Abstract
Objective
Understanding polysubstance use among US sexual minority adults is important to serve as a population-level baseline to promote health equity around substance use prevention and public health strategies. This study quantifies the number of substances used by sexual identity among US adults.
Methods
We used the 2021 National Survey on Drug Use and Health and included adults (aged ≥18) (unweighted n=47,291). We conducted multivariable Poisson regression models to examine the number of substances used in the past year (count variable; range: 0–18) by sexual identity (“heterosexual”, “gay/lesbian”, “bisexual”, “unknown” [don’t know, refused, blank]), after adjusting for covariates (i.e., age, sex, race/ethnicity, income level, education level, having insurance status, living in urban area, past-year distress level (Kessler-6), any drug or alcohol use disorder in the past year, and sexual attraction).
Results
Of the total sample (51.4% were female, 12.1% were non-Hispanic Black and 17.0% were Hispanic adults), 88.3% were heterosexual, 2.4% were gay/lesbian, 5.0% were bisexual adults, and 4.3% reported “unknown” sexual identity. After adjusting for covariates, a greater number of substances were used in the past year among gay/lesbian individuals (aIRR=1.44, 95% CI=1.09, 1.75), bisexual individuals (aIRR =1.34, 95% CI=1.26, 1.41), and individuals reporting an “unknown” sexual identity (aIRR=1.22, 95% CI=1.09, 1.36) (vs. heterosexual adults).
Conclusions
Tailored substance use prevention and public health strategies specializing in sexual minority populations are warranted.
INTRODUCTION
Polysubstance use (i.e., use of multiple substances) is a public health concern associated with exposure to multiple toxicants in which combinations and interactions of toxicity might occur, posing a higher risk than exposure to one drug compound.1 Polysubstance use, particularly concurrent polysubstance use, is associated with a greater risk for substance use disorders and negative mental and physical health consequences such as drug overdose, greater mental health comorbidities (e.g., mood disorders), risky sexual behaviors, and poorer substance use disorder treatment outcomes.2–7
Sexual minority individuals show a higher prevalence of any substance use, including alcohol, tobacco, cannabis, opioids, and illicit drugs (e.g., ecstasy, cocaine, methamphetamine) than heterosexual peers.8–11 Concerningly, polysubstance use is common in sexual minority populations. For instance, according to the 2020 National Survey on Drug Use and Health (NSDUH) report 66.8% of sexual minority adults reported past-year cannabis use with alcohol use, 18.1% for past-year opioid misuse with cannabis use, and 21.9% for past-year cocaine use with opioid misuse.12 Nonetheless, an understanding of the number of substances used among individuals engaging in polysubstance use, particularly by sexual identity, is still lacking. Among individuals engaging in polysubstance use, it is critically important to understand the number and patterns of substances used by sexual identity to inform potential public health strategies for sexual minority populations.
Therefore, we analyzed the most recent publicly available NSDUH data (2021) to quantify the number of substances used among sexual minority groups. We hypothesized sexual minority adults (vs. heterosexual) would use a greater number of substances. We also identified the most frequently used combinations of substances by sexual identity. Understanding specific patterns is important to inform public health and clinical implications. The findings of this study will inform public health strategies, substance use prevention, treatment, and harm reduction strategies for substance use directed at sexual minority populations.
METHODS
We used the most recent publicly available dataset, the 2021 National Survey of Drug Use and Health (NSDUH), which is a nationally representative dataset that assesses substance use behaviors among noninstitutionalized, civilian individuals in the United States.13 We included all adults (aged ≥18) (unweighted n=47,291) to estimate disparities in the overall prevalence of polysubstance use. Then, we limited our sample to adults who used any two or more substances in the past year (n=17,138) to quantify and identify the patterns of substance use among adults who used multiple substances.
For the outcome, we summed the number of past-year substances used and categorized them as used none, used one substance, used two substances, and used three or more substances. Substances included alcohol, tobacco, cannabis, cocaine, crack, hallucinogens, LSD, PCP, ecstasy, DMT/AMT/Foxy, Ketamine, Salvia, inhalant, methamphetamine, misuse of opioid (i.e., heroin or non-prescribed use of pain-relievers), tranquilizers, stimulants, sedatives (ranged 0–18). Sexual identity was defined as “heterosexual”, “gay/lesbian”, “bisexual,” and “unknown” (i.e., “don’t know”, “refused”, “blank”) based on self-report. We selected covariates related to substance use and sexual identity based on previous literature,14 including age (18–25 years, 26–49 years, 50 years or older), sex (female, male), race/ethnicity (Non-Hispanic [NH] White, NH Black, NH Native American/Alaskan Native, NH Native Hawaiian/Other Pacific Islander, NH Asian, NH multiracial, Hispanic), income level (<$50,000, ≥$50,000), education level (<college, ≥college), having insurance (no, yes), urbanicity (non-metro, small metro, large metro), past-year serious psychological distress (assessed as Kessler-615), past-year any drug or alcohol use disorder (none, any), and sexual attraction (assessed as “Which statement best describes your feelings?”; recoded as “only/mostly attracted to opposite sex,” “equally attracted to all,” “only/most attracted to same sex,” and “not sure/unknown”).
We conducted descriptive analyses of sample characteristics by sexual identity using Rao-Scott adjusted chi-squared tests. We then conducted a multivariable Poisson regression model on the number of substances used in the past year (count variable; range: 0–18) by sexual identity, after adjusting for covariates. To estimate disparities in the overall prevalence of polysubstance use, we first modeled substance use among overall adults (Model 1), and then among adults who used two or more drugs (Model 2). Since the recall of past-year substance use might be less precise than past-30-day use, we ran sensitivity analysis with the same models with past-30-day use to approximate current use. We also identified the top 5 most frequently used combinations of substances by sexual identity among adults who used two or more drugs (Supplemental Figure 1).
We used NSUDH sampling weights and considered 0.05 (two-tailed) as the statistical significance cut-off and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The data analysis of publicly available de-identified data was deemed exempt from the Yale University Institutional Review Board.
RESULTS
Among overall adults, 88.3% (weighted) were heterosexual (straight), 2.4% gay/lesbian, 5.0% bisexual and 4.3% had an “unknown” sexual identity. There were statistically significant differences in the number of used drugs in the past year by sexual identity – used two drugs: 19.1% of heterosexual (straight) vs. 25.7% of gay/lesbian and 24.7% of bisexual; and used three or more drugs: 11.3% of heterosexual (straight) vs. 25.1% of gay/lesbian and 34.2% of bisexual (p-values<0.05; Table 1). Distributions of the number of substances used in the past year by sexual identity among adults who used two or more substances are described in Supplemental Figure 2.
Table 1.
Sample Characteristics by Sexual Identity among US adults, National Survey on Drug Use and Health (NSDUH) 2021
| Sexual Identity | ||||||
|---|---|---|---|---|---|---|
| Overall (%) | Heterosexual (N=39,751; 88.3%) | Gay/Lesbian (N=1,334; 2.4%) | Bisexual (N=3,792; 5.0%) | Unknown (N=2,399; 4.3%) | P-value | |
| Number of drugs | <0.001 | |||||
| 0 | 25.0 | 9,752 (25.6) | 204 (14.9) | 583 (15.4) | 615 (29.5) | |
| 1 | 42.7 | 16,794 (44.0) | 425 (34.3) | 950 (25.7) | 824 (41.1) | |
| 2 | 19.4 | 7,688 (19.1) | 348 (25.7) | 986 (24.7) | 489 (15.5) | |
| 3 or more | 12.9 | 5,517 (11.3) | 357 (25.1) | 1,273 (34.2) | 471 (13.9) | |
| Age, years | <0.001 | |||||
| 18–25 | 13.2 | 10,560 (11.4) | 513 (20.6) | 2,131 (41.3) | 762 (13.9) | |
| 26–49 | 40.3 | 18,832 (39.5) | 636 (47.0) | 1,517 (49.1) | 1,163 (42.8) | |
| 50–65+ | 46.5 | 10,359 (49.1) | 185 (32.4) | 144 (9.6) | 474 (43.3) | |
| Sex | <0.001 | |||||
| Female | 51.4 | 21,380 (50.3) | 661 (41.4) | 2,926 (72.3) | 1,420 (54.1) | |
| Male | 48.7 | 18,371 (49.7) | 673 (58.6) | 866 (27.7) | 979 (45.9) | |
| Race/Ethnicity | <0.001 | |||||
| Non-Hispanic White | 62.2 | 24,870 (62.7) | 836 (64.4) | 2,424 (65.4) | 1,215 (48.7) | |
| Non-Hispanic Black | 12.1 | 4,399 (12.1) | 155 (12.1) | 342 (9.8) | 344 (14.9) | |
| Non-Hispanic Native American/Alaskan Native | 0.6 | 374 (0.6) | 10 (0.2) | 52 (0.9) | 31 (0.8) | |
| Non-Hispanic Native Hawaiian/Other Pacific Islander | 0.4 | 155 (0.3) | 6 (1.1) | 11 (0.2) | 13 (1.0) | |
| Non-Hispanic Asian | 5.9 | 2,392 (5.9) | 45 (3.0) | 132 (4.3) | 167 (8.2) | |
| Non-Hispanic multiracial | 1.8 | 1,449 (1.7) | 63 (1.5) | 224 (3.5) | 123 (2.0) | |
| Hispanic | 17.0 | 6,112 (16.7) | 219 (17.7) | 607 (16.0) | 506 (24.4) | |
| Income level | <0.001 | |||||
| < $50,000 | 44.9 | 17,134 (43.9) | 672 (48.4) | 2,264 (58.3) | 1,240 (49.4) | |
| > $50,000 | 55.1 | 22,617 (56.1) | 662 (51.6) | 1,528 (41.7) | 1,159 (50.7) | |
| Education level | <0.001 | |||||
| Less than college | 69.0 | 24,629 (68.7) | 807 (61.2) | 2,746 (73.0) | 1,717 (74.1) | |
| Higher than college | 31.0 | 15,122 (31.3) | 527 (38.8) | 1,046 (27.1) | 682 (25.9) | |
| Health insurance status | 0.002 | |||||
| No | 10.0 | 3,974 (9.7) | 142 (10.5) | 489 (12.9) | 342 (13.4) | |
| Yes | 90.0 | 35,777 (90.3) | 1,192 (89.5) | 3,303 (87.1) | 2,057 (86.7) | |
| Living area a | <0.001 | |||||
| Non-Metro | 14.9 | 7,006 (15.3) | 168 (8.7) | 670 (13.6) | 325 (9.9) | |
| Small Metro | 30.7 | 15,072 (30.6) | 500 (29.0) | 1,514 (34.3) | 911 (28.4) | |
| Large Metro | 54.5 | 17,673 (54.1) | 666 (62.3) | 1,608 (52.1) | 1,163 (61.8) | |
| Past-year psychological distress b | <0.001 | |||||
| No | 86.2 | 33,523 (88.4) | 884 (74.2) | 1,887 (54.5) | 1,819 (84.5) | |
| Yes | 13.8 | 6,228 (11.6) | 450 (25.8) | 1,905 (45.5) | 580 (15.5) | |
| Past-year any substance use disorder | <0.001 | |||||
| None | 82.6 | 32,651 (84.0) | 909 (72.0) | 2,446 (65.5) | 1,814 (79.5) | |
| Any | 17.4 | 7,100 (16.0) | 425 (28.0) | 1,346 (34.5) | 585 (20.5) | |
| Sexual attraction | <0.001 | |||||
| Only/mostly attracted to opposite sex | 87.8 | 38,539 (97.0) | 38 (4.7) | 1,142 (30.9) | 181 (10.9) | |
| Equally attracted to all | 3.3 | 203 (0.5) | 30 (2.8) | 2,105 (55.4) | 36 (1.3) | |
| Only/most attracted to same sex | 3.1 | 244 (0.6) | 1,230 (90.1) | 293 (7.2) | 14 (0.5) | |
| Not sure / Unknown | 5.8 | 765 (1.9) | 36 (2.3) | 252 (6.6) | 2,168 (87.3) | |
categorized based on the 2013 Rural/Urban Continuum Codes
assessed with Kessler-6
In the total sample, gay/lesbian individuals (aIRR=1.44, 95% CI=1.19, 1.75), bisexual individuals (aIRR=1.34, 95% CI=1.26, 1.41), and the “unknown” sexual identity group (aIRR=1.22, 1.09, 1.36) reported using a greater number of substances in the past year than heterosexual individuals (Table 2, Model 1). Similarly, among adults who used two or more substances in the past year, gay/lesbian (aIRR=1.21, 95% CI=1.03, 1.42) and bisexual individuals (aIRR=1.14, 95% CI=1.08, 1.20) reported using a greater number of substances in the past year than heterosexual individuals (Table 2, Model 2). Our sensitivity analyses with past-30-day use outcomes still found similar patterns, but there were no significant differences in the numbers of substances used in the past 30 days by sexual identity among those who used more than two drugs in the past 30 days.
Table 2.
Results of multivariable Poisson regression on number of substances used in the past year by sexual identity among US adults in 2021 NSDUH
| Number of substances used in the past year | ||||
|---|---|---|---|---|
|
|
||||
| Model 1: Overall adults (n=47,291) | Model 2: Among adults who used 2 or more substances (n=17,138) | |||
|
|
||||
| aIRR (95% CI) | p-value | aIRR (95% CI) | p-value | |
|
| ||||
| Sexual Orientation | ||||
| Heterosexual (Straight) | Reference | Reference | ||
| Gay/Lesbian | 1.44 (1.19, 1.75) | <0.001 | 1.21 (1.03, 1.42) | 0.021 |
| Bisexual | 1.34 (1.26, 1.41) | <0.001 | 1.14 (1.08, 1.20) | <0.001 |
| Unknown | 1.22 (1.09, 1.36) | 0.001 | 1.08 (0.99, 1.17) | 0.095 |
The models were adjusted for age, sex, race/ethnicity, income level, education level, having insurance status, living in urban area, past-year distress level (Kessler-6), past-year substance or alcohol use disorder, and sexual attraction.
The top 5 most frequently used combinations of substances in the past year slightly varied by sexual identity (see Supplemental Figure 1). The most frequently used combinations of substances are mostly legal substances such as “tobacco + alcohol” for heterosexual (38%), “alcohol + cannabis” for gay/lesbian (23.5%), “tobacco + alcohol + cannabis” for bisexual (23.4%) and “tobacco + alcohol” for unknown sexual identity group (24.2%).
DISCUSSION
This study determined sexual minority adults had a greater number of substances used in the past year than heterosexual individuals among all adults and adults using multiple substances. This finding is concerning since substance use–related health disparities in sexual minority populations may accelerate social, economic, and public health burdens. Further, while the majority of polysubstance use involved alcohol, tobacco, and cannabis, some polysubstance use among gay/lesbian and bisexual adults was characterized by the use of inhalants and hallucinogens, respectively. Combinations involving opioid use were found among individuals identifying as heterosexual or an “unknown” sexual identity. The finding will provide public health and clinical implications on tailored substance use prevention and treatment programs specializing in sexual minority individuals.
The greater number of substances used by sexual minority individuals may be due to stress from structural marginalization such as social stigma, systematic discrimination, or risk of harassment and violence.16 Alternatively, this might occur due to sexual minority-targeted marketing by the tobacco, alcohol, and cannabis industries such as featuring Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ)-related symbols (e.g., rainbow), placing advertisements and promotions on venues where sexual minority individuals are populated and using messaging to specifically appeal to sexual minority populations.17 Future studies should examine the underlying mechanisms of polysubstance use among sexual minority populations to inform culturally appropriate substance use prevention and treatment programs tailored to sexual minority populations to address unique components of polysubstance use.
The rigorous examination of the most recent US national data confirms previous research findings of elevated polysubstance use among sexual minority individuals.18 This novel examination of polysubstance use by sexual identity can inform public health strategies for prevention and harm reduction to reduce disparities in health outcomes. Though, there are limitations to this study. This study relied on self-report and there may be recall or social desirability bias. We examined past-year substance use, so we were unable to contextualize polysubstance use as concurrent or simultaneous use. Lastly, the NSDUH did not assess gender identity (e.g., cisgender, transgender, non-binary, pangender, agender).
Despite its limitations, the greater number of substances used among sexual minority vs. heterosexual individuals suggests future research directions and clinical implications. Continuous surveillance and regulation on tobacco, alcohol, and cannabis marketing content targeting sexual minority individuals, and developing counter-messaging for prevention and cessation of substance use directed at sexual minority individuals are warranted. Clinical efforts might include tailored substance use prevention and treatment programs specializing in sexual minority populations such as addressing homophobia, violence, childhood trauma, and social isolation.19 Such a tailored approach to polysubstance use treatment and prevention by specifically addressing unique components related to sexual minority populations will increase the efficacy of substance use treatment, dismantle substance-related health disparities among sexual minority populations, and may decrease the risk of developing or exacerbating a substance use disorder.
Supplementary Material
Supplemental Figure 1. Most frequently used combinations of substance by sexual identities among adults who used two or more substances, 2021 NSDUH adults Note. Among persons who used 2+ substances in the past year
Supplemental Figure 2. Number of substances used in the past year by sexual identity among adults who used 2 or more substances in the past year, 2021 NSDUH adults
Supplemental Table 1. Results of multivariable Poisson regression on number of substances used in the past 30 days by sexual identity, 2021 NSDUH adults
Highlights.
Sexual minority adults had a greater number of substances used than heterosexuals.
Most frequently used combinations of substances varied by sexual identity.
Tailored substance use prevention specializing in sexual minority are warranted.
FUNDING:
Juhan Lee’s effort was supported by grant number U54DA036151 from the National Institute on Drug Abuse (NIDA) and U.S. Food and Drug Administration (FDA) Center for Tobacco Products (CTP). Rebecca Evans-Polce’s effort is funded by the National Institute on Alcohol Abuse and Alcoholism (R01 AA030243).
Glossary
- NSDUH
National Survey of Drug Use and Health
- NH
Non-Hispanic
- STROBE
Strengthening the Reporting of Observational Studies in Epidemiology
- IRR
Incidence-Rate Ratios
- LGBTQ
Lesbian, Gay, Bisexual, Transgender, and Queer
Footnotes
CONFLICT OF INTEREST: None
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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REFERENCES
- 1.Crummy EA, O’Neal TJ, Baskin BM, Ferguson SM. One Is Not Enough: Understanding and Modeling Polysubstance Use. Front Neurosci. 2020;14. doi: 10.3389/fnins.2020.00569 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Wilson N, Kariisa M, Seth P, Smith H, Davis NL. Drug and Opioid-Involved Overdose Deaths - United States, 2017–2018. MMWR Morb Mortal Wkly Rep. Published online 2020. doi: 10.15585/mmwr.mm6911a4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Connor J, Gullo M, Chan G, Young R, Hall W, Feeney G. Polysubstance Use in Cannabis Users Referred for Treatment: Drug Use Profiles, Psychiatric Comorbidity and Cannabis-Related Beliefs. Front Psychiatry. 2013;4. 10.3389/fpsyt.2013.00079 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Salom CL, Betts KS, Williams GM, Najman JM, Alati R. Predictors of comorbid polysubstance use and mental health disorders in young adults—a latent class analysis. Addiction. 2016;111(1):156–164. doi: 10.1111/add.13058 [DOI] [PubMed] [Google Scholar]
- 5.Mimiaga MJ, Reisner SL, Vanderwarker R, et al. Polysubstance use and HIV/STD risk behavior among Massachusetts men who have sex with men accessing Department of Public Health mobile van services: implications for intervention development. AIDS Patient Care STDS. 2008;22(9):745–751. doi: 10.1089/apc.2007.0243 [DOI] [PubMed] [Google Scholar]
- 6.Lewis MA, Zhou Z, Parks KA, et al. Polysubstance use among young adults and differences in negative alcohol-related sexual experiences. Addict Behav. 2023;138:107571. doi: 10.1016/j.addbeh.2022.107571 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Staiger PK, Richardson B, Long CM, Carr V, Marlatt GA. Overlooked and underestimated? Problematic alcohol use in clients recovering from drug dependence. Addiction. 2013;108(7):1188–1193. doi: 10.1111/j.1360-0443.2012.04075.x [DOI] [PubMed] [Google Scholar]
- 8.Schuler MS, Stein BD, Collins RL. Differences in substance use disparities across age groups in a national cross-sectional survey of Lesbian, Gay, and Bisexual Adults. LGBT Heal. 2019;6(2). doi: 10.1089/lgbt.2018.0125 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Medley G, Lipari RN, Bose J, et al. Sexual orientation and estimates of adult substance use and mental health: Results from the 2015 National Survey on Drug Use and Health. Natl Surv Drug Use Heal. 2016;(October). [Google Scholar]
- 10.Rosner B, Neicun J, Yang JC, Roman-Urrestarazu A. Substance use among sexual minorities in the US - Linked to inequalities and unmet need for mental health treatment? Results from the National Survey on Drug Use and Health (NSDUH). J Psychiatr Res. 2021;135:107–118. doi: 10.1016/j.jpsychires.2020.12.023 [DOI] [PubMed] [Google Scholar]
- 11.McCabe SE, Hughes TL, West BT, et al. Sexual Orientation, Adverse Childhood Experiences, and Comorbid DSM-5 Substance Use and Mental Health Disorders. J Clin Psychiatry. 2020;81(6). doi: 10.4088/JCP.20m13291 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Substance Abuse and Mental Health Services Administration (SAMHSA): Substance Abuse and Mental Health Services Administration. 2020 National Survey on Drug Use and Health: Lesbian, Gay, & Bisexual (LGB) Adults (Annual Report). Published 2022. Accessed August 24, 2023. https://www.samhsa.gov/data/report/2020-nsduh-lesbian-gay-bisexual-lgb-adults [Google Scholar]
- 13.Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health (NSDUH). Accessed December 15, 2022. https://www.datafiles.samhsa.gov/study-series/national-survey-drug-use-and-health-nsduh-nid13517 [PubMed] [Google Scholar]
- 14.McCabe SE, Hughes TL, Bostwick WB, West BT, Boyd CJ. Sexual orientation, substance use behaviors and substance dependence in the United States. Addiction. 2009;104(8). doi: 10.1111/j.1360-0443.2009.02596.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003;60(2):184–189. doi: 10.1001/archpsyc.60.2.184 [DOI] [PubMed] [Google Scholar]
- 16.Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull. 2003;129(5). doi: 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Dilley JA, Spigner C, Boysun MJ, Dent CW, Pizacani BA. Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities? Tob Control. 2008;17(6). doi: 10.1136/tc.2007.024216 [DOI] [PubMed] [Google Scholar]
- 18.Goodwin SR, Moskal D, Marks RM, Clark AE, Squeglia LM, Roche DJO. A Scoping Review of Gender, Sex and Sexuality Differences in Polysubstance Use in Adolescents and Adults. Alcohol Alcohol. 2022;57(3):292–321. doi: 10.1093/alcalc/agac006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Green KE, Feinstein BA. Substance use in lesbian, gay, and bisexual populations: An update on empirical research and implications for treatment. Psychol Addict Behav. 2012;26(2). doi: 10.1037/a0025424 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Figure 1. Most frequently used combinations of substance by sexual identities among adults who used two or more substances, 2021 NSDUH adults Note. Among persons who used 2+ substances in the past year
Supplemental Figure 2. Number of substances used in the past year by sexual identity among adults who used 2 or more substances in the past year, 2021 NSDUH adults
Supplemental Table 1. Results of multivariable Poisson regression on number of substances used in the past 30 days by sexual identity, 2021 NSDUH adults