Is Substance Use Problem Recognition Influenced By the Type of Substance Use Disorder?

Background and Purpose: In the U.S., approximately 90% of persons with a substance use disorder (SUD) do not receive treatment for their condition. One possible reason is that those with a SUD do not perceive their substance use as problematic. While researchers have studied factors associated with treatment utilization, study of factors associated with SUD recognition (a precursor to behavior change and seeking treatment) is lacking. To address this gap, we explored whether perceptions of having problematic substance use differed by SUD type. For example, alcohol consumption is common. Individuals who drink problematically may socialize with others who do the same, inhibiting problem recognition. Perception of cannabis’ harmfulness has decreased, perhaps affecting recognition of problematic cannabis use. On the other hand, public attention on the opioid crisis may have increased individuals’ awareness of their opioid use as problematic.

Methods: Study data came from the 2022 National Survey on Drug Use and Health. The analytic sample included adults who screened positive for a past-year SUD (N = 9,487). The outcome variable was whether respondents perceived their substance use as problematic. The independent variable was type of substance use disorder diagnosis, coded as alcohol, cannabis, opioid, other, or multiple substance use disorders. Sociodemographic covariates included sex, age, race/ethnicity, education, employment, and geographic area. Clinical covariates were chronic health conditions, mental health comorbidity, nicotine dependence, treatment history, and legal involvement. Poisson regression modeling with a log link function was used to test for associations between SUD diagnoses and perceived problematic substance use, adjusting for covariates. Results are presented as incident risk ratios (IRR) with 95% confidence intervals.

Results: Two-thirds of adults with a SUD did not perceive their substance use as problematic. Multivariable analyses showed that relative to persons with alcohol use disorder, persons with cannabis use disorder did not differ in their risk for perceiving problematic substance use. Persons with opioid use disorder had a 1.15 times higher risk (IRR=1.15, 95% CI = 1.06-1.25), and those with other SUDs had a 1.24 times higher risk (IRR=1.24, 95% CI = 1.11-1.38) of not perceiving their substance use to be problematic. Persons with multiple substance use disorders were at lower risk of perceiving their substance use to be non-problematic (IRR= 0.79, 95% CI = 0.71-0.88). African Americans, Latinos, younger adults, and persons not in the work force were at higher risk of perceiving their substance use as non-problematic.

Conclusions and Implications: Findings indicate that persons with opioid and other illicit substance use disorders are less likely to recognize their substance use as problematic than persons with alcohol use disorder. This was surprising given the substantial public health response to the opioid epidemic over the last decade, indicating a need to address variations in substance use problem recognition across specific substance use disorders. Identifying factors that promote problem recognition may foster treatment engagement and behavior change. Racial disparities require exploring cultural barriers to problem recognition that can better inform interventions and treatment services for diverse populations.