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标题：Refining the Notion of Maturing Out: Results From the National Epidemiologic Survey on Alcohol and Related Conditions
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作者：Alvaro Vergés ; Angela M. Haeny ; Kristina M. Jackson 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2013
卷号：103
期号：12
页码：e67-e73
DOI：10.2105/AJPH.2013.301358
语种：English
出版社：American Public Health Association
摘要：Objectives. Our aim was to determine if the decrease in drug use disorders with age is attributable to changes in persistence, as implied by the notion of maturing out. Also, we examined the association between role transitions and persistence, recurrence, and new onset of drug use disorders. Methods. We performed secondary analysis of the 2 waves of the National Epidemiologic Survey on Alcohol and Related Conditions data (baseline assessment 2001–2002, follow-up conducted 2004–2005). We conducted logistic regressions and multinomial logistic regression to determine the effect of age on wave 2 diagnosis status, as well as the interaction between age and role transitions. Results. Rates of persistence were stable over the life span, whereas rates of new onset and recurrence decreased with age. Changes in parenthood, marital, and employment status were associated with persistence, new onset, and recurrence. We found an interaction between marital status and age. Conclusions. Our findings challenge commonly held notions that the age-related decrease in drug use disorders is attributable to an increase in persistence, and that the effects of role transitions are stronger during young, compared with middle and older, adulthood. Since Winick’s seminal report of cessation in drug addiction during the third decade of life, 1 the notion that most drug users mature out has been extensively discussed and replicated across different samples and substances. 2–6 Indeed, it is widely recognized that the rates of both drug consumption and drug use disorders (i.e., abuse and dependence) decrease dramatically over the life span 7–11 (with an exception to this regarding alcohol use 12 ). For example, Chen and Kandel 7 reported longitudinal data on high-school students followed up until their 30s. They found that initiation of drug use tends to occur during late teens and early 20s, whereas cessation tends to occur before the late 20s. Two nationally representative studies, the National Comorbidity Survey (NCS) 11 and the National Longitudinal Alcohol Epidemiologic Survey (NLAES) 9 yielded similar results regarding past-12-month prevalence of use by age, with the youngest participants reporting the highest prevalence. With regard to drug use disorders, both NCS and NLAES also reported a significant decrease with age in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) 13 and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) 14 drug dependence, respectively. In addition, results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) have shown a linear decrease of DSM-IV past-12-month drug abuse and drug dependence with age (although the same pattern is not evident in lifetime estimates). 8 The robust empirical finding of a decrease in drug use and drug use disorders has been interpreted as evidence for a maturational process that leads to cessation in drug consumption. Although this notion of maturing out has been criticized for its vagueness and because it conflates description of the phenomenon with its hypothesized explanation, 15 it has inspired more formal theoretical developments. Both role incompatibility 16 and social control 17 have been proposed as descriptions of the process that leads to maturing out. According to these perspectives, involvement in adult roles—such as marriage or parenthood—puts the drug user in a situation in which consumption is not compatible with the demands and expectations of those responsibilities (role incompatibility) or in which other individuals in the social environment can exert an influence on the drug user’s behavior to reduce or eliminate consumption (social control). Consistent evidence has emerged supporting the notion that involvement in adult roles is associated with changes in drug use and, although less consistently, drug use disorders. The Monitoring the Future Study has shown that unemployment is associated with higher rates of drug use, and that being married and being a custodial parent are associated with lower rates of drug use among adults, 18 although these effects may vary with age. 19–21 In addition, prospective Monitoring the Future Study data have shown that family role transitions, including marriage and parenthood, are strongly associated with reductions in drug use beyond selection effects. 22 Likewise, Kandel and Raveis 23 reported that first-time marriage predicted cessation of marijuana use among men and women, and becoming a parent predicted cessation of both marijuana and cocaine use among women. However, the evidence regarding drug use disorders is not as pervasive or consistent. Overbeek et al. 24 found that changes in marital status and parenthood prospectively predicted the onset of DSM-III-R drug use disorders. However, findings from the first wave of NESARC showed that remission from cannabis and cocaine dependence is not associated with marital status. 25 Although this report used cross-sectional data, results cast doubt on the generalization of findings from drug use to drug use disorders. Regardless of the evidence related to role transitions, the general notion of maturing out can be questioned by examining data on drug use disorder persistence. In particular, the concept of maturing out assumes that most individuals with a drug use disorder achieve remission relatively early in life, so that rates of remission are higher among younger than older individuals. When the same issue is examined in terms of persistence, the expectation is that older people will have higher rates of persistence than their younger counterparts (i.e., decreases in overall drug use disorder prevalence with age will be reflected in increases in drug use disorder persistence with age). However, the limited evidence on persistence available shows the opposite pattern; in both NCS 11 and NLAES, 9 the rates of drug dependence persistence (assessed retrospectively) decreased with age. Although the definition of persistence used in NCS has been criticized 9 for using an inappropriate subsample (i.e., past-12-month dependence among individuals with lifetime dependence), NLAES used a more appropriate definition of persistence (i.e., past-12-month dependence among individuals with prior-to-past-year dependence). However, even the latter definition can be questioned because it is based on cross-sectional data and conflates persistence and recurrence. 26 The first goal of the current study was to investigate to what extent the decline in drug use disorders with age is attributable to changes in persistence, as implied by the notion of maturing out. An advantage of the current study over previous studies addressing the issue of persistence is that we used longitudinal data from both waves of NESARC to define persistence as the rate of past-year drug use disorders among individuals diagnosed 3 years earlier. In addition, the availability of longitudinal data permits distinction between persistence and recurrence (by using information about prior-to-past-year vs past-year diagnosis at wave 1). Thus, the relative contribution of persistence to the rates of drug use disorders can be compared with the contribution of 2 other components, recurrence and new onset, to determine which component better accounts for the decrease in drug use disorders across the life span. The second goal was to determine the association of role transitions and rates of persistence, recurrence, and new onset. As mentioned previously, although there is consistent evidence regarding the effect of role transition on changes in drug use, this has yet to be shown for drug use disorders. Moreover, we also examined the extent to which this association is moderated by age, given that the concept of maturing out implies a stronger effect of role transitions among younger individuals. If this is true, a significant interaction of age and role transitions should be found, whereas nonsignificant interactions or interactions showing the opposite pattern (i.e., stronger effects among older individuals) should be taken as evidence against the concept of maturing out.