If you were to look at the drug use of a group of people over a 3-year period, how many do you think would start using illicit drugs during the period and what would happen to them? The answers to these and related questions are discussed in a recent, important study published in the American Journal of Psychiatry by Wilson Compton and colleagues. Some of the results may surprise you.

This study involved interviewing over 34,000 persons 18 years and older and then interviewing them again 3 years later. Based on their drug use behavior during the year prior to the first assessment, people were classified as non-users, asymptomatic users, and problem users of illicit drugs. Illicit drugs included illegal drugs as well as prescription drugs used recreationally. 

During the intervening 3 years, 4.6% of non-users tried an illicit drug. Of those who initiated drug use during this period, over half progressed to problematic drug use. Problematic drug use was defined as developing one or more DSM-IV-defined symptoms of drug abuse or drug dependence.

Of those entering the study with a recent history of asymptomatic (non-problematic) use of illicit drugs, 66% stopped using drugs during the 3-year period. Of those still using, over half progressed to problematic use.

Of those who already demonstrated problematic use when entering the study, about half stopped using during the 3-year follow-up period, 11% continued using but without problems, and about 40% persisted with problematic use.

Did any factors predict which individuals would progress to a worse state? Specifically, were there predictors that might help us prevent progression to problem use? Yes. One predictor was age. The younger the person was when s/he started using, the worse the outcome. Other predictors included heavy alcohol and/or tobacco use. Also, the presence of depression and certain personality disorders, including borderline personality disorder, correlated with worse outcomes.

So, what can we do to decrease progression to problematic drug use? First, the longer we can delay the onset of illicit drug use, the better. Since young people progress more rapidly to problem use, targeting prevention programs to that population makes sense. Second, the more we can prevent cigarette smoking and minimize alcohol use, the more we can delay or prevent illicit drug use. Third, the better the medical community becomes at recognizing and treating depression as well as personality disorders, the better our chances of decreasing illicit drug use.

It is also important to note that half the people with problematic drug use stopped using during the study period. This occurred more often in those who had been abusing less addictive drugs, did not suffer from certain personality disorders (schizotypal or narcissistic), and started abusing drugs at a later age. Two-thirds of those who were asymptomatic (non-problematic) users also stopped using during the 3-year period. These results indicate that we should aggressively try to get help for those using drugs. Even if initial efforts at treatment fail in a particular individual, many will succeed longer term. As more successful treatment methods are developed, the number of successes should increase.

As we have stated in several earlier postings, alcohol, cigarettes, and illicit drugs are among our most serious public health hazards. Drug use kills either by direct toxic effects of the drugs, or indirectly, by the drugs contributing to risk factors leading to heart disease, cancers, and strokes. Importantly, the major drivers of societal costs associated with drug use are not illegal drugs, but rather alcohol and tobacco, and these two legal drugs significantly impact the transition of some people to problematic illicit drug use. This raises serious concerns about unintended consequences of efforts to legalize marijuana and other illicit drugs.

Psychiatric illnesses and drug use disorders are serious medical conditions that the entire medical community, including internists, family practice physicians, pediatricians, and ob-gyn doctors, must become comfortable in addressing. Mental health professionals, including psychiatrists, can and should be involved as expert collaborators. Some progress is being made, but we all can do a lot better.

This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.

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