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JAMA Psychiatry. 2019 Mar 13. doi: 10.1001/jamapsychiatry.2019.0163. [Epub ahead of print]

Association of Cohort and Individual Substance Use With Risk of Transitioning to Drug Use, Drug Use Disorder, and Remission From Disorder: Findings From the World Mental Health Surveys.

Author information

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
Department of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse, National Institute of Health, Bethesda, Maryland.
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
College of Medicine, Al-Qadisiya University, Diwaniya Governorate, Iraq.
Health Services Research Unit, Institut Hospital del Mar Investigacions Mèdiques, Barcelona, Spain.
Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública, Barcelona, Spain.
Pompeu Fabra University, Barcelona, Spain.
Section of Psychiatric Epidemiology-Laboratórios de Investigação Médica No. 23, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil.
School of Psychology, Ulster University, Londonderry, United Kingdom.
Anxiety Disorders Center, Buenos Aires, Argentina.
Unit of Epidemiological and Evaluation Psychiatry, Istituti di Ricovero e Cura a Carattere Scientifico-St John of God Clinical Research Centre, Via Pilastroni 4, Brescia, Italy.
Developmental Psychology, Department of Psychology, Rijksuniversiteit Groningen, Groningen, Netherlands.
Interdisciplinary Center Psychopathology and Emotion Regulation, Department of Psychiatry, University Medical Center Groningen, Groningen, Netherlands.
Department of Psychiatry, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
Department of Psychiatry, University College Hospital, Ibadan, Nigeria.
Parc Sanitari Sant Joan de Déu, Centro de Investigación Biomédica en Red en Salud Mental, Universitat de Barcelona, Sant Boi de Llobregat, Barcelona, Spain.
School of Public Health, The University of Queensland, Brisbane, Australia.
Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, Australia.
Shanghai Mental Health Center, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
National Center of Public Health and Analyses, Sofia, Bulgaria.
Institute for Development, Research, Advocacy and Applied Care, Beirut, Lebanon.
Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University, Beirut, Lebanon.
Department of Psychiatry and Clinical Psychology, St George Hospital University Medical Center, Beirut, Lebanon.
Wrocław Medical University, Wrocław, Poland.
University of Lower Silesia, Wrocław, Poland.
Ecole des Hautes Etudes en Santé Publique, EA 4057, Paris Descartes University, Paris, France.
Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria.
Department of Psychiatry, Chinese University of Hong Kong, Tai Po, Hong Kong.
Mental Health Services, Ministry of Health, Jerusalem, Israel.
National Institute of Psychiatry Ramón de la Fuente Muñiz, Mexico City, Mexico.
Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, Michigan.
Unidad de Docencia, Investigación y Formación en Salud Mental, Servicio Murciano de Salud, Murcia, Spain.
Instituto Murciano de Investigación Biosanitaria Virgen de la Arrixaca.
Centro de Investigación Biomédica en ERed en Epidemiología y Salud Pública, Murcia, Spain.
Universidad Peruana Cayetano Heredia, Lima, Peru.
Colegio Mayor de Cundinamarca University, Faculty of Social Sciences, Bogota, Colombia.
Department of Psychological Medicine, University of Otago, Dunedin, New Zealand.
South African Medical Council Research Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
Groote Schuur Hospital, Cape Town, South Africa.
National Institute of Mental Health, National Center for Neurology and Psychiatry, Kodaira, Tokyo, Japan.
Department of Mathematics, Statistics and Computer Science, Dordt College, Sioux Center, Iowa.
Center for Excellence on Research in Mental Health, CES University, Medellín, Colombia.



Limited empirical research has examined the extent to which cohort-level prevalence of substance use is associated with the onset of drug use and transitioning into greater involvement with drug use.


To use cross-national data to examine time-space variation in cohort-level drug use to assess its associations with onset and transitions across stages of drug use, abuse, dependence, and remission.

Design, Setting, and Participants:

The World Health Organization World Mental Health Surveys carried out cross-sectional general population surveys in 25 countries using a consistent research protocol and assessment instrument. Adults from representative household samples were interviewed face-to-face in the community in relation to drug use disorders. The surveys were conducted between 2001 and 2015. Data analysis was performed from July 2017 to July 2018.

Main Outcomes and Measures:

Data on timing of onset of lifetime drug use, DSM-IV drug use disorders, and remission from these disorders was assessed using the Composite International Diagnostic Interview. Associations of cohort-level alcohol prevalence and drug use prevalence were examined as factors associated with these transitions.


Among the 90 027 respondents (48.1% [SE, 0.2%] men; mean [SE] age, 42.1 [0.1] years), 1 in 4 (24.8% [SE, 0.2%]) reported either illicit drug use or extramedical use of prescription drugs at some point in their lifetime, but with substantial time-space variation in this prevalence. Among users, 9.1% (SE, 0.2%) met lifetime criteria for abuse, and 5.0% (SE, 0.2%) met criteria for dependence. Individuals who used 2 or more drugs had an increased risk of both abuse (odds ratio, 5.17 [95% CI, 4.66-5.73]; P < .001) and dependence (odds ratio, 5.99 [95% CI, 5.02-7.16]; P < .001) and reduced probability of remission from abuse (odds ratio, 0.86 [95% CI, 0.76-0.98]; P = .02). Birth cohort prevalence of drug use was also significantly associated with both initiation and illicit drug use transitions; for example, after controlling for individuals' experience of substance use and demographics, for each additional 10% of an individual's cohort using alcohol, a person's odds of initiating drug use increased by 28% (odds ratio, 1.28 [95% CI, 1.26-1.31]). Each 10% increase in a cohort's use of drug increased individual risk by 12% (1.12 [95% CI, 1.11-1.14]).

Conclusions and Relevance:

Birth cohort substance use is associated with drug use involvement beyond the outcomes of individual histories of alcohol and other drug use. This has important implications for understanding pathways into and out of problematic drug use.

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