camps and 4% to7% in the community setting (Horyniak et al., 2016a ). Another study revealed that 14.9% of men and 0.7% of women from refugee background exhibited substance use (Ramachandran et al., 2019 ). The concerning aspect of this situation lies in the fact that substance use and its associated risks are well-documented within refugee setting (Gire et al., 2019 ; Luitel et al., 2013 ), with a growing call to integrate substance use prevention programs into refugee services due to the prevalence of the phenomenon (Horyniak et al., 2016a ). Such recommendation emphasises the importance of addressing the knowledge gap on substance use prevention programs amongst the refugee youth. Research indicates that if the substance use prevention programs are not made known to those at risk individuals, it could have detrimental effects on such individuals (Bauman and Phongsavan,  1999 ). Failure to address the knowledge gap of substance use prevention programs could place, refugee youth at an increasing risk of various negative outcomes such as disorder, higher mortality, accidental injury, liver diseases, violence, dysfunctional work, and school dropout due to substance use (Ji et al., 2021 ; Kuntsche et al., 2017 ; Li et al., 2017 ; Momeñe et al., 2021 ). Hence, it is important to document the knowledge of substance use prevention programs amongst refugee youth in the literature to ensure that the groups are informed about the negative consequences.

As per this study, substance use prevention programs refer to a myriad of substance-free and medication treatments administered to assist individuals to reduce substance use (Alayan et al., 2021 ). While substance use refers to as a prolonged harmful use of any substance, which can result in problems such as non-fulfilling social roles, withdrawal and tolerance symptoms, substance use disorders and attributable to burden of disease and mortality (American Psychiatric Association, 2013 ; Rehm et al., 2013 ). In this case, substances can include alcohol, cannabis, methamphetamine and other stimulants drugs, non-medical use of pharmaceutical drugs, illicit opioids including heroin, tobacco and other emerging psychoactive substances (AIHW, 2020 ). In Australia, youth refers to a person aged between 12 and 24 years (AIHW, 2021 ). Accordingly, refugee youth in this study are those between the ages of 12 and 24.

Substance Use Prevention Programs

There are several substance use prevention programs in the literature, the aim of which are to reduce harms of substance use. The last two decades have witnessed a surge in studies conducted on substance use prevention programs for different socio-demographic groups that produced information about the initiation, prevalence and associated behavioural, social, and educational outcomes (Fishbein et al., 2006 ; Gau et al., 2012 ; Gruenewald et al., 2009 ; Springer et al., 2004 ). The surge in research reaffirms that substance use prevention programs play an important role in reducing the consequences of substance use. Notably, there are several factors which permit individuals to engage in use substance. These include peer pressure, poor neighbourhood, inability to cope with difficulties, cultural norms, family history of drug use and lower level of education. Family structure and mental disorder play a vital role in initiation and maintenance of substance use (Gattamorta et al., 2017 ; Peloso et al., 2021 ). The knowledge of various factors, that induce individuals to use substances is vital as they play a significant role when designing substance use prevention programs.

Some of the known substance use prevention programs include individual and group counselling, alternative programs, and family and community interventions (Barrett et al., 1988 ; Foss-Kelly et al., 2021 ; Radoi, 2014 ). These programs are designed to influence social and psychological factors associated with the initiation and maintenance of substance use (Barrett et al., 1988 ). The social factors include peer pressure, a deviation from conventional values. Including those of one’s family, school, and religion, while the psychological characteristics include low self-esteem and an attitude of tolerance towards deviancy (Barrett et al., 1988 ; Hater et al., 1984 ; Radoi, 2014 ). Substance use prevention programs aim to approach social and psychological factors in a unique way depending on their goal and outcome. Each of the factors requires a different approach when designing a substance use prevention program. For example, the primary objective of providing counselling to young individuals who engage in substance use is to assist them in overcoming their low self-esteem and embracing the positive societal norms that are linked to such behaviour (Barrett et al., 1988 ). The effectiveness of an individual program depends on the participants’ attitude toward intervention and their outcomes (Espada et al., 2015 ). For instance, participants sometimes refuse to join the prevention program due to fear of being reported to authorities (Kvillemo et al., 2021 ).

Peer pressure is widely acknowledged as a significant source of the initiation and maintenance of substance use amongst youth. According to social learning theory, youth substance use is a consequence of peer pressures originating from their reference groups (Watkins, 2016 ). To address the substance use where such pressure is deemed to be the initiation and maintenance factor, group counselling is believed to be a key prevention program (Barrett et al., 1988 ). This is because peer relations play a powerful influence, and therefore, researchers often use group counselling rather than individual counselling to promote healthy and acceptable relationships, foster social skills, and thus to develop healthy forms of recreational activities amongst peers.

Apart from counselling, adopting alternative programs such as substance-free strategies reduce the initiation and maintenance factors of substance use. Behavioural economic theory suggests that an increase in rewarding substance-free activities can lead to a reduction in substance use (Murphy et al., 2019 ). The structured substance-free activities approach is based on the relationship between the reinforcement derived from substance-related activities to the reinforcement derived from substance-free activities (Correia et al., 2005 ). Research shows that substance use programs that are supplemented with either relaxation training or a behavioural economic session focused on increasing substance-free activities are associated with reductions in substance use (Murphy et al., 2019 ). Notably, increasing substance-free activities is suggested to be useful in substance use prevention in vulnerable youth (Andrabi et al., 2017 ).

Community, family, academic engagements, work, and religious activities play a significant role in reducing the initiation and maintenance of substance use and its related consequences. Similarly, individual and group counselling, alternative programs, and family and community interventions have also led to a reduction in the initiation and maintenance of substance use amongst youth. Research demonstrated a negative relationship between commitment to conventional values such as family, religion, and education, and substance use amongst the youth (Sussman et al., 2006 ). This evidence is supported by social bond theory, which postulates that commitment to conventional values of one’s family, religion, and school act to prevent deviant responses (Nijdam-Jones et al., 2015 ). Similarly, the Family Interaction Theory suggests that social learning, parent attachment, and intrapersonal characteristics equally discourage youth risk-taking behaviours (Ismayilova et al., 2019 ). The evidence appeared in several substance use prevention programs (Huang et al., 2014 ; Ishaak et al., 2015 ; Liddle et al., 2006 ). For instance, the Adolescent Day Treatment Program (ADTP) in Canada implements a social learning approach stressing positive support for appropriate substance, anti-social coping behaviour, and social skills (Liddle et al., 2006 ).

Some substance use prevention programs are designed to assist individuals with the development of skills and attitudes through a community approach. The approach has seen youth cessation of substance use and helped them make changes leading to substance-free lifestyles (Wade-Mdivanian et al., 2016 ). One of the substance use prevention programs, which adopts a community approach is Multidimensional Family Treatment (DFT). DFT targets the initiation and maintenance of youth substance use by addressing coping strategies, parenting practices, other family members, and interactional patterns that contribute to the continuation of substance use and related consequences (Liddle et al., 2006 ). DFT also addresses the functioning of youth and family using the social systems influencing the youth’s life such as school, work, peer networks, and the juvenile justice system (Liddle et al., 2006 ; Valente et al., 2007 ). In support of the community approach, researchers argue for the inclusion of the perspectives of community members in substance use prevention programs because they understand the unique needs of the people with whom they share a bond (Bermea et al., 2019 ). Researchers also focus the interconnected nature of their socio-environmental relationships that can facilitate advocacy for change at the community level (Bermea et al., 2019 ).

Research Gap

Despite the vast knowledge of substance use prevention programs in the literature, research on the refugee youth remains scarce. The lack of research on substance use prevention programs for refugee youth may be due to many factors. First, scholars might have ignored the severity of the issues amongst the groups. Secondly, the socio-economic benefits of the prevention programs might have been underestimated in the literature. Thirdly, the political aspect of substance use prevention programs for refugee youth might have not been thoroughly evaluated in the policy frameworks. The socio-economic benefit of substance use prevention programs underscores a pressing need to begin synthesizing evidence given the deleterious nature of substance use if it is left unmitigated. The knowledge of substance use prevention programs is significant to vulnerable groups like refugee youth because they seek assistance whenever they succumb to substance use. As a result, they will avoid the negative consequences of substance use and subsequently exploit the social benefit. Furthermore, the knowledge of substance use prevention programs can assist organisations and advocacy groups assisting refugee youth to provide them with better services.

This study aims at contributing to substance use prevention programs literature by conducting a systematic literature review to synthesize evidence on such programs, their attitudes towards the program, and amongst refugee youth to fill the gaps in knowledge and provide directions for future research.

Research Questions

The following questions are designed to achieve the aims and objectives of the systematic literature review:

What different substance use prevention programs are used to assist refugee youth with substance use?

What is the refugee youth’s attitude toward substance use prevention programs?

What are the outcomes of a substance use prevention program?

To ensure the validity and reliability of this study, systematic review guidelines are followed (Toews, 2017 ). This is because the systematic review is useful in mapping out areas of uncertainty, identifying the lack of research on a particular topic, and pointing out an area where research is needed (Rethlefsen et al., 2021 ). The systematic review method provides complete and accurate reporting, which facilitates assessment of how well reviews have been conducted (Toews, 2017 ).

Unlike a traditional review, a systematic review uses a transparent, replicable, and scientific steps purposely to mitigate the risk of bias by conducting a comprehensive literature search and providing an audit trail of procedures, decisions, and conclusions (Caldwell and Bennett,  2020 ). The systematic review reports a reproducible search strategy that increases the reliability and validity of the study.

By following systematic review guidelines, this study will mitigate bias and increase its validity and reliability. The following steps are adopted to conduct the systematic review:

Step 1: Identifying Keywords

To synthesize the evidence of substance use prevention programs available in the literature amongst refugee youth, a database search began with a simple string of “substance use AND Prevention AND Refugee AND youth” in the library. Then other search terms were obtained using a permutation of the keywords in EBSCOhost Megafile Ultimate (Table  1 ).

Step 2: Search Strategy

In the next step, a comprehensive search for relevant articles was conducted on 12th of October 2021 on three major databases: Scopus, PubMed, and EBSCOhost Megafile databases including Academic Search Ultimate, APA PsycArticles, APA PsycInfo, CINAHL with Full Text, E-Journals, Humanities Source Ultimate, Psychology and Behavioural Sciences Collection, and Sociology Source Ultimate. A total of 485 studies were retrieved following the comprehensive search of the databases (Table  2 ).

Study Selection

All the retrieved studies were exported to Endnote X9, and 199 duplicates were removed. The titles and abstracts of the remaining 286 studies were reviewed and 253 studies were excluded for not focusing on substance use prevention programs. A total of 33 studies were further screened using inclusion and exclusion criteria. As a result of the exercise, 24 studies were excluded and nine were included for quality assessment. The PRISMA workflow diagram below shows the process of identifying and selecting eligible studies for this systematic review (Fig.  1 ). The data visualisation displays identified, included, and excluded papers and their explanations.

PRISMA of workflow

Exclusion and Inclusion Criteria

This systematic literature review on substance use prevention programs amongst refugee youth was conducted after adopting exclusion and inclusion criteria. To assist in the process of selecting relevant studies in this systematic literature review, studies were limited to peer-reviewed articles published in the English language. Unpublished articles were excluded, and no restriction was placed on the date of publication of the studies.

Furthermore, the selection of articles was restricted to the following eligibility criteria:

Inclusion Criteria

Studies that explored substance use and prevention/reduction/treatment/intervention programs amongst refugee youth.

Studies that explored substance use amongst refugee youth included another perspective of substance use prevention programs.

Studies that investigated and reported motivation for substance use refugee youth.

Exclusion Criteria

Studies that addressed substance use but did not include any intervention.

Studies that addressed substance use prevention and never mentioned refugee youth.

Studies that addressed substance use prevention programs amongst refugees in general.

Studies that addressed immigrant youth but did not mention refugees.

Quality Assessment

The quality of studies included in the systematic literature review was evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist (von Elm et al., 2007 ). This quality assessment tool is chosen for this study because to its usefulness and applicability to all studies (Vandenbroucke et al., 2014 ; von Elm et al., 2007 ). The explanation and elaboration of the different components of the STROBE provide readers with a clear understanding of the study (Vandenbroucke et al., 2014 ).

A total of twenty STROBE items from the checklist were used to assess the quality of the studies. These include 1 A. title, 1B. abstract, 2. background/rationale, 3. objective, 4. design, 5. setting, 6. eligibility of the participants, 7. variables, 8. data source/measurement, 10. study size, 13a. participant number, 14a. descriptive data, 15. outcome data, 16a. main result, 16b. Category of Continuous variable, 19. limitation, 20. interpretation, 21. generalisation, and 22. funding (items 1 A, 1B, 2, 3, 4, 5, 6, 7, 8, 10, 13a, 14a, 15, 16a, 18, 19, 20, 21, 22). Each item was coded as: Y = present, N = not present, P = partially present, N/A = not applicable, and finally, the percentage of the positive judgement’s total calculation (Table  3 ). If an article’s total percentage of positive judgement is less than 50%, then it is deemed poor quality and excluded from the study.

Table  3 : Quality Assessment .

Data Extraction

Systematic reviews conduct data extraction to minimise human error and bias (Tranfield et al., 2003 ). The purpose of the data extraction is to directly link to the formulated review question and the planned assessment of the incorporated studies, providing as a visual representation and historical record of decisions made during the process, and as the data-repository for the analysis (Tranfield et al., 2003 ). Below is the data extraction table developed for this systematic literature review (Table  4 ). Data extractions contain valuable information such as title, author, findings, concepts, journal, study design, setting, population, and emerging themes.

Study Characteristics

Study objectives and designs.

The study designs include four qualitative, one ethnographic, two mixed methods, one random controlled trial, and one two-cluster sample. The studies were published in nine different journals (Table  5 ).

Study Setting and Participants

Nine peer-reviewed articles met the inclusion criteria for this systematic literature review. They were published from 2009 to 2020. Four studies were conducted in the USA, two in Australia, two in the Middle East, and one in Kenya. Participants in these studies are refugees youth from these host countries.

The findings revealed a gap in the literature about substance use prevention programs amongst refugee youth. In the nine articles that met the inclusion criteria for this study, only two substance use prevention programs emerged. The substance use prevention programs identified in the study included Adelante Social and Marketing Campaign (ASMC) and Screening and Brief Intervention (SBI).

ASMC is a community-based intervention program offered by the Advance Centre for the Advancement of Immigrant/Refugee Health in Washington, DC, USA. This is a well-known primary prevention program, which addresses risk factors for substance use and other co-occurrences amongst Latino adolescents aged 12 to 19 years in a suburb of Washington, DC (Andrade et al., 2018 ; Edberg et al., 2015 ). The study employed the 4-year Adelante primary prevention program to address risk factors for substance use and other issues amongst Latino adolescents, aged 12 to 19 years (Andrade et al., 2018 ). In the two studies, ASMC was used to investigate two distinct scenarios. Firstly, it was used to identify post contents and features that resulted in greater user engagement (Andrade et al., 2018 ). Secondly, Edberg et al. ( 2015 ) used ASMC to provide a brief description of the background for community-level health disparities intervention that aims to help close the gap. The intervention is organised in a group of one to five short psychotherapeutic sessions for substance users (Karno et al., 2021 ; Widmann et al., 2017 ). Participants engage in a standardized screening for substance use problems, receive systematic feedback on substance-related risks, and participate in a motivational intervention to reduce substance use (Saitz, 2014 ).

On the other hand, SBI is used by non-psychiatric healthcare providers for substance use prevention. The approach relies on motivational interviewing focusing on empowering patients during the intervention (Karno et al., 2021 ; Widmann et al., 2017 ). SBI was successfully used to assist refugee youth in addressing substance use issues.

Six studies explore the strategies and protective factors for substance use prevention. Giuliani et al. ( 2010 ) and McCann et al. ( 2016 ) identified protective factors that influence the cessation of substance use amongst refugee youth, including strong community support systems, family, and friends. Protective factors such as trustworthiness, confidentiality of help sources, perceived expertise of formal help sources, and increasing young people’s and parents’ substance use literacy play a vital role in reducing the initiation and maintenance of substance use. Research has shown that providing refugee youth woth counselling, ongoing case management coordination, residential detoxification programmes, and individual strategies such as self-imposed physical isolation can mitigate substance use amongst them (Horyniak et al., 2016a ; McCleary et al., 2016 ). Moreover, researchers identified protective factors including academic success, and participation in voluntary activities can assist in reducing substance use (Massad et al., 2016 ).

The findings highlight protective factors that shield refugee youth from substance-use. These protective factors included religion, positive peer pressure, health, relief, and social services (Giuliani et al., 2010 ; Khader et al., 2009 ; McCann et al., 2016 ). More importantly, connecting with substance use treatment is suggested to be one way refugee youth can reduce substance use (McCann et al., 2016 ; McCleary et al., 2016 ).

Participants’ Attitudes toward Substance use Prevention Programs

The studies that attempt to investigate the attitude of refugee youth towards substance use prevention programs have revealed mixed results. First and foremost, refugee youth demonstrated a lack of confidence in the institution that provides substance use prevention programs (Massad et al., 2016 ; McCann et al., 2016 ). For instance, refugee youth in substance use treatment expressed a sense of scepticism towards the institution that provides counselling and rehabilitation (McCann et al., 2016 ; McCleary et al., 2016 ). Other researchers found out that refugee youth’s participation in substance use treatments is not motivated and therefore they are too reluctant to seek treatment (McCann et al., 2016 ; McCleary et al., 2016 ). While other research shows that refugee youth are unaware of any local institutions to support youth with substance use problems (Massad et al., 2016 ). The refugee youth who participated in the Adelante intervention and utilise social media demonstrated a positive propensity towards engaging in more passive forms of social media usage (Andrade et al., 2018 ).

Outcomes of Substance Use Prevention Programs

ASMC showed that prevention topics were significantly associated with post-engagement behaviour, such as substance use (Andrade et al., 2018 ). ASMC also identified the inequalities that promote substance use amongst the refugee youth such as a lack of community attachment, social support and social space, isolation rather than connection, and a racialized identity (Andrade et al., 2018 ; Edberg et al., 2015 ). The study indicated lack of social space leading to refugee youth finding sanctuary in gang activities (Edberg et al., 2015 ). ASMC also indicated that the most engaging topic discussed in social media posts was substance use prevention, which accounted for 8.4% of the posts with the p-value < 0.001 (Andrade et al., 2018 ).

The outcome for SBI was significant. The findings indicate that there was a decline in the amount of time that refugee youth spent using substances as their functional time increased among refugee youth (Widmann et al., 2017 ). As a result, SBIs appear to reduce substance use to some extent.

Overview of the Findings

The study aimed to explore different substance use prevention programs, summarise refugee youth’s attitudes towards these programs and outline the outcomes of the prevention programs. This systematic literature review appeared to be the first of its kind to systematically synthesis substance use prevention programs amongst refugee youth. The findings from this study supported the hypothesis that research on substance use prevention programs amongst refugee youth is scarce. Only two substance use prevention programs were identified in the study: SBI and ASMC. Although ASMC was included in only one study on substance use prevention programs, its main objectives were to identify the activities in which refugee youth participate and to outline potential areas for intervention. ASMC did not employ strategies to reduce substance use. Moreover, most studies included in this context outlined strategies and protective factors that assist in reducing substance use and related consequences amongst refugee youth. If refugee youth adhere to protective factors such as family attachment, religion, and commitment to social norms, then there is a likelihood that they can avoid the initiation and maintenance factors of substance use. Another important strategy that emerges from this study is the need to increase refugee youth and parents’ substance use literacy. Increasing literacy can help refugee youth to understand the risk substance use can have on their health, social interactions, and economic wellbeing.

Previous studies asserted that the efficacy of substance use prevention program depends on the participants’ attitude towards intervention and its outcomes (Espada et al., 2015 ). However, what is alarming is refugee youth have a negative attitude about institutions providing substance reduction services. Although the ASMC and SBI demonstrated positive outcome, such an approach can be associated with high dropout rates and subsequently, poor outcomes in substance use prevention programs. Individuals who have confidence in professional services are more likely to seek assistance and therefore, reduce substance use.

Implication

The dearth of research on substance use prevention programs programmes may have significant ramifications, considering the substantial body of literature indicating the widespread occurrence of substance use amongst refugee youth. There exists convincing evidence that the refugee youth cohort could be at risk of substance use disorders but are not seeking help. Substance use has a debilitating impact on an individual’s health, social and economic well-being. For refugee youth not seeking assistance to reduce substance use may indicate they are suffering significant consequences on top of their challenges before and after migration.

Previous studies conducted on youth in general has identified many substance use prevention programs in the literature that can mitigate the prevalence of substance use and related consequences (Barrett et al., 1988 ). However, little is known in the literature about the extent and effectiveness of substance use prevention programs including individual and group counselling, alternative programs, and family and community interventions, applicable for refugee youth (Barrett et al., 1988 ; Foss-Kelly et al., 2021 ; Radoi, 2014 ). Researchers only indicated that refugees are aware of some substance use treatment services. There are substantial differences between being aware of a service and actively interacting and engaging with it. Therefore, it is significant for refugee youth to be aware of substance use prevention programs and seek assistance to reduce substance dependence.

Refugee youth’s lack understanding of substance use prevention programs might be compounded by their inability to seek professional help. Scholarly literature suggest that refugee youth do not seek professional help because of barriers including lack of understanding of the new health system, poor mental literacy, language problem, limited transportation and cultural differences (Posselt et al., 2014 ; Shaw et al., 2019 ). Additionally, young refugees, particularly those who are forced to flee their countries due to persecution or violence, frequently encounter substantial trauma and stress without adequate access to mental health services. The pressures encompass a dearth of livelihood opportunities, familial separation, risky journeys, and vulnerability to assault and abuse. Despite managing to escape life-threatening situations in their native countries, these youth individuals often face further prejudice and become targets of in their host countries. They frequently encounter challenges accessing appropriate services, especially when it comes to disparities in mental healthcare services caused by socio-cultural factors. While additional resources and support are necessary, it is crucial to provide culturally sensitive and customised interventions to refugee youth.

Conclusion and Future Research

In conclusion, prevention programs for substance use remain obscure despite the prevalence of substance use amongst refugee youth. The prominent finding of this review is that the majority of the investigations failed to address substance use prevention programs, as their focus was primarily on protective factors and strategies to reduce substance-use. While the study does make an attempt to address substance use prevention programs, it also incorporates other risk behaviours as well. In such investigations, it is difficult to deduce the outcome and attitudes of the participants. Future research is warranted regarding the implementation of substance use prevention programs amongst refugee youth. The findings are an indication of the need to conduct a robust substance use prevention program such as individual and group counselling, alternative programs, and family and community interventions tailored specifically to refugee youth. Furthermore, research should demonstrate the efficacy of each substance use prevention program by exploring participants’ attitudes towards intervention and measuring the outcome of the study. This can fill the gap in the literature with empirical evidence on how refugee youth participate in substance use prevention programs and maximise the benefits by reducing substance use.

It is essential to acknowledge the limitations of this study. The primary constraint lies in the study’s narrow focus on refugee youth, restricting the search to this specific keyword. Consequently, fewer articles satisfied the inclusion criteria. The study may have overlooked relevant articles that employ alternative terms such as ‘immigrant’, ‘migrant’, or ‘cultural linguistic diverse individuals’. Using broader and more inclusive terms can improve the quality of future research by redesigning the search strategy. .

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Aleer, E., Alam, K. & Rashid, A. A Systematic Literature Review of Substance-Use Prevention Programs Amongst Refugee Youth. Community Ment Health J 60 , 1151–1170 (2024). https://doi.org/10.1007/s10597-024-01267-6

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Adolescents and substance abuse: the effects of substance abuse on parents and siblings

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Introduction

Theoretical framework: bowen’s family theory, research methodology, discussion of main themes and sub-themes, theme 1: financial effects of substance abuse, conclusions and recommendations, disclosure statement, additional information.

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This study aimed to describe the adverse effects that adolescent substance abuse has on the levels of care giving and well-being of families. The researchers used a qualitative case study design which focused on an issue of concern (such as adolescent substance abuse) and thus selected one case to elucidate the issue, i.e., a single case study. The case would be the family members of substance abusing adolescents in Mitchells Plain, a township in Cape Town, as an exemplar for the study. Purposive sampling was used to select 12 participants, seven parents (mothers) and five siblings. Individual semi-structured interviews were utilized for data collection through the use of interview schedules. The data were analysed in the form of qualitative thematic analysis where four themes emerged, which focused on the various effects (for example, financial, physical, emotional, and distrust) on family well-being resulting from living with a substance-abusing adolescent.

• Adolescence
• care giving
• substance abuse

Prior to the first democratic elections in South Africa (SA), substance abuse primarily involved drugs such as alcohol, cannabis and methaqualone. With SA’s transition to democracy and the subsequent opening of its borders, there had been an influx of substances and a growing burden of harm associated with illicit substance abuse (Herman et al., Citation 2009 ). Post-apartheid SA has been combating numerous environmental stressors, including the transition from apartheid to a democratic dispensation, poverty, high crime, violence and the HIV pandemic. These stressors have contributed to the upsurge in substance use (Brook et al., Citation 2006 ).

Alcohol use by young people is an increasing concern worldwide (World Health Organization (WHO), Citation 2015a ). Alcohol use is initiated at a worrying age; 14% of adolescent girls and 18% of boys between the ages of 13–15 years in low- and middle-income countries (WHO, Citation 2015a ). Consequently, 5% of deaths of young people below 30 years are attributed to alcohol abuse (World Health Organization (WHO), Citation 2016 ). In Central and Eastern Europe, it was reported that 25% of under 20-year-olds use drugs (World Health Organization (WHO), Citation 2015b ), high usage across Western Europe, Australasia and North America (Romo-Avilés et al., Citation 2016 ), as well as lifetime cannabis use in these countries (Degenhardt et al., Citation 2016 ). The age-of-onset was similar across countries (16–19 years) except South Africa where it was 20 years.

In SA, the prevalence of substance abuse is twice the global average, and the Western Cape (WC) is particularly disturbing with the highest prevalence of alcohol and drug use (Kadalie & Thomas, Citation 2013 ). Morojele and Ramsoomar ( Citation 2016 ) confirm SA’s worrying drinking habits. SA is one of the world’s main alcohol users, with a large number of people who misuse alcohol and drugs (Visser & Routledge, Citation 2007 ), historically founded on the widely used tot system (paying labourers with alcohol) (Williams, Citation 2016 ).

The Medical Research Council (MRC) (Mudavanhu, Citation 2013 ) indicated that there were about 200,000 methamphetamine users in Cape Town with 70% of those less than 20 years of age, and where the majority of users were teenagers between the ages of 13–17 years old. Ramson and Chetty ( Citation 2016 ) confirmed that Cape Town (the Cape Flats) had the most methamphetamine consumption anywhere else in the world. Concerning, adolescents were over-represented in seeking treatment for methamphetamine abuse (Ramson & Chetty, Citation 2016 ). Adolescent substance abuse in SA is one of the most significant health and social problems.

According to Hoeck and Van Hal ( Citation 2012 ), substance abuse places an excessive burden on the parents of the substance abusers. Alcohol and drug addiction have been found to have significant effects on family well-being; however, very little research has focused on the effects on the family when an addict is an adolescent (Swartbooi, Citation 2013 ). Most research studies focused on parents as factor in the subsequent substance abuse of adolescents, but not eliciting the concomitant experiences of their parents and siblings (Swartbooi, Citation 2013 ).

Few studies in SA were conducted on the effects of substance abuse on family well-being when the substance user is an adolescent. One particular study, conducted on the infamous Cape Flats focused on the experiences of the adolescent’s substance abuse (Swartbooi, Citation 2013 ). Likewise, the current study also focuses on area (Mitchell’s Plain) on the Cape Flats because of its significant levels of substance abuse. The Cape Flats is regarded as a high-risk area with high crime rates and associated gang-related activities (Dolley, Citation 2018 ; Dziewanski, Citation 2020 ; Pinnock, Citation 2016 ). The qualitative study by Asante and Lentoor ( Citation 2017 ) focused on the use of crystal methamphetamine by widely used by Coloured Footnote 1 youth, and where the participants were also mothers of users.

The effects of the adolescent’s substance abuse on parents and other siblings are a complex and important research topic that is minimally researched. Therefore, the aim of the study was to understand the effects of adolescent substance abuse on care giving and family well-being within a specific area in Cape Town as a starting off point. The research objective was to explore and describe the perceptions and experiences of parents and siblings regarding the effects of adolescent substance abuse on family relationships and well-being.

The effects of substance abuse on family well-being

Substance abuse during adolescence.

The use of substances by youth is described primarily as intermittent or intensive (binge) drinking and characterized by experimentation and expediency (Degenhardt et al., Citation 2016 ; Morojele & Ramsoomar, Citation 2016 ; Romo-Avilés et al., Citation 2016 ). Intermittent or intensive substance use is linked to the adolescent’s need for activities that resonate with being ‘cool or fun’ and unrestrained self-indulgence; for a happy mood and peer sanction as key motivations (Romo-Avilés et al., Citation 2016 ).

Substance abuse often develops in the transitional phase of adolescence, a time when puberty and physical growth are occurring and when a young person seeks independence (Morojele & Ramsoomar, Citation 2016 ). Adolescence is a momentous period in that the human body undergoes significant physical growth and psychological changes; not only bodily changes but also in the brain (Morojele & Ramsoomar, Citation 2016 ). Winters et al. ( Citation 2011 ) contend that adolescents are at greater risk of substance addiction, due to the physiological and psychological effects of drugs on the developing adolescents’ brain. Adolescent’s substance use ranges from early stage experimental use, to compulsive and problematic drug abuse; which in turn is compounded by various social problems, such as troubled relationships, family difficulties, and challenging peer relationships.

Oldfield et al. ( Citation 2016 ) confirm that an adolescent tends to start looking towards their peers for guidance as opposed to their family and become less subjected to parental control. Adolescence is also the time for experimentation with risky behaviours (Feldstein & Miller, Citation 2006 ; Morojele & Ramsoomar, Citation 2016 ). According to Trucco ( Citation 2020 ), substance use during adolescence can continue into adult years, increasing the likelihood of dependency on the drug. In particular, youth use methamphetamine through gang membership for income generation especially in struggling communities (Hobkirk et al., Citation 2016 ). Consequently, there is a substantial connection between the drug trade, drug abuse, organized crime networks, and gang membership in Cape Town (Goga, Citation 2014 ; Ramson & Chetty, Citation 2016 ).

Implications and effects on parents and family

Zimic and Jackic ( Citation 2012 ) aver that the impact that substance abuse has on the family and on the individual family members merit attention. Lander et al. ( Citation 2013 ) maintains that family members are affected by the individual’s substance abuse; however, each individual is affected differently together with, but not limited to, having unmet developmental needs, impaired attachment, economic hardship, legal problems, emotional distress and sometimes violence being perpetrated. The manner in which a family copes or manages the addiction issue has a profound effect on the way others experience the problem, as well as the course and severity of the problem.

The family remains the primary source of attachment, nurturing and socialization for individuals in society. According to Templeton et al. ( Citation 2007 ), as the course of substance abuse progress, the emotional responses of family members are worsened in families where substance abuse is prevalent. Families tend to experience considerable stress-related difficulties including insomnia, anxiety and depression. Orford et al. ( Citation 2010 ) further contend that isolation and suicidal ideation, betrayal and resentment from family members are present. Substance abuse is regarded as an illness of the entire family, not just the substance abuser but the other family members as well. Thus, substance abuse is viewed as a ‘family disease’ which affects most if not all family members (Klostermann & O’Farrell, Citation 2013 ). In a substance-affected family, functional family roles are often missing or distorted (Gruber & Taylor, Citation 2006 ). According to Vernig ( Citation 2011 ), members of the family do not only experience the effects of substance abuse but also play an active role in supporting this pattern of behaviour.

In 2007 South Africans were transfixed by the unfolding true story of Ellen Pakkies, who strangled her 20 year-old son who was addicted to methamphetamine (Pieterse, Citation 2019 ; Walker, Citation 2018 ). She related how she and her husband had been abused by their son, how he constantly stole their possessions and used violence or threats against them – all to extort money to buy drugs. Although the event might seem astonishing that a mother might kill her son, but Walker ( Citation 2018 ) contends two underlying factors: the difficulty of living with a substance abuser; and that any person can be pushed beyond their limits. For Pieterse ( Citation 2019 ), the Ellen Pakkies story illuminates the utter vulnerability of family in the midst of substance abuse and the lack of protection and support from community and social services.

It is a complex challenge for any parent to acknowledge or deal with their child’s substance abuse. Barnard’s ( Citation 2005 ) study revealed that families were shocked by the knowledge that one or more of their children abused substances; one parent describing their experiences as ‘being in hell’. Barnard’s ( Citation 2005 ) findings underscored the Pakkies family experiences. In a study conducted by Jackson et al. ( Citation 2007 ), findings confirmed that an adolescent’s substance abuse had a significant effect on family functioning, touched every member of the immediate family, and highlighted every aspect of family life. Parents found it demanding, overwhelming and very stressful. A significant theme that emerged from the qualitative study by Mathibela and Skhosana ( Citation 2021 ) is that the parents wished that their adolescent substance abuser would die.

Murray Bowen (1913–1990) was an American psychiatrist who conceived the family systems theory which he developed throughout his many years of professional practice with families Thompson et al., Citation 2019 ). According to Swartbooi ( Citation 2013 ), Bowen’s family theory proposes that one cannot be fully understood in isolation from one’s surroundings; and thus family forms a system which consists of independent individuals who can only be understood in relation to their broader system. Adelson ( Citation 2010 ) asserts that Bowen’s family theory relates to the adjustments and accommodations, which families put in place in order to keep a sense of normality in the face of substance abuse. Furthermore, this theory also highlights the importance of functional roles and emotional relationships between families. According to Swartbooi ( Citation 2013 ), ‘each family member fulfils a specific role such as “father or brother”. In addition to the mentioned roles, each member within this system also takes on additional roles as a peacekeeper or the emotional one’ (p. 29). Bowen’s theory has been useful in this study, as it assisted in understanding the family as an emotional unit. The theory has demonstrated how families have a profound effect on their family member’s thoughts, feelings and actions.

Research approach

The researchers selected the qualitative approach due to the focus on participants’ experiences. According to Willig ( Citation 2009 ), qualitative research is mainly concerned with meaning and with how people make sense of their world and how they experience events. This approach allowed the researchers to obtain information in a more detailed and comprehensive way which inevitably led to a greater understanding of the topic.

Research design

Case study design involves an exploration of a bounded system which is used to study a situation within a specific context and a period of time (Babbie, Citation 2016 ; Creswell, Citation 2013 ; Denscombe, Citation 2014 ). The researcher used the single instrumental case study (Creswell, Citation 2013 ; Fouché & Schurink, Citation 2011 ) because the researchers focused on an issue of concern (such as adolescent substance abuse), and thus selected one case to elucidate the issue. The case was the family members (parents and siblings) of adolescents abusing substances in Mitchell’s Plain, as the specified boundaried context.

Research context

Mitchell’s Plain is a densely populated area of Cape Town, which falls within a desolated area known as the Cape Flats. Mitchell’s Plain was established in the 1970s, during the notorious apartheid era as a township racially designated under the Group Areas Act 1950 for the Coloured community (Bowers du Toit, Citation 2014 ; Petrus, Citation 2013 ). The area has evolved into a community battling with crime, gangsterism, unemployment, overcrowding, substance abuse and poverty. The researchers identified Mitchell’s Plain as the area is beset with high levels of crime and substance abuse – a rich source of data for the researchers to use to explore and describe the effects of drug misuse on the community. This community is a low socio-economic community; it is situated among many other poorly resourced socio-economic communities. These communities are plagued by major social issues such as poverty, unemployment and gangsterism (Florence & Koch, Citation 2011 ).

Population and sampling

With regards to this study, the population was the parents and siblings of adolescent substance abusers in the Mitchell’s Plain area. Purposive sampling was used to select participants if they had the specific qualities and experiences needed for the study (Denscombe, Citation 2014 ). The sample choice would consist of families who have an adolescent using substance. By the 12th interview data saturation had been attained, reaching the sample of seven parents and five siblings. It’s not surprisingly that all participants were females (the dominance of gender in seeking help) who identified as being Coloured (the geographic and socio-political connotations attached to the area).

Data collection and analysis

The researchers’ obtained approval from the selected university’s research committees to conduct the study. This study used in-depth interviews for data collection to explore the views, experiences, beliefs and/or motivations of individuals on specific matters (Silverman, Citation 2000 ). A semi-structured interview schedule was used as a guide. The data were analysed using qualitative thematic analysis according to the eight steps of Renata Tesch (Marshall & Rossman, Citation 2006 ; Schurink et al., Citation 2011 ).

Trustworthiness of the study

For credibility, the researchers used member checking to ensure that participants’ realities had been represented appropriately; transferability was tested by comparing the findings with the literature review as well as other studies conducted on the same topic; dependability was done by undertaking an inquiry audit in which accurate and detailed records were kept of the research methods and strategies in data collection and analysis; and for confirmability, a research journal and memoing was used to address matters pertaining to researcher reflexivity.

The four themes focus on the adverse effects of substance abuse in the home. The themes provide an understanding of what parents and siblings endured having an adolescent substance abuser in the home.

Substance abuse places a huge financial strain on the family system. The financial costs of substance abuse have had a significant effect on family functioning and well-being, as can be seen in the change in family earnings. This is as a consequence of financing the substance abusing relative’s habit as the substance abuser very often is unemployed, the deliberate or unintended destruction of household possessions, the selling of household items to purchase alcohol and other drugs, legal costs, healthcare costs and rehabilitation costs (Benishek et al., Citation 2011 ).

Sub-theme 1.1: financial effects on parents

This sub-theme will exemplify the financial effects of substance abuse on parents living with a substance abuser.

No, some people know she’s not working now she lend by them money until my mommy is coming, until my mommy is coming so now they know she’s not working but they still give her the money. and I mean it’s not a R20 [$1.35] or R30 [$2.00], every time its R50 [$3.35] cause why she tell them my mommy is not here and there’s no electricity in the house there’s no bread and the children want to eat now and stuff she must buy electricity, bread and something to eat . [Participant 3]

There would have been money for everything and for the children school, you know sometimes I feel heartsore to think that the children must go without bread to school because there isn’t money, if she was there working for her children things would have been better . [Participant 5]

The narratives display the anguish as a result of the substance abuse of the family member and the immense influence substance abuse has on the family well-being. The Cape Town study by Asante and Lentoor ( Citation 2017 ) also found that the drain of substance abuse on the family’s financial situation was immense. The narrative of Participant 3 is that of a parent who has endured her daughter’s actions on creating debt and taking no responsibility thereof. The participant has thus adopted the role of the rescuer, to which Gerlock ( Citation 2012 ) asserts that by rescuing the substance abuser, the rescuer protects the substance abuser from suffering the consequences of their actions. In the instance of this particular narrative, one of the original rescuing behaviours is that of paying off the individual’s debts (Gerlock, Citation 2012 ).

The narrative of Participant 5 is a reflection of how substance abuse not only affects the mother of the abuser; it reflects how the abuse affects the children of the abuser. It is clear from this study that the mothers of the substance abuser attempt to fill the void which the children of the abuser may be feeling. A common trait which has been noticed in this study and in the field of social work is that grandmothers, especially the maternal grandmothers, would care unconditionally for their grandchildren with the little monetary assistance they received from the South African government.

According to Sandau-Beckler et al. ( Citation 2002 ), there has been a significant increase in second generation parents, as children of substance abusers are more likely to be abused and neglected than children of parents who do not abuse substances. As a result, they are removed from their biological parents care and placed in the care of their grandparents or other family members. Grandparents now inhabit the full-time parenting role of their grandchildren (Cox, Citation 2000 ; Fitzpatrick, Citation 2004 ; Richards, Citation 2001 ), through legal means (foster care, adoption) or non-legal means (familial care). Worldwide grandparenting is an increasing phenomenon (Buchanan & Rotkirch, Citation 2018 ; Fauziningtyas et al., Citation 2018 ; Kropf & Kelley, Citation 2017 ), calling them unseen custodians (Kropf & Kelley, Citation 2017 ).

Sub-theme 1.2: financial effects on siblings

Financially, we had to take responsibility of her child. So financially it is a bit hard and especially when it’s not your child and your husband is the type of person who never had to deal with drug addicts. So financially it was hard on us and it put strain on my relationship with my husband. Like for example, when she went to grade R she never went to school the first day because she never had anything. My mom never told me she was enrolled in the school, but she was actually now staying by my mom . [Participant 8]

At the end of the day then we must suffer financially at home because now my mommy’s sugar is gone it’s supposed to keep for a month . [Participant 9]

I stopped giving because I would still sometimes buy toiletries or give money or whatever, but I had to stop that because I don’t want to be an enabler but it’s so hard to do, when you in it. It’s one thing telling people you should stop doing that, but when it happens to you and your family, it’s difficult . [Participant 11]

The narratives above are of siblings who experienced the financial effects of having a substance abusing sibling. Participant 8 has given a detailed description of how her sister’s substance abuse has affected the financial well-being of her own child, and how the family were compelled to ensure that the child of the substance abusing sibling was being cared for (to the detriment of her marriage). This meant that the substance abusing sibling had no responsibility to her child as the family was ensuring that the basic needs of the child was being met.

The narrative of Participant 11 reflects what Bowen referred to as ‘sibling position’. Bowen (as cited in Rasheed et al., Citation 2011 ) theorized that the ‘younger sibling does best when others look out for him or her, and it’s not natural for the younger sibling to assume leadership or accept responsibility’ (p. 184). In the case of Participant 11, she was slightly older than her substance abusing brother, in consequence she took care of him which later felt as if she was enabling his substance abusing behaviour.

According to Drugscope & Adfam ( Citation 2009 ), family members are often a voluntary and unconsidered resource in providing health and social care to their substance abusing relatives. Family members carry a significant burden concerning the expenditures associated with the substance abuse of a family member. Understanding what is known concerning substance abuse and the effect on the family, it can be thought that the costs of substance abuse on families are extensive and significant (Copello et al., Citation 2009 ).

Theme 2: physical effects of substance abuse

Substance abuse in the family frequently causes problems where family members experience high levels of stress which significantly comprises their health and subjective well-being (Butler & Bauld, Citation 2005 ; Jackson et al., Citation 2007 ). The following sub-themes will demonstrate what the participants have experienced:

Sub-theme 2.1: physical effects on the parents

And then she worked so on my nerves and then she shouted and she swore and then when I get cross I just want to take her and hit her. And then, then I have to control myself, because I’m asthmatic like I told you and then I sommer [without warning] get an attack . [Participant 1]

I was so stressed out because every time I go to the doctor he tells me you not sick man, you stress too much . [Participant 2]

I’m an asthmatic and I was totally drained . [Participant 6]

Participant 2’s experiences indicate that her physical well-being is a manifestation of her mental well-being. Parents in the Barnard ( Citation 2005 ) study described developing health problems as a direct result of living with their substance abusing child. A study conducted by Orford et al. ( Citation 2013 ) also achieved similar finding which explain that the experiences of stress and strain are unpredictable for the family members who are affected by the substance abuser. Orford et al. ( Citation 2013 ) elaborate further that stress is felt as a result of the relative’s substance abuse and shows in cognitive, emotional, physical, relational and economic strain. Local and international research confirms that mothers are forced to handle a myriad of challenges regarding their adolescent’s poor behaviour (Orford et al., Citation 2010 ), which negatively affected their health. Furthermore, parents particularly reported developing health problems as a direct result of living with their substance abusing child; resulting from the exhaustion of their demands, constant arguments, and worrying about the health and well-being of their child (Barnard, Citation 2005 ). Parents worried about the unpredictability of their child’s behaviour, due to the influence of substance abuse. This meant not really knowing where they were, if they were coming back home, the kind of trouble he or she may be in and whether the knock on the door would bring the police or drug dealers in search of payment (Barnard, Citation 2005 ).

Sub-theme 2.2: physical effects on siblings

The sub-theme elucidates the physical effects of a sibling’s substance abuse on the well-being of the non-using siblings.

So physically for me it’s just draining and tiring to always be there and trying to be there for everyone else, yes it’s just a draining thing . [Participant 11]

Physically she’s drained us, we’ve got to a point now that we really don’t want her part of our lives anymore, we’ve got to that point . [Participant 8]

Participant 8 and 11 both described their siblings’ substance abuse as physically draining. The siblings appear to be exhausted, and ostracizing the substance abuser was easiest or most effective means of managing the substance abusing behaviour. The participants appear as almost helpless and to some extent resentful, as though they have given up the possibility of the substance abuser rehabilitating and leaving the sibling to deal with the day to day of family life. The presence of substance abuse has been linked to physical, psychological and social problems experienced by family members (Gruber & Taylor, Citation 2006 ). Similarly, Ronel and Haimoff-Ayali ( Citation 2010 ) found family members presented with symptoms of anxiety by depression, psychosomatic complaints and various emotional and behavioural disturbances. Research suggests having a family member with a substance abuse problem has negative effects on both physical and mental health (Orford et al., Citation 2010 ).

Theme 3: emotional effects of substance abuse

Participants described having a substance abusing family member as distressing and creating feelings of defeat; which were emotionally draining and stressful. Two sub-themes show the emotional effects.

Sub-theme 3.1: emotional effects on parents

This sub-theme provides insight into the emotional effects of substance abuse on parents. The parents (mothers) of substance users found it difficult to express themselves when having to think of the emotional roller coaster which they have been through. The parents describe a sense of loss, underlying anger and disappointment.

Yes, I would cry a lot at times because I can’t talk with them. If I talk to them the other one would say yes it’s you that’s making the trouble and then they say yes it’s you and then he say you not my sister and then I would walk out by the door. I walk and I walk and sommer go stand there by the grave yard then I stand there . [Participant 2]

It’s a sore deep down in your heart and in your soul only God knows that sore. If he understands that sore, if he is the healer, only he can heal that sore it’s not an easy road for a mother to go through but when you have God you can say if it wasn’t for Him you wouldn’t make it. He comforts you, He heals you and that’s why you can make. But deep down in my soul, deep down in my heart I’m very sore . [Participant 5]

I’m not the same person that I use to be, I was a jolly person. I used to go out, I like to dress up when I go out with my friends, my colleagues that I used to work with; but since I found out that my daughter was on drugs I totally changed . [Participant 6]

Participant 2’s feelings of being alone and unsupported links with the finding of Orford et al. ( Citation 2010 ) who found that parents tended to experience emotional isolation which had a negative effect on the functioning of the family system. Participant 6 also described the dramatic change in her social habits and connections to others. Orford et al. ( Citation 2010 ) argued that these behaviours may cause further damage and unhappiness in the family. The study by Asante and Lentoor ( Citation 2017 ) also found emotional distress, self-blame and fear by their participants. These feelings were previous revealed by the study of Groenewald ( Citation 2016 ) who also found signs of depression. The experiences of participant 2 concur with Bowen’s theory relating to the emotional distance which is temporarily caused by the participant in order for her to manage the tension within her family (Rasheed et al., Citation 2011 ).

The narrative of Participant 5 displays the emotional pain which has become so unbearable that placing one’s faith in religion and religious beliefs is the only way to manage the emotional effects of having a substance abusing child. The finding of participant 5 supports previous studies relating to the use of religion as a means of coping during a difficult time (Kendler et al., Citation 1997 ; Pardini et al., Citation 2000 ).

Sub-theme 3.2: emotional effects on the siblings

This sub-theme depicts the emotional state that siblings often found themselves in. Each narrative provides an account of the siblings’ experience.

Emotionally, it really broke our family because it came to a point where in the beginning my mother was in denial with her addiction and when my father got sober now he could see what she was doing. But my mother couldn’t fathom the fact that her daughter was a drug addict she would always say no she’s going to come right now, it’s just a phase she’s going through but it wasn’t and it really tore our family apart . [Participant 8]

I asked my mommy if their burial was squared up [paid] because anything can happen to them then we can be in a financial crisis we already struggle to keep head above water to help my mommy look after them and their kids so where we going to get money to bury them we might as well put together and square the burials. Then my mother questioned why her children turned out the way they did, then I said to my mommy, mommy … we know what is going to happen at the bitter end at the end they not going to bury you, you going to bury them . [Participant 9]

The narratives describe how participants’ siblings’ substance abuse affected the emotional state of the family. Participant 8 asserted that they were in total disbelief as they have spent most of their lives suffering from their father’s addiction; when her father became sober, her sister started the cycle of substance abuse. A study conducted by Coviello et al. ( Citation 2004 ) confirmed that people who have a family history of substance abuse are prone to repeat the cycle. The above could be further explained by Bowen’s theory of multigenerational transmission process, where the addiction has spread to the next generation.

Participant 9 highlighted the trauma of having a substance abusing sibling, as her mother would remind or request the family to pay the burial of the substance abusing sibling as they prepared themselves for the worst, thus living in a perpetual state of anxiety. The above narrative concurs with a study conducted by Choate ( Citation 2011 ) where the fear of death was a common concern amongst families who experience substance abuse. Brabandt and Martof (as cited in Craig, Citation 2010 ) explain that ‘when unresolved or exaggerated, this sense of loss can manifest as anxiety, behavior, substance abuse, eating disorders, depression, and relational difficulties’ (p. 137). The study by Swinton ( Citation 2020 ) also focused on the experiences of having a sibling who had a substance abuse problem, revealing the heightened worry and fear that they lived with. Dudley ( Citation 2019 ) also reported that having a substance-abusing sibling compromised the parents ability to fulfill the needs of other siblings in the household.

Theme 4: distrust

Most of the participants experienced a lack of trust towards their substance abusing family member. Participants revealed that they barred their substance abusing family member from their house as things would gradually go missing without the participants realizing that their belongings had disappeared. This was an on-going occurrence and represented a key concern as result of the persistent stealing of belongings and money from the family home. The following sub-themes give insight to the extent of the problem and the stress it caused siblings and parents.

Sub-theme 4.1: loss of trust by parents

She steals the stuff, my house stuff, like maybe groceries and pack it in her bag and if I look for that groceries, then she sells it somewhere else. I’m missing my stuff like the clothing with the tag I just bought the stuff and I mean it’s for a special occasion . [Participant 3]

Everything disappears; my jewelry disappeared, even shoes disappeared. She doesn’t steal her own things she steals things that belong to other people . [Participant 6]

The above narratives are experiences of mothers who have endured their substance abusing child’s stealing. Their experiences were remarkedly similar. The narratives provide a detailed explanation of how belongings would go missing out of their houses and they wouldn’t know until they wanted to use the item. As a result, the lack of trust grew between the parent and the substance abuser is affected, which is vital in the parent–child relationship (Shek, Citation 2010 ).

A qualitative study conducted by Jackson et al. ( Citation 2007 ) revealed the changes in the attitude of parents towards their substance abusing child and the manner in which it altered the trust in the relationship. Usher et al. ( Citation 2007 ) also reported that families were unhappy about their substance abusing family member’s stealing and harmful behaviours which resulted in feelings of mistrust and duplicity. Shek ( Citation 2010 ) also argued that there was insufficient attention paid to the perceived mistrust between parents and adolescent children as it is an important component in attachment and the relational quality for current and future outcomes. Current literature still do not focus attentively on trust/mistrust as a consequence of adolescent substance-abusing behaviour.

Sub-theme 4.2: loss of trust by siblings

This sub-theme provides the narrative of siblings who have experienced a loss of trust due to their sibling’s substance abusing behaviours.

When she comes here to my house, I cannot trust her as she has stolen from me before. I have been betrayed by her before so I am aware of the feeling if someone takes something from me which doesn’t belong to them. When she visits I would follow her all around the house to ensure that nothing goes missing . [Participant 8]

He stole my daughter’s new clothes, he stole all my silver jewellery, he steals, he performs with me [harasses] every day for money and I still give him the money and he still steal my stuff . [Participant 12]

The participants reiterated that the substance abusing sibling couldn’t be trusted within the house and the family always had to be on their guard. By things going missing within the house, extra expenses are needed to be forked out to compensate for the things that went missing. The above findings support the studies by Garney ( Citation 2002 ) and Webber ( Citation 2003 ) that pointed to a breakdown of trust between siblings and their substance abusing sibling. Few studies have focused on trust as an issue between siblings.

The themes have provided a detailed account of how substance abuse affects the well-being and functioning of the family. It also demonstrates how family’s change and how they relate to the substance abuse. The role to be played by non-substance abusing family members is also strongly established in the findings. It is evident that substance abuse is a family’s priority and it also automatically becomes a family’s disease. The effects of substance abuse are devastating for all involved. The themes have revealed that even if it is only one person abusing the substances, the entire family is affected.

The themes also afford an understanding that family members, especially mothers and siblings, are forced to pick up the slack for the substance abuser. This article also reflected the devastating effect on the family’s financial position, physical health and psychological well-being, as they are constantly worrying about the abuser and their next step. Good insight was gained in terms of the roles which family members adopted, especially siblings as they felt they needed to save their sibling from destroying their lives. A dominant role which often surfaced was the role of the enabler, and the ways in which family members adjusted their behaviours and reactions to the substance abuser. An important aspect revealed was the support rendered to families, and that often family members were overlooked as emphasis and attention is more on the healing of the substance abuser. Thus, support services should be rendered and family members should be encouraged to seek assistance for themselves, and guidance in terms of how to cope with the challenging issue of substance abuse.

Helping professions like social work have a distinct role to play in providing much needed support and therapeutic services to parents and siblings focused on the myriad aspects in the relationship that have become distorted as a result of the substance abuse of the adolescent as daughter/son and sister/brother. Involving the community in intervention is a vital component if society hopes to address the scourge of addiction. Strengthening policy advocacy and political lobbyist roles in community organizing and policy intervention is imperative. Specific political portfolios is an example of harnessing political power and funding especially for areas and regions like the Cape Flats which is particularly burdened. Funding and sufficient treatment centres are always in short supply but it is vital that appropriate forward planning is done and enacted.

Substance abuse and addiction is not an isolated, minimum impact issue, but affects and attacks as many as it can and thus collaboration amongst all the role players and stakeholders should be key to address its many concerning facets.

Ethics approval

This study has been approved by the University of the Western Cape Research Ethics Committee (reference HS16/2/11) and the Western Cape Government: Research, Population and Knowledge Management (reference 12/1/2/4).

Conflict of interest statement

On behalf of the authors, as corresponding author I declare that there is no conflict of interest to declare.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.

No potential conflict of interest was reported by the authors.

Notes on contributors

Glynnis dykes.

Dr Glynnis Dykes is a senior lecturer in the Department of Social Work at the University of the Western Cape. She completed her PhD in social work learning and teaching at the University of Stellenbosch. She is published in learning and teaching and the adverse childhood experiences of social work students, and specifically the effects on how students are able to learn within their individual contexts and own personal experiences. Her research interests include family well-being and parenting, and youth in gangs; especially the learning and teaching of these topics in social work which are context-driven.

Riefqah Casker

Ms Riefqah Casker is a foster care social worker at the Department of Social Development, in the Mitchells Plain area. She completed her social work degree in 2013 and her Master’s degree in social work in 2019. She has been a practicing social worker for the past 7 years. Her special interest is in substance abuse and the ways in which the adolescent substance abuse affected the care and well-being of family members, with specific focus on siblings and mothers of substance abusers.

1. In SA, Coloured means people of mixed race and ethnic heritage ( Petrus, Citation 2013 ).

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• Open access
• Published: 12 September 2024

The effect of alcohol consumption on human physiological and perceptual responses to heat stress: a systematic scoping review

• Nathan B. Morris 1 ,
• Nicholas Ravanelli 2 &
• Georgia K. Chaseling 3  

Environmental Health volume  23 , Article number:  73 ( 2024 ) Cite this article

Metrics details

Ethyl alcohol (ethanol) consumption is ostensibly known to increase the risk of morbidity and mortality during hot weather and heatwaves. However, how alcohol independently alters physiological, perceptual, and behavioral responses to heat stress remains poorly understood. Therefore, we conducted a systematic scoping review to understand how alcohol consumption affects thermoregulatory responses to the heat.

We searched five databases employing the following eligibility criteria, studies must have: 1) involved the oral consumption of ethanol, 2) employed a randomized or crossover-control study design with a control trial consisting of a volume-matched, non-alcoholic beverage, 3) been conducted in healthy adult humans, 4) reported thermophysiological, perceptual, hydration status markers, and/or behavioral outcomes, 5) been published in English, 6) been conducted in air or water at temperatures of > 28°C, 7) involved passive rest or exercise, and 8) been published before October 4th, 2023.

After removing duplicates, 7256 titles were screened, 29 papers were assessed for eligibility and 8 papers were included in the final review. Across the 8 studies, there were a total of 93 participants (93 male/0 female), the average time of heat exposure was 70 min and average alcohol dose was 0.68 g·kg 1 . There were 23 unique outcome variables analyzed from the studies. The physiological marker most influenced by alcohol was core temperature (lowered with alcohol consumption in 3/4 studies). Additionally, skin blood flow was increased with alcohol consumption in the one study that measured it. Typical markers of dehydration, such as increased urine volume (1/3 studies), mass loss (1/3 studies) and decreased plasma volume (0/2 studies) were not consistently observed in these studies, except for in the study with the highest alcohol dose.

The effect of alcohol consumption on thermoregulatory responses is understudied, and is limited by moderate doses of alcohol consumption, short durations of heat exposure, and only conducted in young-healthy males. Contrary to current heat-health advice, the available literature suggests that alcohol consumption does not seem to impair physiological responses to heat in young healthy males.

Peer Review reports

Introduction

Each year, there are approximately 20,064 heat-related deaths in North America and 489,075 deaths globally [ 1 ], with this number expected to rise by 70% to 100% by the year 2050 [ 2 ]. Identifying factors that increase the risk of morbidity and mortality during heatwaves will be critical to help mitigate this tremendous loss of life. One identified risk factor is ethyl alcohol (ethanol) consumption (referred to by its colloquial name “alcohol” for the remainder of this review) [ 3 , 4 , 5 , 6 , 7 , 8 , 9 ]. Recently, the World Health Organization acknowledged there is no level of safe alcohol consumption for our health [ 10 ]. Yet, an estimated 2.3 billion people worldwide consume alcohol [ 11 ], and of particular concern, alcohol consumption is seasonal, peaking during summer months [ 12 ]. During heatwaves, official heat-health guidelines from major international health authorities such as the Center for Disease Control [ 13 ], Red Cross [ 14 ], and World Health Organization [ 15 ], and national public health authorities such as Drinkaware UK [ 16 ] and the American National Weather Service [ 17 ], commonly suggest avoiding alcohol use, both for its potential effects on thermoregulation as well its effects as a diuretic. Despite these recommendations, a recent study of the daily habits of 285 participants, from three different countries, found that 15% of the surveyed adults reported alcohol consumption as a “thirst management solution” during heatwaves [ 18 ].

There are four main pathways through which alcohol consumption could put a person at risk for heat-related illness: 1) by impairing thermophysiological responses to the heat, 2) by compromising hydration status through its diuretic effect, 3) by impairing behavioral responses, and 4) by impairing decision making. Whether alcohol consumption conclusively affects physiological, perceptual, or behavioral responses to the heat, however, reamins equivocal. For example, all public health authorities recommend against the consumption of alcohol due to its effects on hydrations status [ 13 , 14 , 15 ], yet, studies investigating the effect of alcohol on hydration markers have shown hydration status remains unchanged following alcohol consumption, particularly when alcohol is used for rehydration after an athletic event [ 19 , 20 ]. Similarly, some health guidelines state that alcohol impairs the body’s ability to lose heat during a heatwave [ 13 ], however, laboratory studies have reported alcohol consumption increases skin vasodilation, which would help—not hinder—heat loss, as well as reduced core temperatures [ 21 ].

Further obfuscating how alcohol may place individuals at greater risk for heat illness is that many public health recommendations concerning alcohol consumption for humans during heat stress have been based on animal studies [ 22 , 23 ], demonstrating impaired behavioral [ 24 , 25 ] and physiological [ 24 , 26 ] responses to the heat. However, given the vast differences in anatomy, metabolism and thermoregulatory mechanisms between humans and animals, the clinical relevance of these findings are limited and caution should be taken when extrapolating these findings to inform human clinical guidelines [ 27 ]. Accordingly, the purpose of this systematic scoping review was to search the literature to assess the influence of alcohol consumption on thermal physiological, behavioral, hydrational, and cognitive responses to heat stress in humans.

Search strategy

To identify all available studies investigating the effects of alcohol on thermoregulatory responses, a literature search was performed. Following the creation and organization of the original search terms into a PICO table (Supplementary Table 1), we developed the search strings, using appropriate meSH terms, and translated the searches into the correct format for each database with support from a University of Colorado Colorado Springs Librarian. The systematic search was conducted in Scopus, Academic Search Premier, MEDLINE, CINAHL, and EMBASE and included articles published until October 4th, 2023. The search was conducted using a list of key search terms identified and agreed upon by the authors and organized into a Boolean search strategy (supplementary materials). The review protocol was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses’ guidelines for scoping reviews [ 28 ].

Eligibility criteria

Studies were considered eligible if they: 1) involved the oral consumption of ethanol, 2) employed a randomized or crossover-control study design with a control trial consisting of a volume-matched, non-alcoholic beverage, 3) were conducted in healthy adult humans, 4) reported thermophysiological (core temperature, skin temperature, sweating, and skin blood flow), perceptual (thermal comfort and thermal sensation), hydration status and behavioral outcomes (change in the use of a cooling device, cool seeking behavior, etc.), 5) published in English, 6) conducted in air or water at temperatures of > 28°C, 7) involved passive rest or exercise, and 8) published before October 4th, 2023. In situations where multiple interventions were used (e.g., two different alcohol concentrations), all relevant interventions were included in the data synthesis.

Study selection and data extraction

Titles and abstracts were screened in duplicate by two different screening teams, consisting of either NM or GC with support from an undergraduate assistant, in order to identify relevant papers using Rayyan title screening software [ 29 ]. Following the completion of title screenings, NM and GC compared title inclusion lists and resolved any discrepancies between lists. Data extraction was similarly performed in duplicate, and the following metrics were extracted using a standardized template: first author, year, country of origin, number of participants (male and female), study population, active or passive heat exposure, length of heat exposure, alcohol dose and delivery method, blood alcohol content, ambient temperature and humidity the study was conducted in, the stated aim of the study, the protocol employed by the study, reported outcome measures, main results, discussion points, notes of relevance, and any studies referenced investigating the effects of alcohol on thermoregulation that were not detected in the initial review. Whenever possible, if the stated alcohol dose and blood alcohol content were not in g/kg and g/dL, respectively, standardized dose were calculated based on the reported data. Data extracted from the included papers are presented in tables as means with standard deviation. Subsequently, the extracted data were presented graphically, or in text, as Cohen’s d, with 95% confidence intervals, using standard calculations [ 30 ].

Search overview

The screening process of the systemic search is detailed in Fig.  1 . Following the removal of duplicate findings between databases ( n  = 7253) and the addition of records identified through other sources ( n  = 3), 7,256 unique titles were screened. From this, 7,227 titles were further excluded. An additional 19 papers were removed as they were conducted below the cut-off threshold of > 28°C and two papers were removed as they did not use a control trial. This left 8 papers that were included in our analysis [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ].

Flow diagram of the review screening process

Study characteristics

A summary of the study designs for the eight studies included in the review are displayed in Table  1 . The year of publication ranged from 1979 to 2015, with only two papers published in the 2000’s. Two of the studies came from from France, while one paper came from Japan, Poland, Spain, Sweden, Canada and the USA, each. Collectively, there were 93 participants tested across the eight papers (an average of 12 participants per study, range: 6 to 27). The primary area of interest was the effect of alcohol on thermoregulatory responses in five papers, markers of hydration status in two of the papers, and cardiovascular responses in one paper.

Study Participants

All 93 of the participants were male (0% female). All eight studies were conducted in young healthy participants. The mean age of the study participants was 27 years, ranging from 21 to 41 years. Age was not reported in two studies, but in both studies the participants were described as “young and healthy males”.

Study design

A visual overview of the trial duration, alcohol dose, and heat stress type is depicted in Fig.  2 . Three of the papers used active heat stress (i.e. exercise), five papers used passive heat stress only. Of the five passive heat exposures, three were in air temperatures ranging from 30 to 43°C and two were conducted in 40°C water. The average heat stress exposure-time was 70 min, with the shortest duration being 21 min and the longest being 120 min. Between the eight different studies, there were nine different alcohol doses administered. However, in one of the studies [ 35 ], neither alcohol dose expressed as g/kg nor the participants’ weights were given, and as such, the dose could not be standardized. Of the eight conditions where the standardized dose could be attained, the average dose was 0.68 g/kg, ranging from 0.27 g/kg to 1.2 g/kg. Of the nine alcohol dose conditions, blood alcohol content was measured in four of them. The average blood alcohol content was 0.082 g/dl, with a range of 0.04 g/dl to 0.11 g/dl.

Experimental set up of eight alcohol-standardized studies. One study was not included in this figure because not enough information was provided to calculate a standard dose in g/kg. Studies by number: Allison 1992 (0.54 g/kg dose), 1; Allison 1992 (0.27 g/kg dose), 2; Desruelle 1996, 3; Gibiński 1979, 4; Jiménez-Pavón 2015, 5; Mekjavic 1987, 6; Saini 1995, 7; Yoda 2005, 8

Study outcomes

Thermophysiological markers.

Individual study data can be found in Table  2 and a visual summary of the thermophysiological effect sizes and 95% confidence intervals can be found in Fig.  3 . Core temperature was measured in four studies [ 31 , 32 , 36 , 38 ]. Of these studies, one reported no difference in core temperature [ 31 ] for either the 0.27g/kg or 0.54 g/kg dosing conditions, two reported a lower resting core temperature with alcohol consumption [ 32 , 38 ] and two reported a lower end exposure core temperature with alcohol [ 36 , 38 ], although end exposure core temperature neared statistical significance ( p  = 0.06; d = -0.23[95%CI:-0.60 to 0.14]; n  = 8) in a third study [ 32 ].

Effect sizes (Cohen’s d) with 95% confidence intervals for core temperature (panel A ), skin temperature (panel B ), sweat rate (panel C ), heart rate (panel D ), systolic blood pressure (panel E ) and diastolic blood pressure (panel F ) when consuming alcohol compared to a volume matched control beverage. Values above the dashed-line denote an increase, whereas below the line denotes a decrease, in the variable with alcohol consumption, relative to control. Closed circles denote physiological responses pre heat exposure, open squares are responses post heat exposure, grey diamonds are the peak response, black downward triangles are during supine positioning following heat exposure and open upward triangles are after a head-up tilt procedure following heat exposure

One study measured whole-body sweat rate, reporting no difference with alcohol consumption compared to a control fluid [ 33 ]. Four studies measured local sweat rate [ 31 , 32 , 33 , 38 ], two studies reported no difference [ 31 , 33 ], one study reported a non-significant increase with alcohol consumption (reported p value: > 0.05; calculated effect size: 0.15 [95%CI: -0.20 to 0.51]; n  = 8) [ 32 ], and one study reported significantly elevated local sweat rates with alcohol ingestion [ 38 ].

One study measured skin blood flow [ 38 ] that found a significant increase with alcohol ingestion. Four studies measured skin temperature [ 31 , 32 , 35 , 38 ] and none of them found any differences. Additionally, one study [ 36 ] inferred a reduction in total peripheral resistance (i.e. greater skin blood flow) with alcohol ingestion based on a lower diastolic blood pressure, with an elevated heart rate. In total, three studies measured heart rate [ 31 , 36 , 38 ], one showing no difference [ 31 ], one showing a significant elevation in heart rate [ 38 ] with alcohol consumption, and one reported a non-significant elevation in heart rate with alcohol consumption ( p  > 0.05; d = 0.20 [95%CI: -0.02 to 0.43]; n  = 6) [ 36 ]. Of the two studies measuring blood pressure [ 31 , 36 ], one found a reduction in mean arterial pressure with alcohol ingestion [ 36 ], while the other found no difference [ 31 ].

Thermal sensation and thermal comfort were only measured in two studies [ 31 , 38 ], with conflicting results. In the first study [ 31 ], both thermal sensation and thermal comfort were unaffected by alcohol and insufficient data were presented to calculate effect sizes. In the other study [ 38 ], thermal sensation was greater (participants felt hotter) with alcohol consumption (end exposure: d = 0.73 [95%CI: 0.04 to 1.42]; peak response: d = 0.46 [95%CI: -0.18 to 1.10]), however, they felt more comfortable in the heat following alcohol consumption compared to a control fluid (end exposure: d = 0.36 [95%CI: -0.27 to 0.99]; peak response: d = 1.17 [95%CI: 0.37 to 1.96]).

Hydration and biomarkers of fluid regulation

A detailed summary of the hydration marker and biomarker data can be found in Table  3 and a visual summary of the effect sizes with 95%CI can be found in Fig.  4 . Three studies examined whole-body mass loss [ 33 , 34 , 37 ] and one found greater mass losses with alcohol consumption [ 37 ]. Three studies investigated the effect of alcohol consumption on urine volume [ 33 , 34 , 37 ]. Of these studies one [ 37 ] found that urine output was higher with alcohol consumption, while the others found no differences. Two studies [ 33 , 34 ] measured urine osmolality and found no differences with alcohol consumption compared to a control fluid.

Effect sizes (Cohen’s d) with 95% confidence intervals for mass loss (panel A ), urine volume (panel B ), urine osmolality (panel C ), plasma volume (panel D ), vasopressin (panel E ), urione sodium (panel E ), and urine potassium (panel G ) when consuming alcohol compared to a volume matched control beverage. Values above the dashed-line denote an increase, whereas below the line denotes a decrease, in the variable with alcohol consumption, relative to control. Closed circles denote physiological responses pre heat exposure and open squares denote responses post heat exposure

Two studies measured plasma volume [ 34 , 37 ], with both studies finding no difference with alcohol consumption. Two studies looked at circulating antidiuretic hormone/vasopressin [ 33 , 37 ]. One study found lower vasopressin levels with alcohol consumption [ 37 ], while the other found no differences. Two studies examined the effect of alcohol on plasma sodium and potassium concentrations [ 34 , 37 ], with no differences in either plasma sodium or potassium levels with alcohol consumption. One study [ 37 ] examined the effect of alcohol consumption on plasma osmolality (pre exposure: d = 1.55 [95%CI: 0.97 to 2.13]; end exposure: d = 2.36 [95%CI: 1.60 to 3.13]), finding a very large increase with alcohol consumption. Additionally, this study [ 37 ] examined natriuretic peptide (pre exposure: d = -0.13 [95%CI: -0.52 to 0.27]; end exposure: d = -0.24 [95%CI: -0.64 to 0.15]) and aldosterone (pre exposure: d = -0.45 [95%CI: -0.86 to -0.04]; end exposure: d = -0.09 [95%CI: -0.48 to 0.31]), finding no differences in either. Finally, one study [ 34 ] examined the effect of alcohol on hematocrit (pre exposure: d = -0.09 [95%CI: -0.33 to 0.15]; end exposure: d = -0.42 [95%CI: -0.42 to 0.05]), and found no effect of alcohol consumption.

This review sought to to determine what evidence currently exists demonstrating the impact of alcohol consumption on human physiological and perceptual responses to heat exposure. The most consistent finding was a lowered core temperature with alcohol consumption (observed in 3/4 studies). Skin blood flow was higher with alcohol consumption in the one study that measured it, and local sweat rate was higher with alcohol consumption in one of the four studies that measured it. Moreover, traditional hydration markers were generally unaltered with alcohol consumption compared to a control beverage, with the exception of increased urine volume and reduced antidiruretic hormone and body mass in one study. Collectively, these limited findings suggest that acute alcohol consumption generally does not impair physiological responses during heat stress.

The effect of alcohol on physiological responses

Findings from this review demonstrate that alcohol consumption increased skin blood flow in the one study that measured it and reduced core temperature in three of the four studies where it was measured. These findings are consistent with research dateing back to 1861 that demonstrated the vasodilatory effect of alcohol consumption [ 39 , 40 ]. This peripheral vasodilation following alcohol consumption likely leads to a redistribution of warm blood from the viscera to the extremities, thereby leading to a lower resting core temperature.

In addition to lowering core temperature by redistributing blood to the skin, this process can alter thermal perception and influence thermal sensation and behavior [ 41 ]. Only two studies in this review examined alcohol's effects on thermal comfort: one found no difference, while the other reported improved comfort, despite increased feelings of warmth [ 38 ]. No studies explored the effects of alcohol consumption on thermoregulatory behavior. The increased risk of hospitalization during heatwaves with alcohol consumption could be due to reduced thermal discomfort, potentially leading to inadequate cooling behaviors. More research is needed, especially on heat-vulnerable populations like the elderly, who already have reduced thermal perception [ 42 ]. Additionally, while alcohol is known to affect cognition [ 42 , 43 , 44 , 45 ], its interaction with heat stress remains unexplored.

This review found limited evidence to support the notion that alcohol ostensibly leads to dehydration and should be avoided during heatwaves [ 13 , 14 , 15 , 16 , 17 ], with only the study using the highest alcohol dose (1.2 g/kg) demonstrating increased markers for dehydration (e.g. greater urine output and mass loss, and lower plasma vasopressin, with alcohol consumption) [ 37 ]. These findings are consistent with other studies examining the effect of low doses of alcohol consumption on hydration markers in thermoneutral conditions, where low doses of alcohol did not affect hydration status [ 19 , 20 ], but higher doses delayed rehydration post exercise [ 19 ]. Further, an increase in urine volume of 100 ml per 10 g of ethanol ingested, independently of the fluid volume consumed, has been previously reported [ 46 ]. Moreover, the average heat stress exposure-time of the analyzed studies was 93 min, the shortest being 21 min and the longest being 310 min (5.2 h). In contrast to these short study durations, increases in morbidity and mortality during a heatwave typically increase following the third day of elevated tempratures [ 47 ]. Therefore, whether the dehydrating effects of alcohol, especially at higher doses, begin to compond over multiple days, crtitically needs to be investigated.

Limitations of the reviewed articles

The largest omission observed in this review was the complete lack of female participants in any of the included studies. This absence of female representation is particularly concerning considering the known discrepancy between how alcohol affects women compared to men [ 48 ]. Similarly, there was a lack of ethnic diversity among study populations. Seven studies included in this review were from primarily Caucasian countries whereas only one [ 38 ] was conducted in a non-Caucasian country (Japan). This lack of multi ethnic group representation is important due to the well-known differences in alcohol metabolism between Asians (particularly Japanese, Chinese, and Koreans) and Caucasians [ 49 , 50 , 51 ]. Specifically, these Asian populations have a genotypical lack of aldehyde dehydrogenase, the enzyme responsible for metabolizing acetaldehyde, thereby causing the skin flush reaction [ 52 ]. This may be an important consideration given the one study on Japanese participants observed the strongest physiological responses to alcohol, such as a prolonged reduction in core temperature, increases in skin blood flow, sweating, and heart rate, and greater feelings of comfort, despite feeling warmer [ 38 ].

In general, the sample size of the studies was low with an average of 12 participants per study (range: 6—27 participants per study). In several of these studies, the authors reported consistent but not statistically significant differences in physiological responses with alcohol consumption compared to a control fluid. As such, the lack of differences observed in some of these studies may be due to an inadequate sample size. Further, the average age of the participants studied was 25 years (range: 21—41 years). As lab-based physiological studies have established that thermoregulatory function can decrease past the age of 40 years [ 53 ], and that age-related increases in morbidity and mortality during heatwaves typically occurs in those above the age of 65 years [ 54 ], future studies should examine alcohol consumption in older populations, to determine whether the effects of alcohol on physiological responses is age-dependent.

As mentioned above, the dose and peak blood alcohol content used and observed in the analyzed studies was relatively low compared to recreational alcohol doses. Specifically, the average blood alcohol content from the analyzed studies was 0.082 g/dl, with a range of 0.04 g/dl to 0.11 g/dl. This is equivalent to just over the legal driving limit of 0.08 g/dl in most American states [ 55 ], Canada, Singapore, and most African countries [ 56 ]. Conversely, alcohol levels in epidemiological and case studies demonstrating an association between temperature and increased morbidity and mortality, typically report objectively higher BAC values than this, such as 0.2 g/dl [ 3 ] and 0.22 g/dl [ 9 ], or non-numerical categorizations, suggesting higher levels of alcohol consumption, such as “alcohol misuse” [ 4 ], “alcohol misuse disorder” [ 6 ], “alcoholic dementia” [ 3 ], and “alcohol abuse disorder” [ 5 ]. Future studies should consider higher doses of alcohol to better understand the effects of alcohol consumed at higher concentrations. These low doses may also explain why, in this review, few markers of hydration status were affected by alcohol consumption, as previous studies have found that the diuretic effect of alcohol typically occurs at higher levels of alcohol consumption [ 37 , 57 ].

All studies focused on the effects of acute alcohol consumption on physiological and perceptual responses in healthy young individuals, without considering long-term alcohol use and abuse. Approximately 10% of Americans qualify as having alcohol use disorder [ 58 ], as well as 1.4% of the global population [ 59 ], which is well known to cause damage to the body’s vasculature [ 60 ], chronically increase blood pressure [ 60 , 61 , 62 , 63 ], and inhibit the endothelia from producing nitric oxide, thereby greatly impeding peripheral vasodilation [ 64 , 65 ]. As such, heat exposure in this population would likely result in a diminished thermoregulatory vasodilation response, putting this group at greater risk for heat stress and heat related illness. As such, future research of how chronic alcohol users/abusers respond to heat stress are needed.

A final consideration for future studies on the effect of alcohol consumption on thermoregulation is how alcohol may interact with other diseases and medications. In one study comparing occlusive artery disease patients to young healthy controls, alcohol consumption increased cutaneous vasodilation in the young-healthy but not the occlusive artery patients [ 66 ]. Accordingly, alcohol consumption could be particularly dangerous for any health condition in which the peripheral vasculature is impaired. Similarly, for those taking anti-hypertensive medications, such as alpha-blockers, alcohol can interact with the anti-hypertensives to cause hypotension [ 67 ]. Combined with the lowering of blood pressure caused by heat exposure [ 68 ], this could greatly the increase the risk of dizziness, loss of consciousness, and falls during heatwaves [ 69 ].

Conclusions

Findings from the limited studies included in this review demonstrate that acute alcohol consumption does not negatively influence thermoregulation or hydration and hormone markers of fluid balance in the heat, compared to a control fluid. Despite these findings epidemiological research still demonstrates a well-established association between alcohol consumption and a greater morbidity and mortality risk during heatwaves. Therefore, research in this area will be crucial to understand the impact of alcohol on overall health outcomes during heat exposure, including potential interactions with pre-existing conditions, long-term alcohol use, and the effects on behavior and cognition.

Declerations

All authors and those named in the acknowledgements consented to the publication of this manuscript. All review data are published within the manuscript and supplementary file. None of the authors have any competing interests to disclose. Georgia Chaseling was supported by the SOLVE-CHD Australian Government National Health and Medical Research Council (NHMRC) Synergy Grant (Grant no:1182301). NBM and GKC designed the review and conducted the title screening and data extraction. NBM, GKC, and NR contributed to the writing and editing of the manuscript, as well as the production of the figures. The authors would like to thank Susan Vandagriff for her help preparing the search strings for the review, as well as Anna Carrier and Taigan Lowman for their help screening titles.

Availability of data and materials

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors would like to thank Susan Vandagriff for her help preparing the search strings for the review, as well as Anna Carrier and Taigan Lowman for their help screening titles.

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Morris, N.B., Ravanelli, N. & Chaseling, G.K. The effect of alcohol consumption on human physiological and perceptual responses to heat stress: a systematic scoping review. Environ Health 23 , 73 (2024). https://doi.org/10.1186/s12940-024-01113-y

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Substance Abuse A Literature Review of the Implications and Solutions

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Substance or Drug abuse is a serious public health problem affecting usually adolescents and young adults. It affects both males and females and it is the major source of crimes in youth and health related problems in many communities. It harms unborn babies and destroys fami lies. As indicated by the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition, DSM DSM-5 “ The essent ial feature of substance use disorder is a cluster of cognitive, behavioral and physiological symptoms indicating the individual continues to use the substance despite significant substance related problems”. SubstanceSubstances that are abused are many and include alcohol, tobacco/nicotine, caffeine, cannabis, inhalants, opioids , sedatives, anti anti-anxiety and hypnotics, psychostimulants like cocaine, amphetamine, methamphethamine and hallucinogens.

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A review of recent literature on the impact of parental substance use disorders on children and the provision of effective services

Affiliation.

• 1 New York University Silver School of Social Work, New York, New York, USA.
• PMID: 29794556
• DOI: 10.1097/YCO.0000000000000421

Purpose of review: To provide an update of recent studies of the incidence and impact of parental substance use disorders (SUDs) on children, and to identify effective treatment programs to assist parents with SUDs and their children.

Recent findings: Children of parents with alcohol and drug use disorders (COPADs) suffer from physical, mental and behavioral problems at higher rates than other children and are more likely to develop their own SUDs in adolescence. Parenting styles and familial dysfunction contribute to the intergenerational transmission of SUDs. Studies of the negative effects of parental SUDs on children identified the effects of inconsistent, disengaged or harsh parenting practices on mother-child bonding. Exposure to violence and father's hostility contribute to children's externalizing and internalizing behaviors. Family- based intervention programs, as well as programs for mothers with SUDs and their young children, have shown positive results. For high-risk families with multiple needs, the ongoing support of multidisciplinary services is required.

Summary: Parental SUDs have a profound impact on their children, including intergenerational transmission of SUDs. A variety of interventive programs are being studied in order to devise effective programs to assist these children.

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• Mental disorders and harmful substance use in children of substance abusing parents: A longitudinal register-based study on a complete birth cohort born in 1991. Jääskeläinen M, Holmila M, Notkola IL, Raitasalo K. Jääskeläinen M, et al. Drug Alcohol Rev. 2016 Nov;35(6):728-740. doi: 10.1111/dar.12417. Epub 2016 Jun 1. Drug Alcohol Rev. 2016. PMID: 27246821
• Pathways From Parental Substance Use to Child Internalizing and Externalizing Behaviors in a Child Protective Services Sample. Seay KD. Seay KD. Child Maltreat. 2020 Nov;25(4):446-456. doi: 10.1177/1077559520913638. Epub 2020 Apr 1. Child Maltreat. 2020. PMID: 32233800
• Risk for behavior problems in children of parents with substance use disorders. Bountress K, Chassin L. Bountress K, et al. Am J Orthopsychiatry. 2015 May;85(3):275-86. doi: 10.1037/ort0000063. Am J Orthopsychiatry. 2015. PMID: 25985113 Free PMC article.
• A literature review: addressing indigenous parental substance use and child welfare in Aotearoa: a Whānau Ora framework. McLachlan A, Levy M, McClintock K, Tauroa R. McLachlan A, et al. J Ethn Subst Abuse. 2015;14(1):96-109. doi: 10.1080/15332640.2014.947460. Epub 2014 Dec 23. J Ethn Subst Abuse. 2015. PMID: 25536360 Review.
• Children of substance abusers: overview of research findings. Johnson JL, Leff M. Johnson JL, et al. Pediatrics. 1999 May;103(5 Pt 2):1085-99. Pediatrics. 1999. PMID: 10224196 Review.
• Effectiveness of a Web-Based Individual Coping and Alcohol Intervention Program for Children of Parents With Alcohol Use Problems: Randomized Controlled Trial. Wall H, Hansson H, Zetterlind U, Kvillemo P, Elgán TH. Wall H, et al. J Med Internet Res. 2024 Apr 10;26:e52118. doi: 10.2196/52118. J Med Internet Res. 2024. PMID: 38598286 Free PMC article. Clinical Trial.
• Strategies to Help CWS-Involved Parents Complete Substance Use Treatment and Protect their Children in Hawai'i. Calistro YT, Worthington K. Calistro YT, et al. Hawaii J Health Soc Welf. 2022 Dec;81(12 Suppl 3):37-42. Hawaii J Health Soc Welf. 2022. PMID: 36660281 Free PMC article.
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Substance Use Prevention Programs

Youth substance use prevention programs aim to promote abstinence from alcohol and illicit drugs and the misuse of over-the-counter drugs. They differ from treatment programs, which focus on youths who have been clinically diagnosed with a substance abuse problem. A variety of approaches have been developed that work with families, schools, and communities to help children and adolescents develop skills and approaches to prevent or reduce substance use (Griffin and Botvin, 2010; Hennessy and Tanner–Smith, 2015; Smedslund et al., 2017).

Early substance use initiation and continued heavy use can lead to numerous negative consequences (Hanson et al., 2011; Marshall, 2014; Newcomb and Bentler, 1988). Risky behaviors related to substance use include truancy or dropping out of school, unsafe sexual activity, driving while impaired, and interpersonal violence (Cherpitel, Bond, and Borges, 2003; Foran and O’Leary, 2008; DuPont et al., 2013). Additionally, harmful use of alcohol is a leading risk factor for death and disability for people ages 15 to 49 (WHO, 2014).

Rates of self-reported drug and alcohol use differ by type of substance. For example, 15.6 percent of 8th, 10th, and 12th graders surveyed for the Monitoring the Future study in 2020 reported past-year use of illicit drugs, 25.6 percent reported past-year use of alcohol, 19.1 percent reported past-year vaping, and 11.4 percent reported past-year marijuana use (Johnston et al., 2021). However, illicit drug and alcohol use has generally been on the decline since the 1980s.

This literature review focuses on initiation of substance use among children and youth. The review describes the scope of substance use among youth, risk factors that can lead to substance use, protective factors that can buffer against initiation, various types of prevention programs and outcome evidence, and limitations to the research currently available. 

Scope of the Problem

Several surveys provide information on adolescents' self-reported use of alcohol and illicit [ 1 ] and licit [ 2 ] drugs in the United States.

Illicit and Licit Drug Use

The National Survey on Drug Use and Health ( NSDUH ), administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), collects national- and state-level data annually from all 50 states and the District of Columbia. In 2020, more than 36,000 people ages 12 and older were surveyed, including 6,337 interviews conducted with youths ages 12 to 17. Among these youths, 13.8 percent reported use of any illicit drug in the past year (SAMHSA, 2021). The NSDUH also reports use of licit substances, such as tobacco products and cigarettes. The survey found that 8.2 percent of youths ages 12 to 17 drank alcohol in the past month and 1.4 percent smoked cigarettes in the past month (SAMHSA, 2021). In general, tobacco use has declined since its peak in the mid-1990s (SAMHSA, 2020; SAMHSA, 2021).

Another survey, Monitoring the Future ( MTF ), is administered annually to 8th, 10th, and 12th graders and asks questions about attitudes and behaviors related to drug use. Owing to the COVID–19 pandemic, data collection for the 2020 survey ended earlier than usual, resulting in a smaller-than-usual sample size (Johnston et al., 2021). The 2020 MTF surveyed approximately 11,821 students enrolled in 112 secondary schools, compared with the 2019 MTF, which surveyed 42,531 students from 396 secondary schools. Data from the study indicated that, in general, substance use has remained at or close to the historically low levels reported by adolescents in the past several years. Specifically, the results from the 2020 MTF showed the following trends in drug use: 

• Across all three grades, 30-day prevalence of cigarette use has fallen 85.0 percent since its peak in the mid-1990s. This decline slowed in 2020 among 8th and 10th graders; however, 12th graders showed a small increase in 30-day prevalence (although the increase was not statistically significant). Additionally, lifetime prevalence (or having used cigarettes on at least one occasion during one’s lifetime) increased for 8th and 12th graders by small, nonstatistically significant amounts in 2020. For eighth graders, lifetime prevalence increased for the second year in a row, from 10.0 percent to 11.5 percent. For 12th graders, lifetime prevalence increased for the first time since 1996, increasing by 1.7 percentage points to 24.0 percent in 2020.
• The rate of past-year use of illicit drugs (other than marijuana) has declined steadily in the past 5 years for 10th and 12th graders. Past-year use of illicit drugs other than marijuana has also decreased in previous years for eighth graders; however, a small nonstatistically significant increase was reported among the 2020 cohort.
• The past-year use of narcotics other than heroin (such as prescription opioids) is at 2.1 percent among 12th graders—decreasing by a small but nonstatistically significant 0.6 percentage points between 2019 and 2020.
• Annual prevalence for marijuana use has remained fairly steady for several years. In 2020, past-year use was reported to be 11.0 percent, 28.0 percent, and 35.0 percent in grades 8, 10, and 12, respectively. However, among students who use marijuana, daily consumption is on the rise. In 2019, daily marijuana prevalence increased statistically significantly among 8th and 10th graders, with a further increase in 2020 only among 12th graders. In 2020, all three grades were found to have daily marijuana levels that are at or near the highest level recorded since 1991.
• In 2020, adolescent vaping decreased across all grades. This follows the large, statistically significant increases in vaping between 2017 and 2019, when 30-day prevalence of vaping either marijuana or nicotine doubled or tripled in all grades. For example, among 12th graders, vaping marijuana rose from 4.9 percent in 2017 to 14.0 percent in 2019, and vaping nicotine rose from 11.0 percent to 25.5 percent across the same timeframe. However, in 2020, past-30-day prevalence for vaping nicotine and marijuana decreased by small, nonstatistically significant amounts among 10th and 12th graders. For eighth graders, the 30-day prevalence of any vaping and vaping nicotine held steady, whereas vaping marijuana increased by a small, nonstatistically significant amount. [Johnson et al., 2021] 

A third survey, the Youth Risk Behavior Surveillance System ( YRBSS ), covers various risk behaviors, including substance use. The survey is administered every 2 years to students in grades 9 to 12 and is representative of public and private school students from all 50 states and the District of Columbia. The 2019 YRBSS was completed by 13,872 students in 136 schools (Creamer et al., 2020). According to the most recent data available from 2019: 

• Six percent of students had smoked cigarettes or cigars or used smokeless tobacco on at least 1 day during the 30 days before the survey (Creamer et al., 2020). 
• About 37.0 percent of students had used marijuana at least once in their lifetime, with 21.7 percent reporting use within the last 30 days before the survey. There was nonstatistically significant change in reported marijuana use between 2017 and 2019 (Jones et al., 2020).
• About 50.0 percent of students had ever used an electronic vaping device, with 32.7 percent of students reporting they were current users of electronic vapor products (current use was defined as having vaped on at least 1 day in the past 30). This represents a statistically significant increase in electronic vaping from 2017, when 13.2 percent of students reported past-30-day electronic vapor use (Creamer et al., 2020).
• The YRBSS did not report any statistically significant changes in illicit drug use between the 2017 and 2019 surveys. About 1.8 percent of students reported use of heroin one or more times in their lifetime, and 1.6 percent of students had used a needle to inject any illegal drug into their body one or more times in their lifetime (Jones et al., 2020).

Alcohol Use

According the 2020 NSDUH, 8.2 percent of youths reported using alcohol in the past month. The NSDUH also reported on rates of binge alcohol use and heavy alcohol use. [ 3 ] Among the surveyed youths, 4.1 percent reported binge alcohol use, and 0.6 percent reported heavy alcohol use in the past month (SAMHSA, 2021).

According to the 2020 MTF, 38.3 percent of students reported consuming any alcohol in the previous 12 months (for all three grades combined). This is a statistically significant increase from 2019, when 35.9 percent of students reported having consumed alcohol in the past year. Similarly, there were statistically significant increases in lifetime, past-30-day, and daily alcohol consumption across all three grades. Further, binge drinking (defined on the MTF as having five or more drinks in a row in the past 2 weeks), which had been declining until 2018, saw a slight uptick across all three grades in both 2019 and 2020 (Johnston et al., 2021).

Finally, the 2019 YRBSS did not report on lifetime alcohol use. However, 2017 findings indicated that 60.4 percent of students had consumed alcohol at least once in their lifetime. In 2019, the YRBSS examined current alcohol use and binge-drinking behaviors. About 29.0 percent of students reported current alcohol use, defined as having had at least one drink of alcohol on at least 1 day during the past 30 before the survey. The prevalence of current alcohol use was fairly steady from 2017 (29.8 percent) to 2019 (29.2 percent). Additionally, nearly 14.0 percent of students reported binge drinking on at least 1 of the past 30 days. Among students reporting current alcohol use or current binge drinking, more than half (54.8 percent and 61.2 percent, respectively) reported that they engaged in these behaviors 1 to 2 days during the past month (Jones et al., 2020).

Overall Key Findings

Overall, results from the surveys showed that illicit drug use (other than marijuana) remains at the lowest point in 20 years, with a statistically significant reduction in opioid use between 2016 and 2017. Alcohol and marijuana remain the most commonly used substances among youth, and adolescent alcohol use may be on the rise. Two out of five 8th, 10th, and 12th graders reported use of alcohol in the past 12 months, whereas marijuana use trends have remained steady for 5 years, with annual prevalence estimates ranging from 13.2 to 24.6 percent (Johnson et al., 2021; NSDUH, 2020). Finally, while vaping among youths had increased dramatically between 2017 and 2019, recent survey results indicate that youths may be beginning to slow their use of electronic vapor products (Johnston et al., 2021). 

Substance Use by Race/Ethnicity

According to data from the 2019 MTF, [ 4 ] for several years white students had substantially higher rates of using any illicit drug than did Black students. However, in recent years, the differences have narrowed owing to increasing marijuana use among Black students and “some decline” among white students. The MTF also found that the rate of Hispanic student substance use generally falls between that of white students and Black students, though these rates can vary by specific substances and grades (Johnston, 2020). 

According to a detailed report on the complex subgroup differences and how they have changed over the years, across grades, Black students have the lowest levels of use for several licit and illicit drugs, including hallucinogens, synthetic marijuana, and all forms of prescription drugs used without a doctor’s orders. However, in recent years, heroin use among Black students in the 12th grade has been higher than among white students. Additionally, the 2018 annual prevalence of marijuana use was higher among 8th grade Black students, compared with white students, but no different for Black and white students in 10th and 12th grades ( Johnston et al., 2019) .

With regard to alcohol use, the MTF data showed that Black students had the lowest 30-day prevalence for alcohol use, heavy drinking, and self-reports of having been drunk during the prior month. Differences were largest among 12th grade students, with 24.0 percent of white youths reporting having been drunk, compared with 17.0 percent of Hispanic youths and 10.0 percent of Black youths (Johnston et al., 2019). Black students also had lower prevalence of past-month use of an electronic vapor product (19.7 percent), compared with white (38.3 percent) and Hispanic (31.2 percent) students, according to the YRBSS (Creamer et al., 2020). 

Overall, the results suggest that white students have the highest rate of alcohol use, whereas Black students have the lowest use rates for alcohol and nearly all other substances, except for heroin use among 12th graders and marijuana use among 8th graders. Rates of substance use among Hispanic students generally mirror the rates of white students; however, Hispanic youths have recently surpassed white youths in their rates of using illicit drugs such as synthetic marijuana and cocaine.

Substance Use by Gender and Sexual Orientation

Data from the 2018 MTF show that m ales tend to have higher rates of illicit drug use than females; however, gender differences have weakened over time. Specifically, the most recent data have shown few gender differences in marijuana use. In fact, there were no statistically significant gender differences among 12th graders, and 8th and 10th girls had slightly higher rates of marijuana use, compared with boys of the same age, however these differences were also not statistically significant (Johnston et al., 2020). 

Gender differences in regard to alcohol use have also decreased over time. In previous reports, males consistently reported higher 30-day and daily alcohol use rates than females. Yet in more-recent reports, there have been almost no gender differences in alcohol use among 8th and 10th graders. This finding has been consistent for 10th graders since 2002. Additionally, in the past few years, female students have reported higher 30-day prevalence of alcohol use (Johnston et al., 2020). 

Differences in rates of substance use across gender tend to emerge as students grow older. For example, in eighth grade, female students tend to report higher rates of use for some drugs, such as amphetamines. However, this difference disappears with age, with 9.6 percent of male students reporting lifetime prevalence of amphetamine use, compared with 7.3 percent of female students. Overall, substance use prevalence rates for males and females increase with age, but the increase is often more dramatic among males (Johnston et al., 2020). 

In addition, national surveys and other research have shown that gender minority youths (e.g., transgender, nonbinary) and sexual minority youths (e.g., gay, lesbian, bisexual, queer, or youth with same-sex attractions or behaviors) are at greater risk for substance misuse than cisgender or heterosexual youths (Mereish, 2019). For example, compared with heterosexual students or those who only had sexual contact with people of the opposite sex, the YRBSS found that sexual minority students were more likely to inject illegal drugs, misuse prescription opioids, and use select illicit drugs such as cocaine, heroin, methamphetamines, inhalants, hallucinogens, or ecstasy (CDC, 2020). And despite a general decrease in drug and alcohol use from 2005 to 2017, these declines were less evident for sexual minority youth, and in some cases, the disparities between sexual minority youth and heterosexual youth increased (Felt et al., 2020; Fish and Baams, 2018).

[1] Illicit drugs include marijuana (in 40 states), opioids (e.g., heroin), certain stimulants (e.g., methamphetamine, cocaine), hallucinogens (e.g., LSD), and dissociative drugs (e.g., PCP) [NIDA, 2012].

[2] Licit drugs include alcohol, nicotine (e.g., cigarettes), marijuana (in Alaska, California, Colorado, Maine, Massachusetts, Michigan, Nevada, Oregon, Washington, and the District of Columbia), certain stimulants (e.g., coffee), medicines used for illnesses, over-the-counter drugs used as directed, and prescription medicines used by the person to whom the drugs were prescribed (NIDA, 2012).

[3] On the NSDUH, binge alcohol use is defined as drinking five or more drinks (for males) or four or more drinks (for females) on the same occasion (at the same time or within a couple hours of each other) on at least 1 day in the past 30 days; and heavy alcohol use is defined as binge drinking on the same occasion on each of 5 or more days in the past 30.

[4] Owing to the small sample size, the 2020 MTF did not conduct analyses on subgroup differences. The most recent data collected on race and ethnicity come from the 2018 MTF report ( Johnston et al., 2021) .

Theoretical Background

The reasons for the use of alcohol and other drugs by youth are grounded in numerous behavioral theories. These theories inform prevention programming by focusing on the possible factors that may lead to youth substance use. Two prevalent theories are social learning theory and social control theory.

The social learning theory offers a theoretical perspective on why youths engage (or don’t engage) in substance use. Social learning theory posits that people learn behaviors through observation of others and then model or imitate that behavior. People are more likely to imitate behavior if their observations are associated with positive experiences or rewards (Bandura, 1971). In this case, social learning can serve as either a risk or protective factor for substance use, depending on the context in which learning occurs. For example, youths can learn to avoid using alcohol and other drugs by emulating the prosocial behavior displayed by positive adult figures in their lives. Conversely, youths can be pressured into experimenting with substances by following the behavior shown by antisocial peers (Cleveland et al., 2010; Glasgow Erickson, Crosnoe, and Dornbusch, 2000).

The social development model , a part of the social learning theory, presupposes that children and adolescents learn behavior from the following four socializing units: 1) family, 2) school, 3) peers, and 4) community or religious institutions (Cleveland et al., 2012; Haggerty et al., 2007; Cleveland et al., 2010). This model includes both a social perspective and a developmental perspective . The social perspective looks at positive reinforcement; that is, youths who receive positive reinforcement from prosocial activities engage in prosocial activities (Cleveland et al., 2012), whereas youths who receive positive reinforcement from antisocial activities will engage in antisocial activities (Glasgow Erickson, Crosnoe, and Dornbusch, 2000). The developmental perspective focuses on the transitional periods from toddler to child to adolescent. These periods are shaped by changes experienced in one's social environment that influence behavioral changes over time. For example, behavioral changes often occur during the transition from middle to high school, a stressful period for many youths, as they try to fit in with other peer groups. 

Another theory, the social control theory , suggests that when an adolescent’s “conventional ties” are broken, the adolescent is more likely to commit delinquent acts (Vaughn et al., 2009; Church, Wharton, and Taylor, 2009; Glasgow Erickson, Crosnoe, and Dornbusch, 2000). Conventional ties include the bonds to 1) institutions (family or school), 2) beliefs (laws and normative standards), and 3) people (teachers, parents, peers). Family-based risk factors, such as parental substance use, contribute to the weakening of an adolescent’s social bonds (Glasgow Erickson, Crosnoe, and Dornbusch, 2000), and weak social bonds can influence the occurrence of future delinquency, including substance use. Thus, some prevention programs incorporate interactive components that involve both youths and their parents, to improve the family bond (Waldron and Turner, 2008; Liddle et al., 2009).

Risk Factors for Substance Use

Risk factors [ 5 ] consist of personal traits, characteristics of the environment, and conditions in the family, school, and community that are linked to a youth’s likelihood of engaging in delinquency and other problem behaviors such as substance use (Murray and Farrington, 2010). Numerous risk factors contribute to substance use among youth. These risk factors exist at the individual , family , peer group , school , and community domain levels. Much of the research concludes that risk and protective factors interact at multiple ecological levels to influence early substance use initiation (Bacio et al., 2015). Most of the research cited below concentrates on risk factors related to general alcohol and other drug use.

While some longitudinal studies have demonstrated how risk factors predict youths’ initiation of substance use, it is more often the case that research has been able to establish correlation, without definitive findings on causation. Some studies have concluded that many of the relationships between risk factors and substance use may be multidirectional (Winters et al., 2014; Hallfors et al., 2005; Skogen et al., 2014). Another aspect of research on risk factors that complicates findings is that relationships can be direct or indirect, factors can mediate or moderate other factors, factors can interact with one another, and substance use can be influenced by reciprocal multilayered systems (e.g., Bacio et al., 2015; Cooley–Strickland et al., 2009; Pardini, Lochman, and Wells, 2004; Sale et al., 2003; Voce and Anderson, 2020; Yoon, Snyder, and Yoon, 2020; Zapolski et al., 2019).

Individual risk factors vary among youths but stem from many origins such as genetics, early moral development, personality traits, temperament, and negative life events (Wong, Slotboom, and Bijleveld, 2010; Dick et al., 2013; Hodgins, Kratzer, and McNeil, 2001). Individual-level risk factors that may lead to substance use include antisocial behavior, delinquent beliefs, early onset of aggressive behavior, cognitive and neurological disorders, mental health disorders, prodrug attitudes, and violent victimization or exposure to violence (Fite, Schwartz, and Hendrickson, 2012; Swadi, 1999; Compton et al., 2005; O’Neill et al., 2011; Zapolski et al., 2019).

Antisocial behavior and aggression, commonly associated with delinquent behavior during adolescence, are considered major risk factors for initiation of substance use (Dryfoos, 1991; Hawkins, Catalano, and Miller, 1992; Compton et al., 2005). Numerous studies have found a significant relationship between antisocial behavior (such as lying, defiance, or becoming withdrawn) and substance use among youth (Adalbjarnardottir and Rafnsson, 2002; Armstrong and Costello, 2002; Hussong et al., 2004). Studies have found that aggression and conduct disorder during childhood may precede substance use (Harachi et al., 2006; Pardini, White, and Stouthamer– Loeber, 2007; Prinstein and La Greca, 2004). However, while the prevalence of both substance use and antisocial behavior increases during adolescence, aggression declines (Tremblay, 2010). Therefore, while the relationship between antisocial behavior and substance use has been established in research, the findings with regard to aggression and substance use are mixed.

Cognitive and neurological disorders associated with adolescent substance use most commonly include attention deficit hyperactivity disorder (ADHD), conduct disorder, and mood disorders (Swadi, 1999). For example, youths with ADHD are significantly more likely to misuse alcohol, tobacco, and illicit substances, compared with youths who do not have ADHD (Lee et al., 2011; Molina et al., 2007). ADHD is also associated with earlier initiation of substance use and an increased likelihood of using a variety of substances (Horner and Scheibe, 1997; Wilens et al., 2011). Research has shown that youths with ADHD tend to be impulsive and lack decisionmaking skills, leaving them more susceptible to initiation of substance use. Additionally, ADHD is associated with low levels of dopamine, which can be increased through use of several drugs, including cocaine, amphetamines, ecstasy, marijuana, and alcohol. Thus, youths who have ADHD may use substances for sensation-seeking or self-medicating purposes (Wilens et al., 2007).

Youths also may use substances to deal with unaddressed trauma or mental health problems (Garland, Pettus–Davis, and Howard, 2013; Mandavia et al., 2016). For example, adolescents who experience internalizing disorders, such as depression or anxiety, are at a higher risk for early initiation of alcohol or drug use and are more likely to develop substance use disorders (O’Neil, Conner, and Kendall, 2011; Marmorstein, 2009). However, early initiation of substance use also has been found to predict later development of mental health disorders, suggesting that, while a relationship exists between the two, causation cannot always be established or the relationship may be multidirectional (Winters et al., 2014; Hallfors et al., 2005; Skogen et al., 2014).

Finally, certain personality traits may predict initiation of substance use by youth, including fatalism and external locus of control (Bearinger and Blum, 1997; Lassi et al., 2019). For instance, a study of Hispanic youth in Los Angeles found that fatalism, a personality factor that comprises the belief that one’s destiny is out of their control, was associated with a higher risk of lifetime marijuana use and cigarette use (Soto et al., 2011).

Factors at the family level are related to family structure, support, and functioning. Family risk factors related to substance use include lack of parental supervision, poor family attachment, family history of problem behaviors or criminality, parental substance use, marital status of parents, level of parental education and socioeconomic status, child perception that parents approve of their substance use, and child victimization and maltreatment (Development Services Group, 2015; Whitesell et al., 2013; Wong, Slotboom, and Bijleveld, 2010).

Family structure—specifically living in a one-parent household—may be associated with an increased likelihood of substance use initiation (Ewing et al., 2015; Barrett and Turner, 2006). One study found that living in a single-parent household was significantly associated with having been intoxicated at least once in a lifetime and having used cannabis at least once in a lifetime (Bränström, Sjöström, and Andréasson, 2008). Another study, using data from the MTF survey, found that children in mother-only families used more marijuana or amphetamines than children from dual-parent families (Hemovich and Crano, 2009). This study also found that drug use among daughters living with single fathers was greater than drug use of daughters living with single mothers, while gender of parent was not associated with sons’ usage.

However, other research has suggested that parenting style, rather than family structure, has a greater effect on youth substance use (Crawford and Novak, 2008). For example, one study of 400 youths found that having a poor relationship with parents was associated with the onset of both alcohol and marijuana use, and of binge drinking (Rusby et al., 2018). This same study also found that lower parental monitoring was associated with alcohol use, binge drinking, and marijuana use. Some studies find that both parenting style and family structure are independently related to substance misuse. A longitudinal study of Mexican American youths found that both those who experienced less overall parental monitoring and supervision and who came from single-parent homes were at risk for early substance use (Atherton et al., 2016).

Family history of problem behaviors, such as parental involvement in the criminal justice system and parental substance use, is a strong predictor of youth substance use (Lucenko et al., 2015; Shlafer, Poehlmann, and Donelan–McCall, 2012; Whitten et al., 2019). Youths who live with a parent or guardian who uses substances are at a higher risk for using substances themselves, even when controlling for peer influences or parenting styles (Biederman et al., 2000; Adalbjarnardottir and Hafsteinsson, 2001; Li, Pentz, and Chou, 2002; Mrug and McCay, 2013).

Siblings also have been found to be potential risk factors related to youth substance use. Research has found that youths who grew up with one or more older siblings are more likely to initiate substance use (Atherton et al., 2016). Researchers have presumed this is because younger siblings model their older siblings’ antisocial behavior and are more often exposed to older, deviant peer groups. They have found that having deviant, substance-using, or antisocial siblings is associated with initiation of alcohol, tobacco, and marijuana use, even after accounting for peer and parental substance use (Atherton et al., 2016; Low, Shortt, and Snyder, 2012; Whiteman, Jensen, and Maggs, 2013; Yurasek et al., 2019). However, studies that have accounted for the deviance of older siblings separately still found this influence on having an older sibling (Atherton et al., 2016).

Other studies have indicated that youths who have experienced childhood maltreatment, abuse, and neglect are more than twice as likely to use substances and develop substance use problems, compared with youths who have not experienced maltreatment (Danielson, 2016; Lucenko et al., 2015; Proctor et al., 2017). Yet other research has shown that child maltreatment was not directly associated with adolescent substance use, but that deviant peer affiliation fully mediated this relationship (Yoon, Snyder, and Yoon, 2020).

Researchers have found that several peer-level risk factors influence youth substance use. These include friends who engage in delinquent behavior, gang membership, friends’ use of drugs, peer rewards for antisocial behavior, perception of peer substance-use norms,and quality of peer relationships.

Multiple studies have shown that association with deviant and substance-using peers is one of the main risk factors for youth substance use (Cattelino et al., 2014; Cleveland et al., 2008; Dick et al., 2013; Handren, Donaldson, and Crano, 2016; Tomé et al., 2012; Trucco et al., 2011). For example, a study of youth in Ohio that examined multiple risk factors for substance use found that peer delinquency was the strongest correlate, even when other relevant factors related to neighborhood, media, and family were controlled (Ferguson and Meehan, 2011). Specifically, research has shown that youths who are exposed to peers who use alcohol and other drugs (i.e., peer socialization) are more likely to begin using drugs themselves (Nalven, Spillane, and Schick, 2020; Odgers et al., 2008). In addition, gang membership has also been associated with substance use initiation (Gordon et al., 2004; Bjerregaard, 2010; Coffman, Melde, and Esbensen, 2015). Youths are particularly susceptible to peer influence during early and middle adolescence if they are 1) male, 2) exposed to peers who are slightly more deviant, and 3) in unstructured or unsupervised settings (Dishion, Dodge, and Lansford, 2008).

However, there also is evidence that youths who use drugs seek association (i.e., peer selection) with other substance-using youths (Burk et al., 2012; Fergusson and Horwood, 1999; Light et al., 2013; Osgood et al., 2013). Overall, there is growing support for the idea that a causal pathway between peers and substance use cannot be established. Youths select their friends based on similar behaviors and interests (i.e., selection); however, these behaviors and interests are influenced by their peers (i.e., socialization; Young and Rees, 2013). 

Despite findings on peer influence, other research has found that youths who use substances report fewer close social relationships, compared with youths who do not use substances (Power and Estaugh, 1990). A meta-analysis of 34 longitudinal studies (Fairbairn et al., 2018) found that youths with fewer secure attachments or close relationships engage in more substance use than youths with secure attachments. This suggests that a lack of peer relationships may also increase youths’ use of substances.

A related, peer-level risk factor is perception of peer substance-use norms, which may differ from actual peer substance behaviors (Bacio et al., 2015; Duan et al., 2009; Nalven, Spillane, and Schick, 2020; Wambeam et al., 2014). Some researchers suggest that an adolescent’s perception of what goes on in the environment may be more important than the actual reality of that environment (Bacio et al., 2015; Duan et al., 2009). A study of 8,000 students in Wyoming found that as a youth’s levels of misperception increase, substance use likelihood also increases (Wambeam et al., 2014). Another study of more than 500 low-income Black adolescents found that greater perceived risky peer norms correlated with the increased likelihood of substance use and that this risk factor was more influential than the protective effects of parental monitoring (Marotta and Voisin, 2017).

Other characteristics of peer groups have also been studied. For example, a longitudinal study that examined friendship networks found that other-sex friendships (i.e., girls who are friends with boys, and boys who are friends with girls) in early adolescence predicted a greater likelihood of alcohol use in late adolescence for both boys and girls and predicted a greater likelihood of drug use among girls, even after controlling for individual risk factors such as antisocial behaviors (Poulin, Denault, and Pedersen, 2011).

In addition, several studies have examined the potential risky effects of dating and romantic relationships on youth substance use (Aikins, Simon, and Prinstein, 2010; Longmore et al., 2008; Orpinas et al., 2013; Whitton et al., 2018). A study that examined dating trajectories from 6th through 12th grade found that students in middle school who dated more frequently were about twice as likely to report using drugs than youths who reported less dating frequency (Orpinas et al., 2013). In high school, youths who had dated more frequently in middle school and those who dated frequently throughout middle school and high school were 70.0 percent more likely to report using drugs than youths who had low levels of dating experience overall. Another study examining a sample of youth from the Toledo (OH) Adolescent Relationships Study found that the level of a romantic partner’s alcohol use was related to adolescent respondents’ self-reported alcohol use frequency and alcohol-related problems (Longmore et al., 2008). A study of sexual and gender minority youths found that, among bisexual youths, romantic involvement was associated with increased marijuana and other illicit drug use (Whitton et al., 2018).

School-level risk factors for substance use are related to school attendance, academic performance, and attachment and commitment to school (Arthur et al., 2015; Wong, Slotboom, and Bijleveld, 2010). For example, low levels of school attendance, or truancy, are related to earlier substance use initiation (Henry, Knight, and Thornberry, 2012). Other studies found that truancy was significantly associated with the onset and escalation of marijuana use among urban youth (Henry, Thornberry, and Huizinga, 2009; Henry and Thornberry, 2010).

As with other risk factors, the directional relationship between school-related factors and youth substance use initiation can be hard to establish in research. Poor school performance is one example where the directionality of the association is uncertain. Research has shown that initiation of substance use can hinder youths’ grades and engagement in school (Bugbee et al., 2019; Mandell et al., 2002; Meier et al., 2015; Patte, Qian, and Leatherdale, 2017). However, some research also suggests that youth who engage in substance using behaviors are more likely to have received lower grades in school before initiation (Hallfors et al., 2002; Nargiso, Ballard, and Skeer, 2015). This implies that the relationship between academic performance and substance use is complicated and directionality (i.e., whether substance use causes poor academic performance, or whether poor academic performance leads to substance use) is difficult to determine (Crosnoe, 2006; Cooley–Strickland et al., 2009 ). Further, other factors (such as socioeconomic status) may better explain the relationship between low academic performance and substance use initiation (Rogeberg, 2013).

Further, youths who have low levels of academic engagement or school connectedness, marked by poor relationships with peers or teachers, are also more likely to use alcohol or other drugs (Bachman et al., 2008; Bond et al., 2007; Henry, Thornberry, and Huizinga, 2009; Weatherson et al., 2018). For example, a 4-year study of some 33,000 students found that youths who report low levels of school connectedness showed higher levels of binge drinking, marijuana use, and cigarette smoking than students with high levels of school connectedness (Weatherson et al., 2018).

Community-level risk factors are often associated with living in an area characterized by neighborhood disorganization (which is measured by residents’ perceptions of safety levels of crime), number of abandoned or decrepit buildings, frequency of publicly visible alcohol or drug use, accessibility of substances, poverty levels, and residential turnover rates (Crum, Lillie–Blanton, and Anthony, 1996; Hays, Hays, and Mulhall, 2003). Community type (urban versus rural) and laws related to substance availability can also affect levels of youth substance misuse (Gale et al., 2012; Miech et al., 2015; Warren, Smalley, and Barefoot, 2015).

Multiple studies have found that youths who report having greater access to alcohol, tobacco, and other drugs in the community are more likely to initiate substance use (Nargiso, Ballard, and Skeer, 2015; Stanley, Henry, and Swaim, 2011). Much of this research examines alcohol policies, laws, ordinances, and density of alcohol sales outlets (Chen, Gruenewald, and Remer , 2009; Paschall et al., 2012). A longitudinal study of youths in 50 California zip codes found that alcohol outlet density affected youth access to alcohol. The researchers concluded that high alcohol outlet density in a community enabled youth access to alcohol through several sources, such as direct purchase, shoulder tapping, family members, and underage acquaintances (Chen, Gruenewald, and Remer , 2009). State and local laws, ordinances, and policies can also influence youth substance use. A study of MTF data found that, after decriminalization of marijuana, youths in California had more positive attitudes toward marijuana and were 25.0 percent more likely to have used it in the past 30 days than youths in other states (Miech et al., 2015). Before decriminalization California youth did not show higher levels of marijuana prevalence or acceptance relative to their peers in other states.

Additionally, neighborhood disorganization and socioeconomic factors are significantly associated with substance use, even when controlling for individual- and family-level risk factors (Duncan, Duncan, and Strycker, 2002; Hadley–Ives et al., 2000; Jang and Johnson, 2001; Winstanley et al., 2008). For example, an analysis of data from the Seattle (WA) Social Development Project found that living in more socioeconomically disadvantaged neighborhoods was independently associated with increased smoking (Cambron et al., 2018).

Some researchers have also examined rural versus urban environments. One study that examined perceived ease of access to a variety of substances found that rural students reported higher levels of access to licit substances, while urban students reported higher levels of access to illicit substances (Warren, Smalley, and Barefoot, 2015). Another study found that adolescents in rural communities and in small urban communities had greater odds of past-year prescription opioid misuse than adolescents in large, urban environments (Monnat and Rigg, 2016). Another study of more than 18,000 youths from communities with populations of fewer than 50,000 people found that high school students living on farms were exposed to greater numbers of risk factors and had higher levels of substance use (and in some cases higher level of substance use initiation) than students who lived in towns (Rhew, Hawkins, and Oesterle, 2011). Finally, a study using data from the NSDUH found that rural youths started drinking at a younger age and also had higher rates of binge drinking than urban youths (Gale et al., 2012).

[5] For more information, see the Model Programs Guide literature review on Risk Factors for Delinquency .

Protective Factors Against Substance Use

Protective factors [ 6 ]  can help prevent initiation of substances among youth. These factors can be thought of as buffers that reduce the negative effect of adversity on child outcomes (Vanderbilt–Adriance and Shaw, 2008). Like risk factors, protective factors also exist on the individual , family , peer group , school , and community levels, and certain protective factors may exist on multiple levels. Interventions designed to prevent substance use initiation seek to reduce risk factors while enhancing the effectiveness of protective factors by incorporating components that are focused on developing factors such as strengthening family bonds, improving academic connectedness, or developing skills to handle life stressors (Development Services Group, 2015; Waldron and Turner, 2008).

Unfortunately, there has been less research conducted on protective factors, compared with the amount of research on risk factors on alcohol and drug use. In addition, researchers have found that risk factors are better at predicting youths' initiation of substance use than protective factors are at predicting youths’ not initiating substance use (Cleveland et al., 2008).

Individual-level protective factors include resiliency, social competence, problem-solving skills, intrapersonal psychological empowerment, and social skills. Youths who demonstrate high levels of these factors are less likely to engage in substance use, compared with youths who demonstrate low levels (Cleveland et al., 2008; Hinnant and Forman–Alberti, 2018; Lardier et al., 2020).

Ethnic, racial, and cultural identities and values can also protect youths against substance misuse, specifically for youths of color (Brook et al., 1998; Lardier et al., 2020; Zapolski, 2017). For example, one study found that higher ethnic identity was associated with lower past-month drug use for African American, Hispanic, and multiracial youth [ 7 ] (Zapolski, 2017).

On the family level, research has shown that parental monitoring and good relationships between youths and their parents can improve child adjustment during important developmental phases and serve as a buffer to problem behaviors such as aggression and delinquency, which are associated with the initiation of substance use (Tilton–Weaver et al., 2013; Losel and Farrington, 2012; Reingle, Jennings, and Maldonado–Molina, 2011). 

Additional evidence shows that effective parental monitoring can reduce the influence of deviant peers on the initiation of alcohol, tobacco, and marijuana use (Van Ryzin, Fosco, and Dishion, 2012; Pesola et al., 2015). A study examining several protective factors among students in the Delaware School Survey found that quality of the relationship between child and parent is one of the strongest protective factors against alcohol and marijuana use in 8th and 11th grades (DeCamp and Smith, 2019). Studies in other states have found that parental attachment is a protective factor against prescription drug misuse (Park, Melander, and Sanchez, 2016). 

Family structure has also been examined as a protective factor. A study of youths who participated in the MTF survey found that children from two-parent families were less like to use inhalants, marijuana, and amphetamines than children from single-parent families (Hemovich and Crano, 2009). Another study of rural adolescents participating in the NSDUH found that living in a two–parent household was protective against nonmedical prescription drug use (Havens, Young, and Havens, 2011). Similarly, analysis of data from the Seattle Social Development Project found that adolescents living in two–parent households showed slower growth in alcohol use compared to adolescents living in other family structures (Cambron et al., 2018).

Exposure to prosocial peers may serve as a protective factor for substance use initiation. Several studies have found that prosocial peer association is significantly associated with decreased violence, substance use, and delinquency (Osgood et al. 2013; Padilla–Walker and Bean, 2009; Prinstein et al., 2001). However, the research on the relationship between prosocial peer association and youth substance use is limited; few studies have explored the influence of peers' positive behavior on increasing youths' prosocial behaviors and decreasing problem behaviors, such as initiation of substance use (Lee, Padilla–Walker, and Memmott–Elison, 2017).

Further, there is limited research available on the protective effects of dating/romantic relationships on substance use. For example, a longitudinal study of sexual and gender minority youths found that romantic involvement was associated with less drinking for the whole sample and associated with less illicit drug use among gay and lesbian participants (Whitton et al., 2018). However, this study also found that dating may promote drug use in those who identify as bisexual and may promote smoking among the whole sample.

On the school level, protective factors include positive school climate and attachment to school and teachers. Studies that have examined the relationship between school connectedness and substance use initiation have found that perceived teacher support has a protective effect on the initiation of smoking, alcohol, and marijuana (McNeely and Falci, 2004; Weatherson et al., 2018). An analysis of data from the COMPASS study (a prospective cohort study design to collect longitudinal data on a variety of behavioral outcomes from Canadian students in grades 9 to 12) included three forms of substance use behaviors, finding that school connectedness had the strongest protective effect on cigarette smoking, but also reduced likelihood of marijuana use and binge drinking (Weatherson et al., 2018). 

Other factors, such as commitment to school (especially in youths in higher grades), participating in school activities, and high academic performance have also shown a protective effect against recent use of substances (Cleveland et al., 2008; DeCamp and Smith, 2019; Vidourek and King, 2010). The study examining several protective factors in a large sample of students in the Delaware School Survey found that school performance grades (defined as school grades) exhibited one of the strongest positive effects against past-month substance use (DeCamp and Smith, 2019).

On the community level, protective factors include residence in a neighborhood with prosocial opportunities and resources and collective responsibility among neighbors. Youths who live in low-crime communities, where neighbors monitor one another's children, are less likely to have access to or engage in alcohol and substance use (Treno et al., 2007). A study of more than 18,000 youths in Nebraska found that youths who reported that there were fun and legal activities to do in their community were 18.0 percent less likely to have misused prescription drugs, compared with youths who did not have similar activities to engage in (Park, Melander, and Sanchez, 2016). Another study found that living in rural areas may be a protective factor for Black youths by lowering the risk of stress and negative affect (Gibbons et al., 2007). 

Community civic engagement can also serve as a protective factor for youth (Bartkowski and Xu, 2007; Lardier et al., 2020). For example, a study of students in a northeastern urban school district found that youths who participated more often in activities in their communities were less likely to have used illicit drugs in the previous month (Lardier et al., 2020).

Religiosity and Spirituality

Finally, several studies have examined religiosity/spirituality as protective factors (Bartkowski and Xu 2007; Ford and Hill, 2012; Hodge, Cardenas, and Montoya, 2001; Marsiglia et al., 2005; Salas–Wright et al., 2017; Vaughan et al., 2011; Vidourek and King, 2010). A meta-analysis of these studies identified several interesting patterns, including that religiosity/spirituality is multidimensional, involving various interconnected aspects at the individual, family, peer, and community levels (Hardy et al., 2019). Also, there are numerous complex and dynamic processes by which religiosity/spirituality relates to youth outcomes and both its public and private aspects can influence outcomes (Hardy et al., 2019).

Researchers have also found that using different definitions of religiosity/spirituality can result in different findings. For example, one study of more than 10,000 youths found that religious worship attendance was a statistically significant predictor of not using alcohol or marijuana in the past (DeCamp and Smith, 2019).  However, the same study found that identifying with a religion did not have the same protection. Another study found that religious affiliation had no significant effect on lifetime use of any of the studied substances, but that religious attendance was significantly related to lifetime marijuana and inhalant use, and that religious salience was significantly related to less use of cigarettes and marijuana (but there was no effect on alcohol or inhalant use) [Hodge, Marsiglia, and Nieri, 2011]. A meta-analysis found that both high religiosity and attending church often were protective factors for youth against consumption of alcohol (Kelly et al., 2015). Other studies suggest that religious social support may protect adolescents against risk for intergenerational substance use (Ohannessian et al., 2010; Peviani et al., 2020).

[6] For more information, see the Model Programs Guide literature review on Protective Factors Against Delinquency . 

[7] However, high ethnic identity was associated with increased risk for white youth.

Type of Substance Use Prevention Programs and Outcome Evidence

Substance use prevention programs seek to reduce the number of adolescents experimenting with, and potentially developing an addiction to, alcohol and illicit substances (Midford, 2009). The programs target various populations and age groups. Following are descriptions for several different types of prevention programs in terms of their target populations and various components. Specific examples of evidence-based programs from the Model Programs Guide are also provided.

School-Based Programs

Problem behaviors, such as alcohol or other drug use, often begin during the school-age years. Thus, many researchers contend that implementing prevention programs in a school setting increases the odds of averting problems associated with alcohol, tobacco, and other drug use (Botvin and Botvin, 1992; Perry et al., 1996; Tobler and Stratton, 1997). Most school-based prevention programs are universal and are designed for large audiences of students (Botvin and Griffin, 2007); however, some research suggests that curricula delivered in an interactive format with smaller groups of young people can also produce positive results (Tanner–Smith, Wilson, and Lipsey, 2013; Tripodi, et al., 2010; Tobler and Stratton, 1997).

The National Institute on Drug Abuse (NIDA, 2011) suggests that prevention programs should focus on key transition periods during adolescence, particularly the transition from middle school to high school, when youths are at high risk of experimenting with alcohol and other drugs. Classroom curricula give students the tools to recognize internal pressures (e.g., stress or anxiety) and external pressures (e.g., peer attitudes and advertising) that may influence their decision to use alcohol, tobacco, and other drugs, while also developing skills to resist these influences effectively (Sloboda et al., 2009).  

Many prevention programs have been implemented and evaluated in school settings across the country. One example, the LifeSkills Training (LST) program, is a classroom-based drug prevention program for upper elementary and middle school students. LST’s curriculum centers on the development of personal self-management skills, social skills, and drug-resistance skills. One study (Botvin et al., 1995) found that LST had numerous statistically significant effects on students who participated in the program, including the reduction of monthly cigarette use, problem drinking, and polydrug use (i.e., use of more than one drug at one time). However, there were no statistically significant differences on self-reported measures of marijuana use between students who participated and those who did not. Another study (Trudeau et al., 2003) found that the LST treatment group showed a statistically significant reduction in the growth of substance initiation, compared with the control group. 

However, not all classroom-based programs have had the desired effect on students. The original D.A.R.E. (Drug Abuse Resistance Education) , in use from 1983 to 2009, had limited success in reducing youth substance use (Ennett et al., 1996). The core curriculum of D.A.R.E. consisted of 17 lessons, one given each week. The lessons were taught by police officers and covered topics such as drug use and misuse, resistance techniques, and drug use alternatives. In two studies, D.A.R.E. was found to have no statistically significant effects on students’ short- and long-term substance use, attitudes toward drugs, and self-esteem (Clayton, Cattarello, and Johnstone 1996; Ennett et al., 1994). 

Programs for Young Children

Research has also examined younger children and the link between the early presence of conduct disorder and future substance use (Shaw et al., 2006; Webster–Stratton. Reid, and Stoolmiller, 2008; Hopfer et al., 2013). Evidence suggests that programs implemented at earlier stages in a child’s life may be more effective in prevention efforts and behavior adjustments than programs implemented in later adolescent years, especially for high-risk populations (Park, 2008; Phillips, McDonald, and Kishbaugh, 2017; Webster–Stratton, Reid, and Hammond, 2004). Programs implemented in preschool and kindergarten classes are designed specifically to improve the social competence of children and establish skills for prevention. One aspect of prevention programs for younger children is the incorporation of both the family and the teacher/caregiver in program services. During this developmental period, children require proactive involvement and monitoring from parents, for a parent’s response to a child’s behavior is a predictor of future substance use (Shaw et al., 2006). Responses from teachers/caregivers to children’s behavior are also important during this time. As a result, many programs now include both motivational interviewing for parents and emotional and educational training for teachers (Shaw et al., 2006; Stormshak et al., 2021).

The Family–School Partnership Intervention to Reduce Risk of Substance Use is a preventive intervention designed to reduce first grade students' risk for later drug involvement by addressing students' poor achievement, aggressive and shy behavior, and concentration problems by improving teachers' and parents' teaching and behavior-management skills and parent–teacher communication. The findings from the studies  by Storr and colleagues (2002) and Furr–Holden and colleagues (2004) showed a statistically significant reduction in the risk of smoking initiation for students in the intervention group, compared with students in the control group. However, Furr–Holden and colleagues (2004) found no significant differences between the two groups in outcomes related to early alcohol or other drug use (including use of marijuana, inhalants, and other illegal drugs).

The Child–Parent Center Program (Chicago, Ill.) is a family- and school-based program intended for preschool and kindergarten students and their families. The goal of the program is to provide comprehensive educational and family support services. The findings of the study by Reynolds and Ou (2011) indicated that participants were less likely to report substance misuse at age 24, compared with control group participants. This difference was statistically significant.

Family-Based Programs

Family-based programs focus on parental influence, parenting skills, and family cohesion as major factors in substance abuse prevention (Abbey et al., 2000; Cleveland, Feinberg, and Greenberg, 2010; Cleveland, Feinberg, and Jones, 2012 ). Prevention programs seek to provide information to both parents and children about alcohol and drugs and encourage parents to clarify their views about substance use with their children (Cleveland, Feinberg, and Greenberg, 2010; Cleveland, Feinberg, and Jones, 2012 ). During the developmental period from childhood to adolescence, research has shown that parental influence makes a large impact on youth behaviors. Therefore, supportive, motivated parents can greatly affect prevention efforts (Haggerty et al., 2007; Cleveland et al., 2010; Shaw et al., 2006). Family-based programs are designed to prepare parents and children for the changes they will experience during this developmental phase and offer tools to assist youth in resisting drugs and alcohol. Factors such as family functioning, communication, involvement, and supervision are fundamentally important to many programs for adolescents (Riesch et al., 2012). 

Numerous family-based prevention programs have shown effectiveness in improving family functioning and reducing youth substance use. For example, the Positive Family Support (PFS) program is a multilevel, family-centered intervention targeting children at risk for problem behaviors or substance use, and their families. Designed to address family dynamics related to the risk of adolescent problem behavior, the program is delivered to parents and their children in a middle-school setting. In a study (Connell et al., 2007) that examined PFS's effect on substance use and antisocial behavior in students ages 11 to 17, the intervention group reported a statistically significant decrease in the use of tobacco, alcohol, and marijuana, compared with the control group. A study by Dishion and colleagues (2002) also found that students in PFS had a statistically significant lower rate of substance use, compared with control group students. 

Another example of a family-based program is Guiding Good Choices (GGC) . This program is designed for families of middle school–age children, aims to promote healthy, protective parent–child interactions, and reduces children’s risk for early substance use. A 2009 study conducted by Spoth and colleagues found that participation in GGC was associated with a statistically significant reduction in alcohol-related problems and the frequency of cigarette use 10 years later, compared with control group participants. However, there was no statistically significant impact found on the frequency of drunkenness or illicit drug use.

Programs for High-Risk Families

Another type of prevention program focuses on high-risk families or families that need additional one-on-one assistance, therapy, or skills enhancement. High-risk families include single-parent homes, early/first-time mothers, and parents with a history of substance abuse (Hemovich and Crano, 2009). According to NIDA (2011), prevention programs should be tailored to address specific characteristics of particular populations to improve program effectiveness. For example, research has shown that urban communities with low socioeconomic status and strong acceptance of drug use have benefited from more focused, community prevention efforts (Cleveland, Feinberg, and Jones, 2012). At-risk adolescents who have parents with a history of substance abuse or limited concern for their children’s behavior benefit from programs that incorporate interactive family components (Hemovich and Crano, 2009).

Nurse–Family Partnership (NFP) , designed for high-risk families, focuses specifically on first-time mothers and children from birth to 3 years old, who are at risk for conduct problems and possible later substance use. The program provides low-income, first-time mothers of any age with home-visitation services from public health nurses. The nurses work intensively with the mothers to improve maternal, prenatal, and early childhood health and well-being, with the goal of helping at-risk families achieve long-term improvements in their lives. Several studies (Eckenrode et al., 2000; Kitzman, 2010; Olds et al., 2004) examining NFP found statistically significant positive impacts on the targeted populations. For example, a 12-year, follow-up study found that children in the NFP program were statistically significantly less likely to have used cigarettes, alcohol, or marijuana, compared with children in the control group (Kitzman et al., 2010).      

Another program, the Strengthening Families Program for Parents and Youth 10–14 , targets families who use substances. This program is designed to reduce substance use and behavior problems during adolescence through improved skills in nurturing and child management by parents and improved interpersonal and personal competencies among youths. One study (Spoth et al., 2004) found that youths who participated in the program had statistically significantly slower growth in substance use at the 6-year follow-up, compared with youths who did not participate. However, there was no statistically significant impact on lifetime marijuana use or on delaying the growth of tobacco use. Another study (Spoth, Randall, and Shin, 2008) found that youths who participated in the program had statistically significant reductions in substance-related risk at the sixth-grade level.  

Culturally Specific or Culturally Adapted Programs

Several substance use prevention programs are designed or culturally adapted for specific groups within the youth population. Culturally specific or culturally adapted interventions are designed to engage youths and families of color who do not feel represented by mainstream programs and who thus may not benefit from or even participate in the intervention (Dillman Carpentier et al., 2007; Harachi, Catalano, and Hawkins, 1997; Marek, Brock, and Sullivan, 2006). Culturally adapted programs adjust existing programs for a specific ethnic group. Adaptions may include surface-level revisions, such as alterations to language used during the program, either through complete translation or subtle changes to the vernacular phrases used throughout the intervention (Wang–Schweig et al., 2014). Deeper, structural changes to a program may also be necessary for cultural adaptation, such as modifying or adding new intervention components. Unlike adapted programs, culturally specific programs are initially designed for a specific ethnic group. Whether culturally specific or culturally adapted, however, an intervention should be suitable for the target population’s worldview, norms, beliefs, and values (Wang–Schweig et al., 2014). 

Strong African American Families (SAAF) is a program for high-risk, rural, Black families. The SAAF program is designed to help youths and their families cope with life stressors such as discrimination. The program concentrates on enhancing racial pride and family bonding through parental training and family therapy, thereby strengthening the attachment between parent and child (Brody et al., 2002). A study by Brody and colleagues (2006) found that SAAF youths showed a growth rate in alcohol use that was 17.4 percent lower than that of the comparison group, a statistically significant difference. SAAF youths also reported statistically significant reductions in levels of alcohol use initiation, compared with the control group. 

Familias Unidas , a prevention program for immigrant and first-generation Hispanic families, is designed to improve family functioning and reduce drug use and risky sexual behavior in youth. The program works to help parents understand U.S. culture and the strains of the acculturation process on their children, while also maintaining the importance of their Hispanic culture. It seeks to build supportive relationships among Hispanic immigrant parents, to integrate them into the greater community and reduce feelings of social isolation . A study (Pantin et al., 2009) found, at the 30-month follow-up, treatment group youths who participated in the program reported lower substance use, compared with the control group—a statistically significant finding. 

Several culturally specific prevention programs designed for Native Americans focus on providing participants with skills to help resist pressures toward substance abuse—within the Native American community specifically, and within U.S. society in general. Additionally, content is designed to promote holistic concepts of health present in Native American culture, as these values run counter to substance abuse (Schinke et al., 1988). One example, the Cherokee Talking Circle (CTC) , was designed specifically to prevent and reduce substance abuse among youths who are members of the United Keetoowah Band of Cherokee Indians. A study by Lowe and colleagues (2012) found that youths who participated in CTC showed statistically significant reductions on measures of substance problems and symptom severity, compared with youths who participated in other nonculturally specific, substance abuse education programs.

Mentoring Programs

Mentoring programs [ 8 ] may be school based or community based and serve youths living in high-poverty neighborhoods, youths whose parents are incarcerated, youths in foster care, and other at-risk youths (Ahrens et al., 2008; Britner et al., 2006; Goode and Smith, 2005). Mentoring programs provide a youth with positive adult or older peer contact. This mentor–mentee relationship can help reduce risk factors that may lead to the initiation of alcohol or other drug use (e.g., early antisocial behavior, poor parental supervision/monitoring, association with delinquent peers) by enhancing protective factors (e.g., perception of social support from a trusted adult, healthy beliefs and clear standards, positive expectations for the future). 

Across three meta-analyses that examined the impact of mentoring programs on substance use, the findings were mixed. Thomas, Lorenzetti, and Spragins (2011) found that mentoring programs resulted in a statistically significant positive impact on adolescents' substance use. However, DuBois and colleagues (2011) and Tolan and colleagues (2008) did not find a statistically significant effect of mentoring on substance use. 

One example of a mentoring program is the Big Brother or Big Sister (BBBS) Community-Based Mentoring (CBM) Program . The program involves one-to-one mentoring between a Big Brother or Big Sister (the mentor or adult) and a Little Brother or Little Sister (the mentee or youth). Mentors and youths participate in various activities such as going to the movies, attending a sports event, going to a restaurant, reading books, going on a hike, visiting museums, or simply hanging out and talking with one another. These activities are intended to enhance communication skills, develop relationship skills, and support positive decisionmaking (Grossman and Garry, 1997) . Results from one study (Tierney, Grossman, and Resch, 2000) found that youths who participated in the CBM program showed a statistically significant reduction in initiation of drug and alcohol use and antisocial behavior, compared with control group youths. 

Another example, Across Ages , is a mentoring program designed to delay or reduce substance use in at-risk middle school youth. The program pairs adult volunteers (55 and older) with students (10 to 13 years old) to create a special bonding relationship. The project also uses community service activities, provides a classroom-based life skills curriculum, and offers parent-training workshops. The mentors help youths develop the awareness, self-confidence, and skills they need to abstain from drug use and overcome other obstacles. Participation in Across Ages was found to have a statistically significant effect on youths’ reactions to situations involving drug use; however, the program did not statistically significantly affect youths' frequency of substance use (LoSciuto et al., 1996).  

Mass Media Campaigns

Mass media campaigns are a common way of delivering preventive health messages to the general population, particularly to individuals who may be difficult to access through traditional approaches ( Wakefield, Loken, and Hornik, 2010 ). Campaigns can be implemented and disseminated through several different media, including television commercials, radio broadcasts, newspaper or magazine advertisements, billboard posters, brochures or posters on buses and subways, and the Internet. Exposure to a campaign is generally passive, meaning people happen to see the message during routine viewing of media, such as television or magazines. Media campaigns may be part of a larger information or social marketing program, or they may be standalone interventions. The duration of campaigns may vary (Wakefield, Loken, and Hornik, 2010).

One meta-analysis (Ferri et al., 2013) examined the effectiveness of mass media campaigns that are designed to prevent or reduce the use of or intention to use illicit drugs among youth. Notably, the review did not include mass media campaigns that concentrated on alcohol or licit drugs. The researchers analyzed the results of five randomized controlled trials and found no significant effects of media campaigns on illicit drug use. Although youths exposed to antidrug media campaigns tended to, on average, use fewer illicit drugs, compared with youths not exposed to media campaigns, the differences between the groups were not statistically significant. The researchers also found, based on results from four randomized controlled trials, that mass media campaigns had no significant effects on intentions not to use, intentions to reduce use, and intentions to stop use of illicit drugs. Despite their findings, the study authors recommended further evaluation studies of mass media campaigns (Ferri et al., 2013). 

[8] For more information, see the Model Programs Guide literature review on Youth Mentoring and Delinquency Prevention .

Limitations of Research on Prevention Programs

Although research has shown that prevention programs can prevent or reduce youths' use of substances, there are still many limitations to prevention efforts. One challenge is in identifying and overcoming the barriers to program fidelity (Midford, 2009). For instance, with regard to family-based programs, many studies focus on the parents and adolescents who choose to be involved in those programs. There are few studies, however, that analyze the factors that lead to participation or the decision not to participate, and even fewer that recommend specific alternatives to increase participation (Midford, 2009; Midford et al., 2012; Lee et al., 2016).

In addition, programs are designed to focus on "substance use prevention," yet program evaluations often do not measure the actual substance use among adolescents. Rather, program evaluators identify and measure behaviors, attitudes, and perceptions related to substance use (Loxley et al., 2004; Lee et al., 2016). Therefore, it is difficult to determine whether prevention programs specifically affect a youth's actual use of drugs and alcohol.

Finally, further research is required to understand long-term implications of prevention programs. Often, program evaluation research concentrates on measuring outcomes in the short term. Few studies examine the effects of prevention programs in the long term (Shaw et al., 2006). There is a need to understand whether prevention skills will continue through both the transition to high school and the transition to college, as these are periods of development when youths are at greatest risk for experimenting with drugs and alcohol (Lee et al., 2010; Nguyen et al., 2011; Shaw et al., 2006).

Federal and local governments make large investments every year in substance use prevention programs. Although youths' self-reported use of alcohol and other drugs has generally declined over the last few years (Johnston et al., 2021), current research still demonstrates a need for prevention programs (CDC, 2018). 

Although rates of substance use remain high, with as many as 25.0 percent of 12- to 17-year-olds reporting ever having used an illicit drug in their lifetime (SAMHSA, 2018), overall rates are at historically low levels. Although much research has been done to examine the specific risk factors that influence whether youths will initiate substance use, less has been done to explore the protective factors that may buffer youths against choosing to use drugs or alcohol. Many prevention programs—designed for general audiences of youth, or of more at-risk youths and families—attempt to target certain risk factors, to prevent or reduce the use of substances (Trudeau et al., 2003; Brody et al., 2006; Connell et al., 2007; Spoth, Randall, and Shin, 2008; Kitzman et al., 2010). 

While there have been several studies conducted to look at the impact of alcohol and drug prevention programs, future research could overcome some of the current limitations, including measurement of the effect on youths’ actual substance use (rather than only skills, knowledge, or attitudes related to substance use) or evaluations that have longer follow-up periods. Finally, despite use rates leveling off in 2020, vaping remains popular among adolescents (Johnson et al., 2021). Future studies could explore whether current prevention programs influence youths’ decisions to vape or programs should add additional components to address this relatively new drug.

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About this Literature Review

Suggested Reference: Development Services Group, Inc. 2022. "Substance Use Prevention Programs." Literature review. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. https://ojjdp.ojp.gov/model-programs-guide/literature-reviews/substance-use-prevention-programs

Prepared by Development Services Group, Inc., under Contract Number: 47QRAA20D002V.

Last Update: February 2022

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Angiotensin ii—real-life use and literature review.

1. Introduction

2. renin–angiotensin–aldosterone system, 3. classical raas, 4. nonclassical raas, 5. angiotensin ii as a vasopressor.

6. Immunomodulatory Effects of Angiotensin II

7. adverse effects associated with angiotensin ii, 9. conclusions, author contributions, conflicts of interest.

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Möller Petrun, A.; Markota, A. Angiotensin II—Real-Life Use and Literature Review. Medicina 2024 , 60 , 1483. https://doi.org/10.3390/medicina60091483

Möller Petrun A, Markota A. Angiotensin II—Real-Life Use and Literature Review. Medicina . 2024; 60(9):1483. https://doi.org/10.3390/medicina60091483

Möller Petrun, Andreja, and Andrej Markota. 2024. "Angiotensin II—Real-Life Use and Literature Review" Medicina 60, no. 9: 1483. https://doi.org/10.3390/medicina60091483

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Substance-Induced Psychoses: An Updated Literature Review

Alessio fiorentini.

1 Department of Neurosciences and Mental Health, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy

Filippo Cantù

2 Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy

Camilla Crisanti

Guido cereda, lucio oldani, paolo brambilla.

Background: On the current psychopharmacological panorama, the variety of substances able to provoke an episode of acute psychosis is rapidly increasing. Such psychotic episodes are classified according to the major category of symptoms: positive, negative, or cognitive psychotic episodes. On one hand, the abuse of methamphetamines, cannabis, and cocaine plays a big role in increasing the incidence of episodes resembling a psychotic disorder. On the other hand, the progress in terms of pharmacodynamics knowledge has led to the synthesis of new drugs, such as cannabinoids and cathinone's, which have rapidly entered into the common pool of abusers' habits. Regarding these newly synthesized substances of abuse, further clinical studies are needed to understand their psychogenic properties. The topic of this review is complicated due to the frequent abuse of psychotomimetic drugs by patients affected by psychotic disorders, a fact that makes it extremely difficult to distinguish between an induced psychosis and a re-exacerbation of a previously diagnosed disorder.

Methods: The present narrative review summarizes results from clinical studies, thus investigating the psychotogenic properties of abused substances and the psychotic symptoms they can give rise to. It also discusses the association between substance abuse and psychosis, especially with regards to the differential diagnosis between a primary vs. a substance-induced psychotic disorder.

Findings: Our findings support the theory that psychosis due to substance abuse is commonly observed in clinical practice. The propensity to develop psychosis seems to be a function of the severity of use and addiction. Of note, from a phenomenological point of view, it is possible to identify some elements that may help clinicians involved in differential diagnoses between primary and substance-induced psychoses. There remains a striking paucity of information on the outcomes, treatments, and best practices of substance-induced psychotic episodes.

According to the state of the art of literature, a relationship between drug abuse and the onset of psychotic symptoms is strongly supported ( 1 , 2 ). In fact, plenty of findings prove that illicit substances (i.e., cannabinoids, cocaine, amphetamines, and hallucinogens) have psychotomimetic properties ( 3 , 4 ). That is, their use can induce transient psychotic symptoms due to acute intoxication, but also possibly leading to a syndrome directly resembling a primary psychotic disorder ( 5 ).

Furthermore, over the last decades, a vast range of new psychoactive substances has emerged: synthetic cannabinoids, cathinone derivatives, psychedelic phenethylamines, novel stimulants, synthetic opioids, tryptamine derivates, phencyclidine-like dissociatives, piperazines, and GABA A/B receptors agonists are steeply becoming more rampant among the drug abuse panorama ( 6 ).

A struggling clinical dilemma is how to clearly identify a substance-induced psychosis from a primary psychotic illness or a psychotic illness with comorbid substance use. This could possibly be a subtle conundrum and a chance for elucubration, yet it becomes greatly important when treating and choosing the best therapeutic strategy for patients.

The Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition ( 7 ) defines the substance-induced psychotic disorder as a psychiatric disease featured by delusions and/or hallucination during or soon after substance intoxication or withdrawal (please see Table 1 ). Furthermore, the symptoms of a psychotic disorder that is not substance-induced is yet to be properly understood.

Diagnostic criteria of substance-induced psychosis according to the DSM-5 ( 7 ).

The occurrence of drug-induced psychosis seems to be related to several pathogenetic mechanisms: (a) higher levels of central dopamine, especially for hallucinogens or psychedelic substances, stimulants and cathinone derivates, (b) a cannabinoid CB1-receptor agonist, in particular for cannabis-related substances (c) 5HT2A-receptor agonist for hallucinogenic plants, latest phenethylamines and tryptamine derivates, (d) antagonist activity at NMDA receptors (n-methyl-D-aspartate receptors) in ketamine and methoxetamine and, lastly, (e) k-opioid receptor activation in Salvia divinorum and Mitragyna speciosa ( 8 ).

A previous review of our group showed that psychosis due to substance abuse is a common issue in clinical practice and that the propensity to develop psychosis seems to be associated with the severity of use and dependence ( 2 ). However, this topic is continuously changing, with new substances coming out every day. Thus, an update of the previous review is highly required to create a better understanding of substance induced psychosis.

In this review, the presence of associated psychotic symptoms and the differences in clinical presentation will be analyzed for each substance. The second aim of our review is, in this complex framework, to perform an update of our previous work ( 2 ), in order to better define what is new and outstanding with regards to recently abused drugs, hopefully leading to a better comprehension of this topic.

For this review, a PubMed, Medline and PsychINFO search for articles regarding drug abuse as causal or trigger factor for psychosis was performed; relevant studies were by two authors (FC and CC), and controversies were resolved by confrontation with a third author (GC).

In our article search, we only considered articles published from 01/01/2000, in order to exclude excessively outdated works. Specifically, articles of potential interest were identified by using the following terms: (substance * OR drug * OR inhalant * cannab * OR THC OR cathinone OR stimulant * OR cocaine OR amphetamine OR methamphetamine OR hallucinogen * OR LSD OR lysergic OR entactogen * [All Fields]) AND (psycho * OR hallucin * OR delusion * OR parano * [All Fields]).

The selected papers were included in the reference list only if meeting all the inclusion criteria, which consist of being (I) published in a peer-reviewed journal, (II) conducted in humans; (III) written in English and (IV) being an original study or a case-report. The exclusion criteria consisted of: (I) studies focusing on psychoses due to other causes than substances; (II) reviews, commentaries and book chapters; (III) abstracts from conferences; (IV) studies in animal-models and in vitro studies. The pertinent results were then selected on the basis of their relevance to the topic areas covered by the authors, and then synthesized for reporting and discussion. Titles of articles focused only on a small geographical area (e.g., Martinique, France or small Chinese populations), with patients who assumed more than one drug and on population with psychiatric comorbidities were excluded. Furthermore, we decided to exclude studies on the development of psychosis in patient at high risk or at ultra-high risk of developing psychosis. In conclusion, we also excluded not pertinent articles (e.g., forensic articles, psychosocial and not psychiatric articles).

In the choice of articles of interest for out paper, we initially identified, after the removal of duplicates, a number of 157 articles. We then removed not pertinent works (i.e., n = 55), and discrepancies were resolved by authors confrontation; a further number of 12 papers by other sources was found, and a total number of 72 papers was collected.

Due to the extent of the topic studied, it was not possible to adopt a systematic approach to analyse the data collected and to conduct a statistical analysis to compare them. Indeed, the substances described present evident heterogeneous features, and, for this reason, a descriptive approach has been adopted to provide a broad yet thorough overview of this topic.

Clinical Differences in Psychoses

Despite the effort in defining clear-cut criteria of substance-induced psychosis, the results of the present review shows a picture of the complex relationship between psychotic symptoms and the use and abuse of illicit drugs. Furthermore, in most cases, chronological criteria are not sufficient to prove a direct causal effect between the substance and psychosis. In fact, in patients who use drugs and develop a psychotic episode for the first time, the evidence that such psychotic symptoms are primary and independent from drugs requires their persistence during a period of sustained abstinence from psychoactive substances. Indeed, drug-induced psychoses are expected to be resolved during a period of abstinence ( 9 ). On the other hand, subjects affected by drug-induced psychosis were more likely to abuse more than one drug and seemed to also show long-term hallucination after drug interruption ( 9 ).

In their longitudinal study, Mauri and colleagues examined the diagnostic and clinical courses of patients who used drugs while experiencing early-phase psychoses, with the aim to focus on the initial distinction between primary psychosis with drug abuse and substance-induced psychosis. The results obtained showed that the patients with primary psychosis had an earlier age of onset compared to the ones with drug-induced psychosis, it also showed baseline higher scores in the item called “unusual content of thought” according to the Brief Psychiatric Rating Scale (BPRS).

In their systematic review, Wilson et al. ( 10 ) summarized results from six studies, assessing the differences, particularly concerning psychopathology between subjects with a diagnosis of substance-induced psychosis and subjects affected by primary psychosis. The findings did not reveal several consistent differences. However, they found that, compared to primary psychosis, subjects affected by drug-induced psychosis showed a weaker family history of psychotic disorders, a greater degree of insight, fewer positive and negative symptoms, more depressive symptoms, and more anxiety.

The other important issue is that subjects who presented psychotic symptoms after substance abuse seemed to have a higher risk of the development of a primary psychotic illness ( 11 ). In fact, recent studies provide evidences that the abovementioned group of subjects is more likely to develop a schizophrenia-spectrum disorder or a primary psychotic disorder ( 11 , 12 ).

In this regard, Starzer et al. ( 13 ) carried out a longitudinal study in a cohort of 6,788 subjects who received a diagnosis of substance-induced psychosis, investigating the rate of conversion to schizophrenia and bipolar disorder as well as risk factors for conversion. The results obtained showed a strong association between substance-induced psychosis and the development of either bipolar or schizophrenia-spectrum disorder. Moreover, young age was associated with a higher risk of converting to schizophrenia. Finally, self-harm episodes after substance-induced psychosis seemed to be significantly linked to a higher risk of converting to either schizophrenia or bipolar disorder.

In the following paragraphs we will discuss each single drug and its evidence on psychotic episodes. A useful summary on main data is reported in Table 2 .

Summary of major mechanism of action, nature of evidence and prevalence of psychotic symptoms for each substance.

5-HT, 5-hydroxytryptamine receptors; CB1, cannabinoids receptor 1; D2, dopamine deceptor 2; DA, dopamine; NMDA, N-methyl-D-aspartate; NA, evidence lacking in current literature .

Cannabinoids

Introduction.

In recent years, there has been a significant increase in interest in the relationship between cannabis use and psychosis, partly because of concerns related to the growing availability of cannabis and its potential risks to health and human functioning.

Epidemiology

Cannabis is the most widely used illicit substance in the world, with 6–7% of the population in Europe and 15.3% of the population in the USA using it each year ( 30 ). According to the European Monitoring Center for Drugs and Addiction, in 2019 22.2 million adults used cannabis. The lifetime use of this substance can reach 27% of the European population.

The prevalence of psychotic features varies greatly depending on the content of THC in the cannabis, with THC having a direct relation with psychotic symptoms. Interestingly, since 2009 the power of cannabis (the THC content) increased and in some cases duplicated, while the price remained stable. Therefore, defining the real incidence and prevalence of psychotic disorders following cannabis use is not easy, with studies showing a range of 0.87–10.60%.

Pharmacodynamics and Toxicology

The clinical effects of cannabis are caused by its psychotropic main ingredient, delta-9-tetrahydrocannabinol (Δ9-THC), which acts as a partial agonist of Cannabinoids Receptor 1 (CB1) ( 31 ), widely expressed in the CNS, unlike its twin receptor CB2, mostly expressed on peripheral nerve terminals, on T cells of the immune system, on macrophages and B cells, and in hematopoietic cells.

THC is responsible for cannabis adverse effects, such as cognitive deficits ( 32 ) and psychotic and anxiogenic effects ( 33 ).

Symptoms and Clinical Characteristics

The psychoactive effects of Δ9-THC include psychotic symptoms, such as paranoia and hallucination, negative symptoms, feelings of disinhibition or dreaminess, sensations of heightened awareness of music, sounds, and colors or tastes ( 34 ). Acute episodes of cannabis-induced psychosis can last from few days to months, with a duration that varies consistently across studies ( 35 ).

Although most studies confirm the abovementioned psychogenic effect of Δ9-THC, discrepancies exist, highlighting the need to determine the consistency and magnitude of this finding.

On the other hand, in recent years, there has been an increasing interest in the properties of cannabidiol (CBD), the second most present cannabinoid in the common cannabis, which does not seem to induce psychotic symptoms, yet somehow anxiolytic and antipsychotic effects (If there are no such papers this should be stated.

In line with this knowledge, in their randomized, double blind clinical trial, Morgan et al. ( 36 ) administered cannabinoids by inhalation to 48 cannabis users; they planned four sessions, THC (8 mg), THC (8 mg) + CBD (16 mg), CBD 16 mg and placebo. They found an increase in psychotomimetic symptoms following administration of THC alone and the combination of THC and CBD, especially negative, perceptual distortions, and cognitive disorganization. Additionally, lower frequency cannabis users showed a reduction in symptoms following CBD administration alone, compared to placebo. A similar finding was reported by Kleinloog et al. ( 37 ) in a randomized, placebo-controlled, clinical trial on male mild cannabis-users. Specifically, transient positive symptoms were seen after THC administration, as measured by the Positive and Negative Symptoms Scale (PANSS).

Such symptoms seem to be associated with transient neurobiological modification, as proposed by Morrison et al. ( 38 ). In an RCT, comparing i.v. THC or placebo under double-blind condition during EEG recordings, they found that THC can decrease theta coherence between bi-frontal brain regions compared to placebo and that the reduction in coherence was strongly associated with positive psychotic symptoms.

The neurobiological underpinning of cannabis-induced psychotic symptoms, is however still not completely clear. The most common hypothesis involves an imbalance in dopamine levels in the prefrontal cortex ( 39 ). In line with this hypothesis, many genes involved in monoamines metabolism can modulate the effect of acute cannabis administration. Bhattacharyya et al. ( 40 ) showed that psychotogenic effects of cannabis were moderated by two genes that code for proteins that influence dopamine metabolism (i.e. DAT1 3' UTR VNTR and AKT1 rs1130233). Similarly, also polymorphisms in the catechol-O-methyltransferase (COMT) gene seems to moderate the psychosis-inducing effect of cannabinoids ( 41 ), thus strengthening the theory that dopamine moderation can influence psychosis and psychotic-like behaviors.

However, brain imaging SPECT studies reported that THC did not lead to a significant increase in dopamine release even though the dose was sufficient for participants to experience psychotic symptoms, suggesting a non-central role for striatal DA in THC-elicited psychosis ( 42 ).

Interestingly, Radhakrishnan et al. ( 43 ) tested the hypothesis that inducing a GABA deficit in healthy subjects might increase cannabis psychotomimetic properties. In fact, pre-treatment with iomazenil (an antagonist of benzodiazepines on GABA receptors), followed by THC administration, exacerbated subjective and psychophysiological effects of THC in healthy subjects and induced a significantly more severe psychotic episode when compared to THC alone.

In the discussion regarding the detrimental effect of cannabis abuse, there is a need to discuss the difference between a transient psychotic state induced by acute intoxication, a stable psychotic condition, and an increase in the risk of developing further primary psychiatric disorders. In this regard, the longitudinal study carried out by Manrique-Garcia et al. ( 44 ), found that cannabis is a risk factor for the development of schizophrenia in a cohort of 50,087 Swedish men with a history of cannabis use in late adolescence, followed up for 35 years. However, the risk was reported to be associated with the frequency and the dosage of cannabis, with moderate users showing a declining risk over the years. Similarly, a study that followed up 705 subjects for 6–60 months showed that the cessation of cannabis use may be beneficial in terms of reducing the psychotic experiences and subsequent risk of psychiatric disturbances ( 45 ).

Regarding the development of psychosis in specific populations, Valmaggia et al. ( 46 ), prospectively assessed the influence of cannabis use on the transition to psychosis in a sample of 184 subjects at Ultra-High Risk for psychosis, with a follow-up of 2 years. The results showed that lifetime, frequent, early-onset, and continued use were all associated with a more probable transition to psychosis. In addition, transition to psychosis was higher among those who started using cannabis before the age of 15 and continued frequent use.

This is corroborated by brain functional imaging studies showing that repeated exposure to cannabis during adolescence may have detrimental effects on brain resting functional connectivity, intelligence, and cognitive function ( 47 ).

Therefore, cannabis seemed to have acute psychogenic effects and longitudinal studies showed that cannabis can increase the risk of developing psychosis, especially in subjects already at risk for psychiatric disturbances. Moreover, cannabis seems to have the highest conversion rate (47%) to Schizophrenia compared to other substance-induced psychosis ( 13 ). However, such conversion seems associated also with the duration of cannabis use, since Shah et al. found that patients who completely abstained from cannabis after the 1st episode of Cannabis-Induced psychosis had no relapse of psychiatric illness ( 35 ). Moreover, the symptoms of presentation might have a predictive role for the consequent psychiatric disorder. In a recent study ( 35 ) half the patients who developed non-affective psychosis progressed to an independent psychotic disorder (e.g., schizophrenia), while only 7.7% of patients who developed predominantly affective psychosis developed an independent disorder. This latter result shows the importance of distinguishing non-affective from affective cannabis-induced psychosis in clinical practice. However, only a few studies have investigated the long-time effect and the clinical implications in the general population.

Synthetic Cannabinoids

Synthetic cannabinoids (SC), also known as Spice, K2, and Kush, are illicit narcotic substances commonly abused in United States, Europe, and Australia. They are composed of herbal mixtures, sprayed with various SCs ( 48 ).

These substances have been available in Europe since 2004 ( 49 ) and are assumed typically by smoking or inhalation, similarly to cannabis itself; however, unlike cannabis, SCs are not detected by common drug screens ( 50 ).

Since the sixties, several synthetic compounds active on CBD receptors have been synthesized, introducing slight modifications to the original structure, thus, resulting in the emergence of three consecutive generations of synthetic cannabinoids ( 51 ).

Regarding pharmacodynamics, SCs mimic the action of Δ9-tetrahydrocannabinol (Δ9-THC), activating thus CB-1 receptors, resulting in psychotomimetic effects.

While on the one hand Δ9 THC is a partial agonist, SCs are full agonists, also with a higher affinity than Δ9 THC ( 48 ). Regarding the adverse effects of SCs ( 52 ), conducted a systematic review of case reports and case series on adverse events of synthetic cannabinoids, reporting in particular nausea, vomiting, pulmonary injuries, acute kidney injury, generalized tonic-clonic seizures, cardiovascular events and psychiatric conditions (i.e., psychosis, anxiety, paranoia, hallucinations).

In the last decades, several studies investigated the correlation between THC and psychiatric symptoms, in particular psychotic ones, but reports regarding SCs-induced symptoms are scattered and sporadic.

In subjects with a negative psychiatric history, case reports showed transient, acute, psychotic symptoms, such as paranoia, visual and auditory hallucinations, after smoking K2 or Spice ( 53 – 61 ).

Case reports about the occurrence of visual hallucinations after a single dose of JWH-018 ( 62 ) and the presence of JWH-018 metabolites from three people with paranoia and hallucinations ( 63 ) are also documented in the literature.

The risk to develop severe psychotic symptoms, however, seems to increase in presence of a previous psychiatric diagnosis. In this regard, two patients affected by Attention Deficit Hyperactivity Disorder (ADHD) showed a severe psychotic picture, in one case characterized by paranoid delusions and self-mutilation after an acute use of SCs ( 64 ), while in the other by catatonia, self-talk, and inappropriate laughter following 18 months of continuous and heavy SCs use ( 65 ).

Moreover, Peglow et al. observed a patient affected by post-traumatic stress disorder (PTSD) who had visual hallucinations and disorganized, bizarre behavior after Spice use ( 58 ).

Lastly, Rahmani et al. ( 66 ) described psychotic symptoms after using SCs in two adolescent males with a family history of schizophrenia, alcoholism, depression, and anxiety.

Moreover, in patients with a former diagnosis for psychiatric disorders and vulnerable, high-risk, individuals ( 67 ), SCs can precipitate the severity of the disturbances by eliciting a psychotic relapse. This seems particularly true for patients affected by schizophrenia and substance-induced psychosis. Specifically, Celofiga et al. ( 68 ) reported delusions and hallucinations after SCs use in patients with a history of schizophrenia. Similarly, in a follow-up study, Every-Palmer ( 69 ) reported that in 15 patients affected by schizophrenia, schizoaffective disorder, and bipolar affective disorder, 9 of them reported or exhibited psychotic symptoms after SCs use. Furthermore, patients with a previous history of substance-induced psychosis could present severe psychotic symptoms mainly with delusions after smoking Spice, and other SCs ( 61 , 67 , 70 ).

Overall, results obtained from the abovementioned case reports showed that SCs had an important psychogenic effect. However, further studies are needed to confirm these results. Particularly, longitudinal studies could better elucidate the SC's long-term psychogenic effects on abusers without psychiatric comorbidity and on subjects with psychiatric diagnoses.

Cathinone Derivates

Cathinone and its derivatives are drugs related to the family of phenethylamine (as amphetamines and methamphetamines), but with much lower potency ( 71 ).

Synthetic cathinones appeared in drug markets in 2005, when methylone, an analog of MDMA, was the first synthetic cathinone reported to the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA). Even if it had been synthesized ~8 years earlier as an ephedrine homolog ( 72 ) the first reports of 4-methyl-methcathinone, also called mephedrone, emerged in Israel in 2007, spreading then in other countries to worldwide in a relatively short period ( 73 ), becoming the most used synthetic cathinone.

Mephedrone is usually administered orally and snorted. Furthermore, being completely water-soluble, it can be injected intramuscularly or intravenously, or even taken by rectal administration using a needle-free syringe ( 74 ). When taken orally, mephedrone starts to give effects to consumers within 15–45 min after ingestion; when snorted the effects can be felt in minutes with a higher peak, usually reached after 30 min. In both oral and nasal use, the effects last for 2–3 h; Conversely, if taken intravenously, only half an hour ( 75 ).

As mephedrone use became more popular, many authors began to study the pharmacodynamics of this new psychoactive drug, finding, in particular, an increase of dopamine release and inhibition of the reuptake of monoamines ( 15 – 19 ).

Some authors administered mephedrone, MDMA, or amphetamine to rats, concluding that the first and the latter produced a rapid and steep increase of extracellular dopamine (496 and 412%, respectively), while for MDMA the percentage was significantly lower (235%). Parallelly, extracellular serotonin increased by 941% in the case of mephedrone, 911% in MDMA, and only 154% in amphetamine. Psychomotor excitability was the highest in amphetamine, and three times lower in the other two drugs studied.

Furthermore, according to the results of this study, the authors found that high doses of mephedrone cause a fast release of dopamine and serotonin from the nucleus accumbens, but conversely, the elimination rate of dopamine was as fast as the one of amphetamine, leading to a more potent and robust stimulation of the addiction circuits ( 76 ).

The main purpose and desired effects of mephedrone are caused by its entactogenic properties: increased subjective social skills, libido abilities, and a deep sense of wellness. The other more common side effects of mephedrone are sweating, headache, tachycardia, palpitations, nausea, thoracic pain, bruxism, psychomotor agitation, and paranoia. Whereas, cardiac, psychiatric, and neurological signs are some of the adverse effects reported by synthetic cathinone users, agitation, ranging from mild agitation to severe psychosis, is the most common symptom identified from medical observations ( 77 ); such symptom usually presents itself with aggressiveness, hallucinations, delusions, hyperactivity and, in rare cases, sudden death: this clinical syndrome is called “excited delirium,” also common in cocaine and amphetamines consumption ( 78 , 79 ).

To date, no study reports a rate of development of an induced psychotic episode or exacerbation of psychotic symptoms in people already diagnosed.

Cocaine, also known as coke, is a stimulant used as a recreational drug. For thousands of years, indigenous people of South America have chewed the leaves of a plant (i.e., Erythroxylon coca) which is packed with plenty of alkaloids, including cocaine, isolated only in 1855 by Friedrich Gaedcke, who called such compound “erythroxyline” ( 80 ).

It is well-known that cocaine use is associated with various mental disorders ( 81 , 82 ) and that its consumption may lead to both transient psychotic symptoms ( 23 , 24 , 83 , 84 ) and a complete induced psychosis ( 85 ).

Cocaine has been demonstrated to bind to the DAT transporter on the outward-facing conformation, blocking it in this conformation; in addition, cocaine also acts as an inhibitor of serotonin and noradrenaline reuptake, thus making cocaine a full-acting monoamine-reuptake inhibitor ( 20 ). Cocaine has also been shown to antagonize the 5-HT3 receptor, but the exact effects of its properties are still unclear ( 21 ). Cocaine also blocks sodium channels, interfering with the propagation of action potentials, making it act as a local anesthetic ( 22 ).

The onset of any psychotic feature during cocaine use is common, ranging from 29 to 86.5% ( 86 ), although these symptoms do not always accompany the intake and vanish with withdrawal ( 87 – 90 ).

Regarding the clinical features of psychotic symptoms in cocaine users, in a study on 55 patients with cocaine addiction, 29 reported psychotic symptoms: 90% of subjects had paranoid delusions, 96% experienced hallucinations (the most common were auditory), and 29% developed behavioral abnormalities ( 83 ).

In a larger European study, in which 173 patients were enrolled, 53.8% reported psychotic symptoms, with a neat higher frequency of paranoid and suspiciousness beliefs; hallucinations were also present, and data from previous studies confirmed the higher likelihood of visual ones ( 23 ).

Interesting data was found regarding the risk factors for developing psychosis during cocaine use. Firstly, the quantity of cocaine consumed is positively related to the onset of psychosis, with a significant correlation between dose and severity of symptoms ( 91 ). Additionally, using cocaine from a young age leads to higher vulnerability ( 83 , 92 – 94 ), with a negative correlation between age at cocaine use onset and symptoms severity ( 87 ). Even psychiatric comorbidities were proven to be a risk factor, especially regarding ADHD ( 86 ), previous psychotic episodes ( 95 ), and various personality disorders ( 96 ), amongst which the most common are antisocial and borderline personality disorders.

The importance of genetics became fundamental in the study of risk factors: significant correlations for variants of the dopamine transporter (DAT) gene ( 97 ), the catechol-O-methyltransferase (COMT) gene, and other genes coding for enzymes implied in dopamine metabolism were found. Such results need further studies to be confirmed, as different studies have failed to prove significant different genotypes between patients with or without cocaine-induced psychosis ( 98 – 100 ).

Methamphetamines

The parent compound of this class of substances, amphetamine (contracted from alpha-methylphenethylamine), has been chemically modified leading to plenty of variants, including methamphetamine (METH; N-methyl-alpha-methylphenethylamine), methylenedioxyamphetamine (MDA) derivatives, and many others. Some amphetamines, including dextroamphetamine, methamphetamine, and the related methylphenidate, are widely used in the treatment of attention deficit hyperactivity disorder (ADHD), obesity, and narcolepsy. Amphetamine and methamphetamine share similar characteristics, and thus they are generally called “amphetamines,” while MDA derivatives (i.e., 3,4-methylenedioxyamphetamine, MDA); 3,4-methylenedioxy-N-methylamphetamine, MDMA or ecstasy; 3,4-methylenedioxy-N-ethylamphetamine, MDEA) for their effects are called “empathogens” or “entactogens.”

According to the World Drug Report 2019 ( 101 ) published by the United Nations Office on Drugs and Crime, in 2017 there were an estimated 28.9 million past-year users of amphetamine and methamphetamine (MA), corresponding to 0.6% of the global population aged 15–64, 15% lower than the previously estimated 34.2 million in 2016, with the form of the MA used varying considerably in different regions.

Research has shown that MA-induced psychotic disorder (MIP) is a prevalent health concern among methamphetamine recreational users. It is to note that Vallersnes et al. ( 102 ), in the attempt of estimating the frequency of psychosis for different recreational drugs, found a prevalence of psychosis of 14.7% for amphetamine and 11.3% for methamphetamine, while collecting data of cases with acute toxicity induced by recreational drugs accessing the Emergency Departments (EDs). A recent meta-analysis of Lecomte et al. ( 103 ) of 17 studies indicated that 36.5% of MA misusers have a history of MIP and these prevalence rates were higher when only those with methamphetamine use disorder (MUD) are considered (43.3%) and when the period of assessment was a lifetime (42.7%) rather than current (22.1%). Such results are consistent with our precedent review ( 2 ) and with Gan et al. ( 27 ) which found that, in a population of 1,430 participants with MUD, the incidents of MIP was 37.1% in the sample according to DSM-IV. Finally, Su et al. ( 26 ) in a cross-sectional study among 1,685 abstinent methamphetamine users in China found that 17.0% had MIP.

Amphetamine reverses both vesicular monoamine transporter 2 (VMAT2) and the dopamine transporter (DAT) ( 25 ) to effectively increase synaptic concentrations of dopamine (DA) in the striatum in the nigrostriatal pathway. Amphetamines cause an augmented DA release also in the mesolimbic and the mesocortical pathways from the ventral tegmental area (VTA) into the nucleus accumbens (NAc) and the pre-frontal cortex (PFC) ( 104 ). The DA overflow in the striatum leads to excessive glutamate release into the cortex which might, over time, cause damage to GABAergic cortical interneurons, through impairment of NMDA receptors ( 104 ). This process may lead to a dysregulation of glutamate pathways transmitted through the thalamocortical signals and might result in the presentation of psychotic symptoms because of the damage to the cortex ( 104 ).

In 2018 Arunogiri et al. ( 105 ) published the first comprehensive review on 20 studies conducted in 13 populations to examine correlates of psychosis among people who use amphetamine and methamphetamine (MA). They found evidence that greater odds of psychotic symptoms were associated with more frequent MA use, the quantity of MA used, greater severity of MA addiction, and polydrug use. These results were later confirmed by other Authors, and MIP was associated with: earlier onset of drug use ( 27 , 106 – 108 ), longer duration of MA use ( 26 ), higher MA use dose ( 26 , 27 ), greater severity of MA addiction ( 27 , 107 , 108 ), polydrug use ( 26 ) nature of MA use (crystal methamphetamine vs. other forms of methamphetamine) ( 109 ) and comorbid depression or anxiety symptoms ( 26 , 27 , 108 ). Examining the prospective relationship between the duration of MA use and psychotic symptoms, it was found that the risk of experiencing psychotic symptoms was higher during periods of MA use compared with no use and, as the duration of MA exposure increased, the odds of experiencing psychotic symptoms also increased, with a clear dose-response effect of continued MA use on the risk of psychotic symptoms ( 110 ). Nie et al. ( 106 ), conversely, reported a negative association between the development of psychotic symptoms and higher dose of MA use, suggesting protection through tolerance, while Lamyai et al. ( 107 ) stated that the amount of MA use measured by hair analysis was not related to the experience of MA psychosis.

The onset of psychotic symptoms in a patient treated with an amphetamine drug, benzedrine, was reported for the first time in 1938 ( 111 ). In 1958, Connell ( 112 ) described 42 cases of amphetamine psychosis seen at the Maudsley Hospital in London. In the late Seventies, observing that an acute administration of amphetamines produced an accurate phenocopy of schizophrenia, several authors theorized that amphetamine-induced psychosis could be used as a model of schizophrenia ( 113 ) and that its continuous use could itself cause its development ( 114 ). Later, some authors suggested that once the use of amphetamine had induced symptoms, recurrences could be caused not only by its reuse but also by non-specific psychological stressors without any further use, suggesting an evolution of a lasting vulnerability state in the brain during chronic amphetamines abuse ( 115 , 116 ).

More recently, Voce et al. ( 117 ) performed a systematic review of 94 articles that examined the symptom profile in individuals identified as having MIP. The most reported symptoms across all study types were persecutory delusions (reported in 84% of studies), auditory (69%) and visual (65%) hallucinations, hostility (53%), depression (31%), and conceptual disorganization (36%); negative symptoms did not appear characteristic of MIP (6–19%). The same group, Voce et al. ( 118 ) tried to determine with a three-factor model whether a discrete negative symptom syndrome exists in the psychiatric profile of methamphetamine users. They stated that negative symptoms exist among people who use methamphetamine, yet unlike positive or affective symptoms, they were not correlated with current methamphetamine use or with familial risks for psychosis, but appeared to be related to polysubstance use. Similarities and differences in the clinical features of MIP vs. schizophrenia have been studied by Warne and colleagues. While there has been considerable overlap between MIP and schizophrenia, visual and tactile hallucinations appear more prevalent in acute MIP, while schizophrenia is associated with pronounced thought disorder and negative symptoms ( 119 ).

Among MA users, most who experience psychotic symptoms showed a “transient psychosis,” which is experienced exclusively when using methamphetamine and recedes after intoxication ( 120 ). Some studies reported that a minority of people (up to 25%) experienced a “persistent psychosis,” i.e., a more prolonged psychosis that persists after stopping use of the drug (>1 month after abstinence) ( 117 , 121 ). Lecomte et al. ( 122 ) suggested that severe psychotic symptoms, the duration of meth use, and sustained symptoms of depression were the strongest prognosticators of persistent psychosis. McKetin et al. ( 123 ) in a longitudinal prospective cohort study of addicted methamphetamine users, focused on the finding that persistent psychotic symptoms were more specifically related to a family history of a primary psychotic disorder and suggested that such individuals may have a pre-existing vulnerability to psychosis, following Tsuang ( 124 ) and Chen et al. ( 125 ).

Hallucinogens

The term “hallucinogen” was introduced in 1954 by Hoffer, who noted that for the first time certain drugs reproduced psychotic-like symptoms in healthy subjects ( 126 ). More recently, the term “psychedelic,” literally meaning mind-manifesting, has also been employed in the scientific community, to underline the fact that the psychological state induced by hallucinogens is not necessarily defined by pathological features ( 127 ). Nowadays, classic hallucinogens are considered such substances as those with a psychopharmacological profile resembling the one of mescaline, psilocybin, and lysergic acid diethylamide (LSD) ( 128 ).

There are two main chemical classes of classic hallucinogens: tryptamines and phenethylamines. The tryptamines include dimethyltryptamine (DMT), psilocybin (4-phosphoryloxy-DMT), and lysergic acid diethylamide (LSD); the phenethylamines include mescaline and many synthetic hallucinogens such as DOM and DOI ( 128 ).

It is to note that Vallersnes et al. ( 102 ) found a prevalence of psychosis of 20.9% for LSD and 18.8% for psilocybe mushrooms, between recreational drugs users presenting themselves in an Emergency Department. These results should be examined in the light of important limitations (data on previous psychiatric diagnoses not collected, no follow-up data, diagnosis made by ED clinician); in fact, it is reported that a search in 2003 for case reports of LSD-induced psychosis found only three reports in the previous 20 years ( 128 ). Dos Santos et al. ( 129 ) found that the psychotic episodes associated with ayahuasca, a natural hallucinogen, and DMT intake described in the eight case series/case reports examined were associated with several contributing factors, and not only ayahuasca or DMT intake (es. personal or family history of psychiatric disorders, concomitant use of other drugs).

This class of drugs exerts its main effects increasing 5-HT brain levels, through agonist or partial agonist activity on 5HT receptors. 5-HT2A receptors seem to be the most important hallucinogenic targets, since the observation that 5-HT2A antagonists, like ketanserin, blocks tryptamines-mediated hallucinogenic effects ( 130 ). Classical hallucinogens should be considered as potent modulators of cortex network activity through the increase of the 5-HT2A agonist activity in the medial prefrontal cortex, the reduction of the inhibitory activity by the thalamic reticular nucleus, the altered firing of raphe nucleus, and the augmented activity in the locus coeruleus ( 28 ).

The acute effects of classic hallucinogens are similar, differing in duration and intensity, which depend on the specific substance, the dose, and the way of administration ( 128 ). The altered state of consciousness (ASC), a term coined by Ludwig ( 131 ), caused by this class of drugs comprises several symptoms: sensory alterations (affecting in particular visual perception, but also auditory and tactile ones), audio-visual synesthesia's and altered experience of time ( 127 ). Perception changes represent the most characteristic symptoms and include alteration in the perception of shape, size, and color, and the illusion of movement, but also more complex scenes. Anyway, alterations of visual perception infrequently represent true hallucinations, since they can usually be distinguished from real perceptions, at least at moderate doses ( 127 ).

The psychological content and emotional quality of the experience are unpredictable but are probably influenced by the mental state of the person who takes the drug, the environment in which the effects are experienced, and by the dose and the specific drug that has been taken ( 132 ). Liecthi ( 133 ) recently reviewed the controlled clinical studies of LSD published in the past 25 years. Focusing on psychotic symptoms, he found that disordered cognition could be a more fundamental characteristic of LSD's effects than positive or negative mood. However, LSD use was not characterized by unpleasant psychosis-like symptoms but instead by an overall positive mood state in the greater part of subjects.

Focusing on the long-term consequence of hallucinogen use in a retrospective cross-sectional study, Krebs and Johansen ( 134 ) reported that there were no significant associations between lifetime use of psychedelics and increased rate of any of the mental health outcomes. Furthermore, Rucker et al. ( 135 ) found that “no cases of prolonged psychosis or hallucinogen persisting perception disorder have been reported in modern trials with psilocybin, ayahuasca or LSD,” consistently with what was previously reported.

Entactogens

This class of drugs, due to their tendency to enhance emotions and empathy, was originally named “empathogen” in the 1980's. The term “entactogen,” meaning “ producing a touching within ,” was later adopted in 1986 ( 136 ) to avoid the ambiguous nature and negative connotations of the term “empathogen.” The main compound of entactogen is represented by 3,4-methylenedioxymethamphetamine (MDMA), popularly known as ecstasy. Such substance was first developed in 1912 ( 137 ), used as an adjunct to psychotherapy treatment beginning in the 1970's ( 138 ), and became popular as a street drug in the eighties. Entactogens constitute a subgroup of the amphetamine-type stimulants and are composed of MDA derivatives including three compounds: 3,4-methylenedioxyamphetamine (MDA), 3,4-methylenedioxy-N-methylamphetamine (MDMA), and 3,4-methylenedioxy-N-ethylamphetamine (MDEA). The main difference between ecstasy-type stimulants and other amphetamines/methamphetamines is the presence of a methylenedioxy group attached to the amphetamine aromatic ring in the former compound.

Its popularity as a substance of abuse has increased over time; indeed, according to the World Drug Report 2019 ( 101 ) published by the United Nations Office on Drugs and Crime, in 2017 there were an estimated 21.3 million past-year users of “ecstasy,” corresponding to 0.4% of the global population aged 15–64. Vallersnes et al. ( 102 ) found a prevalence of psychosis of 4.3 % (20/461) between MDMA users presenting themselves in an Emergency Department.

MDMA increases brain levels of monoamines such as serotonin (HT), dopamine (DA), and norepinephrine (NE), via complex mechanisms ( 29 ). They may inhibit 5-HT reuptake through the inhibition of serotonin transporter (SERT) activity. They may also stimulate 5-HT release reversing SERT action through trace amine-associated receptor (TAAR1) agonism, inhibiting vesicular monoamine transporter (VMAT2), and inhibiting the monoamine oxidases (MAO) enzymes ( 28 ). Entactogens also act on norepinephrine transporter (NET), increasing norepinephrine release, and, with less affinity, on dopamine transporter (DAT), increasing dopamine release ( 28 ).

As already reported, MDMA combines a psychostimulant effect with highly unusual changes in consciousness, leading to euphoria and an intense love for oneself and others. In some cases, MDMA consumption can lead to psychotic symptoms, but most of the papers describing such features consist of single-case reports or small case series ( 139 ).

Soar et al. found that 29% of cases showing psychiatric symptoms after MDMA consumption involved psychotics symptoms and suggested that MDMA could cause long-term neurotoxicity ( 139 ). Additionally, they found that 24% of the patients had a previously diagnosed psychiatric history and only 34% had a family psychiatric history. Landobaso et al. ( 140 ) presented one of the largest samples of patients (32 patients) with psychotic symptoms induced by MDMA. They reported that the symptoms were most often positive, such as delusions (96%), hallucinations (96%), and conceptual disorganization (96%). Yet, negative symptoms were also detected, such as depressive mood (90%) and blunted affect (81%). Rugani et al. ( 141 ) compared the psychopathological symptoms of psychotic patients with ( n = 23) and without ( n = 46) recent use of MDMA, during their first psychotic episode and hospitalization, reporting that psychotic patients with recent use of MDMA were characterized by a less blunted affect and more hostile behavior.

Moreover, several authors reported that paranoid delusions and visual hallucinations could persist even several days after MDMA consumption ( 142 ). After the examination of several case reports, McGuire ( 143 ) reported that MDMA use may be associated with chronic psychiatric symptoms, which persist long after the cessation of MDMA use, such as psychotic features, panic disorder, depression, and obsessive-compulsive symptoms; however, it was not possible to determine whether MDMA use was directly responsible or it was incidental. Hallucinogen-persisting perception disorder (HPPD), a rare condition linked to hallucinogenic drugs consumption, is rarely diagnosed, yet it has been formulated due to the persistency of psychotic symptoms in a case report of a 19-year-old male ( 144 ). In 2014 Litjens et al. ( 145 ) presented 31 HPPD cases that implicated MDMA as a causative agent for HPPD-like symptoms, alongside classical hallucinogens.

Phencyclidine and Ketamine-Induced Psychosis

Phencyclidine (PCP) and ketamine are uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonists ( 2 ) and act as short-acting general anesthetics for both human and veterinary use ( 146 ). In particular, their pharmacodynamics is the cause of the positive symptoms, related to the increased dopamine level in the prefrontal cortex and explained by the affinity of ketamine and PCP to the dopamine receptor 2 (D2) ( 147 ). Furthermore, such drugs determine the inhibition of GABAergic interneurons in the prefrontal cortex and increase neuronal activity, leading to an excessive glutamate release in the glutamatergic neurons of the prefrontal cortex ( 147 ). Interestingly, ketamine has recently emerged as a potential treatment for major depressive disorder. A single dose of 0.5 mg kg – 1 of ketamine has been shown to have rapid and relatively potent antidepressant effects.

The annual prevalence of ketamine recreational use and abuse ranges from 0.8 to 1.8% in young adults ( 148 ). Since the recreational use of ketamine was first reported in the 1970's, it has become one of the most frequently used drugs, especially among young people and clubbers ( 149 ).

Clinical Features

Both PCP and ketamine show psychotogenic effects, including hallucinations, delusions, illogical thinking, reduced speech and thoughts, disturbance of emotions and affect, withdrawal, decreased motivation, and dissociation ( 2 , 147 ) with a more powerful psychotic response showed by PCP compared to ketamine ( 147 ).

Interestingly, the cognitive and behavioral effects of PCP and ketamine in animals and humans are strongly similar to the positive and negative symptoms of schizophrenia, suggesting that abnormalities in NMDA receptor function might contribute to the biology of schizophrenia ( 150 , 151 ).

Furthermore, differently from what was observed in amphetamine-induced psychosis, PCP and ketamine seem to also cause negative symptoms, such as apathy, reduced speech, perseveration, and catatonic posturing. In this regard, the abovementioned inhibition of GABAergic interneuron in the prefrontal cortex by PCP and ketamine is considered the neurobiological explanation for the negative symptoms ( 147 ).

Cheng et al. administered the Positive and Negative Syndrome Scale (PANSS) to a sample composed of non-psychotic ketamine users, psychotic ketamine users, and subjects affected by schizophrenia. The groups of psychotic ketamine users exhibited significantly greater total PANSS score and subscale score compared to non-psychotic ones, while such scores in psychotic ketamine users and schizophrenic patients did not differ significantly.

Accordingly, in their clinical trial, Hoflich et al. ( 152 ) found an increased PANSS score after i.v. ketamine administration compared to placebo in healthy volunteers and a significant increase of cortico-thalamic connectivity of the somatosensory and temporal cortex. Interestingly, these alterations of thalamic connectivity in healthy volunteers are similar to those reported for patients with schizophrenia (CIT).

In the clinical trial carried out by Driesen et al. ( 153 ), healthy volunteers show an increased PANSS score after i.v. ketamine administration. Moreover, through an fMRI, they found that changes of global brain connectivity in certain region-specific areas predicted the occurrence of psychotic symptoms.

Nagels et al. ( 154 ) found that ketamine administration to healthy volunteers elicited statistically significant psychopathological effects as assessed by PANSS. In fact, participants experienced perceptual abnormalities and dissociative states with a range of psychotic symptoms, including difficulties in thinking as well as in reality appraisal.

In a recent meta-analysis ( 155 ), which assessed the association between ketamine and psychiatric symptoms in healthy subjects, Beck et al. found that exposure to ketamine was associated with a statistically significant increase in transient psychopathology for total, positive and negative symptoms as measured by PANSS, compared to placebo, confirming thus previous results.

In conclusion, PCP and ketamine may transiently induce schizophrenia-like positive, negative, and cognitive symptoms in healthy subjects, leading to a paradigm shift from dopaminergic to glutamatergic dysfunction in the pharmacological model of schizophrenia. Interestingly, apart from the mentioned psychotic symptoms, in the last year's ketamine was approved as an antidepressant for treatment-resistant depression ( 156 ). Interestingly, although the dosage in depression is similar to those that can induce psychotic symptoms, recent studies suggest that the basal pre-drug state of the organism influence the overall outcome. Specifically, ketamine effects on NMDA receptors in depressive brains can lead to amelioration or remission of symptoms, whereas healthy individuals develop psychotic features ( 157 ).

However, the majority of the studies assessed in this review described the effects of ketamine and PCP in healthy subjects and patients affected by schizophrenia: further studies are needed to evaluate the recreative use of ketamine and PCP and their clinical implications.

In the last 20 years, plenty of papers have focused on psychosis induced by cannabinoids, cocaine, and methamphetamines. As we have already described in the previous review ( 2 ), despite the important diffusion of entactogens (MDMA and related substances) and classic hallucinogens (mescaline, psilocybin, and LSD) especially among young subjects, few papers are present on such compounds. Consequently, although the possible association with psychotic symptomatology seems clear, the scientific community is far from being able to provide conclusive evidence on this topic.

As an update of the abovementioned work, the most important finding is the increased number and variety of new psychoactive drugs. In time, more and more potent substances have been created and spread in their use, with more severe effects and consequences for recent users in comparison to the past. In fact, abuse of new drugs (i.e., synthetic cannabinoids, synthetic cathinones) has widened the panorama of secondary psychoses. Specifically, synthetic cannabinoids lead to a similar clinical syndrome to the one caused by cannabinoids, increasing the risk of the onset and chronicization of a fully structured psychotic disorder. Conversely, synthetic cathinones lead to “delirium-like” symptomatology, also called “excited delirium,” with increased psychomotor activity, rage, and increase impulsivity, ranging from a mild episode to a severe one, with sparse psychotic symptoms.

However, distinguishing between substance-induced psychosis, primary psychotic illnesses, and psychotic illnesses with comorbid substance use remains a difficult challenge for clinicians, such as the management of these patients in clinical practice.

The majority of the novel recreational substances are not part of routine urine screening ( 6 ) thus leading to a meaningful difficulty in ruling out a substance-induced psychosis in the differential diagnosis, e.g., in the emergency department where patients often present themselves acutely.

On the other hand, even when the diagnosis of substance-induced psychosis is formulated and psychotic symptoms decrease after metabolization and excretion processes, patients are frequently lost during follow-up ( 11 , 158 ). This specific event is an issue, given that the relationship between substance-induced psychosis and the development of several mental illnesses is well-established and a long-term follow-up period is needed to identify, prevent, and effectively treat further relapses ( 13 ). In fact, up to 32.2% of substance-induced psychoses may convert to either schizophrenia or bipolar disorder ( 13 ). The highest conversion rate was observed in cannabis users. However, except for the substances most studied in the literature (namely, cannabis, cocaine, and methamphetamines), only a few data are available on the persistence of psychosis after acute intoxication and withdrawal. Moreover, even when the diagnosis of substance-induced psychosis is formulated, the conversion rate varies a lot across substances and studies and is influenced by several factors, such as subsequent abstinence ( 35 ) and individual vulnerability ( 46 ). In addition, younger age at the onset of substances abuse plays a fundamental role in the risk of a more probable conversion to a severe condition.

Such findings must be contextualized in the psychosocial background of a progressively younger age of onset of drug use, to focus on prevention strategies rather than diagnosis and treatment in the next future ( 11 ).

Author Contributions

AF and PB contributed to conceptualization and full-text writing. FC, CC, GC, and LO contributed to full-text writing and article selection. All authors read and approved the final manuscript.

This work was funded by Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano (270 R20 and RC 270-02).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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