Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

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Abstract

Background

This study aims to estimate general and racial-ethnic specific cumulative probability of developing dependence among nicotine, alcohol, cannabis or cocaine users, and to identify predictors of transition to substance dependence.

Methods

Analyses were done for the subsample of lifetime nicotine (n = 15,918), alcohol (n = 28,907), cannabis (n = 7389) or cocaine (n = 2259) users who participated in the first and second wave of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). Discrete-time survival analyses were implemented to estimate the cumulative probability of transitioning from use to dependence and to identify predictors of transition to dependence.

Results

The cumulative probability estimate of transition to dependence was 67.5% for nicotine users, 22.7% for alcohol users, 20.9% for cocaine users, and 8.9% for cannabis users. Half of the cases of dependence on nicotine, alcohol, cannabis and cocaine were observed approximately 27, 13, 5 and 4 years after use onset, respectively. Significant racial-ethnic differences were observed in the probability of transition to dependence across the four substances. Several predictors of dependence were common across the four substances assessed.

Conclusions

Transition from use to dependence was highest for nicotine users, followed by cocaine, alcohol and cannabis users. Transition to cannabis or cocaine dependence occurred faster than transition to nicotine or alcohol dependence. The existence of common predictors of transition dependence across substances suggests that shared mechanisms are involved. The increased risk of transition to dependence among individuals from minorities or those with psychiatric or dependence comorbidity highlights the importance of promoting outreach and treatment of these populations.

Introduction

Although only a small proportion of individuals who use addictive substances develop dependence (United Nations Office on Drugs and Crime, 2007), substance dependence represents a tremendous burden to the individual and to society (World Health Organization, 2002). Estimating the risk and predictors of transition from substance use to dependence can provide information about the etiology and course of addiction, guide clinicians in identifying patients at higher risk of becoming dependent, and assist in the organization of primary and secondary prevention services.

Previous epidemiological studies have found that between one-third to one-half of daily nicotine smokers develop nicotine dependence at some point in their lives (Anthony et al., 1994, Breslau et al., 2001, Dierker et al., 2008, Kandel et al., 1997) and that, within a decade of alcohol, cannabis and cocaine use, 12–13% develop alcohol dependence, 8% cannabis dependence and 15–16% cocaine dependence (Wagner and Anthony, 2002a). Several risk factors for the transition from use to dependence have been identified, including being young, male, Black or Native-American, poor, with low levels of educational attained, urban residence, early substance use onset, use of another psychoactive substance, and co-occurrence of a psychiatric disorder (Behrendt et al., 2009, Breslau et al., 2001, Chen et al., 2005, Dawson et al., 2008, Grant and Dawson, 1997, Grant and Dawson, 1998, Kandel et al., 1997, O’Brien and Anthony, 2005, Reardon and Buka, 2002, Wagner and Anthony, 2002a, Wagner and Anthony, 2007, Warner et al., 1995).

Despite the significant contributions from previous studies, important questions remain regarding the factors influencing transition from substance use to dependence. For example, most studies have examined all substances together (Kessler et al., 2001, Merikangas et al., 1998) or focused on a single substance (Breslau et al., 2001, Chen et al., 2005, O’Brien and Anthony, 2005), precluding formal examination of similarities and differences of predictors across substances. Psychiatric comorbidity, a consistent predictor of transition in many studies (Kessler et al., 1997, Merikangas et al., 1998) has been often examined as a single category (Merikangas et al., 1998) or analyzed as invariant over time (Breslau, 1995, Sintov et al., 2009). Few studies have examined racial-ethnic differences in the rates and determinants of transitioning from use to dependence (Grant, 1996, Grant et al., 2004b, Kandel et al., 1997, Ridenour et al., 2005).

To fill these gaps in knowledge, we sought to estimate the risk and identify the predictors of transition from substance use to dependence in a large, nationally representative sample of U.S. adults. The specific goals of this study were: (1) to estimate the general and racial-ethnic specific cumulative probability of developing dependence among nicotine, alcohol, cannabis and cocaine users, and, (2) to assess the association between several socio-demographic characteristics, psychiatric comorbidity and drug-use related variables and the risk of transition to dependence among users of these substances.

Section snippets

Sample and procedures

The 2004–2005 Wave 2 NESARC (Grant et al., 2007b) is the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Grant et al., 2003a). The target population was the civilian non-institutionalized population 18 years and older residing in households and group quarters (GQ) (e.g., college quarters, group homes, boarding houses, and non-transient hotels). Blacks, Hispanics, and adults ages 18–24 were oversampled.

Of the 43,093 respondents interviewed at Wave 1,

Sociodemographic characteristics

Socio-demographic characteristics of the study populations are presented in Table 1. Rates of nicotine, alcohol, cannabis and alcohol use were higher among males, Whites and AI/AN and US-born individuals. While rates of nicotine and cannabis use were higher among individuals in the youngest age group (18–29 years old), rates of alcohol and cocaine use were higher among individuals 30–44 years old. Respondents less educated and with an individual income lower than $35,000 reported higher rates

Discussion

In a large, nationally representative sample of US adults, the cumulative probability of transition to dependence was highest for nicotine users, followed by cocaine users, alcohol users and, lastly, cannabis users. The transition to cannabis or cocaine dependence occurred faster than the transition to nicotine or alcohol dependence. Furthermore, there were important variations in the probability of becoming dependent across the different racial-ethnic groups. Most predictors of transition were

Role of funding source

This study is supported by NIH grants DA019606, DA020783, DA023200, DA023973, MH076051, MH082773 and CA133050 (Dr. Blanco) and AA014223, DA018652, and AA018111 (Dr. Hasin), a grant from the American Foundation for Suicide Prevention (Dr. Blanco), and the New York State Psychiatric Institute (Drs. Blanco and Hasin). The NIH, the American Foundation for Suicide Prevention, and the New York State Psychiatric Institute had no further role in study design; in the collection, analysis and

Contributors

Blanco C designed the study, Lopez-Quintero C managed the literature searches and summaries of previous related work, and wrote the first draft of the manuscript and Wang S conducted the statistical analyses. All authors contributed to and have approved the final manuscript.

Conflict of interest

None.

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