Shifts in Motivation to Seek Substance Use Disorder Treatment in Adolescents, Emerging Adults, and Older Adults

Introduction

In 2019, 7.4% of people ages 12 and older in the U.S. met the criteria for having an active substance use disorder (SUD) in the last year (SAMHSA, 2020). However, only 10.3% of people ages 12 and older that met the criteria for a SUD in the last year received treatment (SAMHSA, 2020). Even though behavioral healthcare, technology, and medicine have improved, the prevalence of SUDs has remained relatively constant.

An interesting area of study that may increase the rate of treatment for SUDs is motivations. There is robust research on how different forms of motivation affect SUD treatment, particularly the impact of intrinsic and extrinsic motivation, but there is little to no research comparing specific motivators, such as the criminal justice system, physical health, and social relationships (Cornelius et al., 2017; Curry et al., 1990; Medalia & Saperstein, 2011; Pelletier et al., 1997) or how the types of motivators may change between age groups.

The research on motivators as they apply to addiction treatment is heavily focused on treatment outcomes and retention and often leaves out the impact the motivators have on treatment initiation. This is important because it does not matter what outcomes a motivator is associated with if it is not effective in influencing people to initiate treatment.

Mandated Treatment

A significant portion of people receiving substance use treatment do so via the criminal justice system; it is currently the largest mental health provider in the U.S. (Torrey et al., 2010). As a result, 43.7% of the population receiving specialty treatment for a SUD are on probation because the overwhelming majority of people with a SUD that are on probation are receiving mandated treatment (Johnson et al., 2020).

Physical Health and Social Relationships

In Andersen and Newman’s 1973 foundational paper, “Societal and Individual Determinants of Medical Care Utilization in the United States,” they highlight the impact that an individual’s perceived health (or lack thereof) and social relationships have on healthcare utilization (Andersen & Newman, 1973).

Early research by Aday and Andersen (1974) mentions that a person’s perception of their illness is “the most immediate cause of health service use.” This phenomenon is related to seeking treatment for a SUD because, within the population of people with a SUD that are hospitalized, the most common reason for seeking treatment for their SUD was physical health. (O’Toole et al., 2006). However, individuals reporting physical health problems as a primary motivator were far less likely to complete the treatment program than those that had an alternate motivator (O’Toole et al., 2006). This suggests that although physical health may be a common primary motivating factor, it leads to decreased treatment retention and successful outcomes.

While health-related motivators can be relatively ineffective, the same may not be true for social motivators. Increased social desirability is a predictor of increased treatment retention and decreased severity of substance use (Zemore, 2012). This suggests that a person’s desire to fit in with friends, colleagues, and family is conducive to treatment retention and successful outcomes. A 2009 study on emerging adults and adolescents in SUD treatment found that these populations “experience less social control” which can result in a lack of interpersonal motivation to stop using (Smith et al., 2010). This means that social relationships may be an effective motivator for people seeking SUD treatment, but it may not be as prevalent as health-related motivation and, therefore, it may be more difficult to cultivate this motivator in adolescents and emerging adults.

Thus far, researchers have studied how each of the three motivator categories individually impact various aspects of treatment, particularly treatment outcomes. However, there is no research that we could find that compared these three age groups within or across each of these three motivator categories. It is hypothesized that the relative effect of physical health, social relationships and criminal justice involvement varies by age. This study will help behavioral health professionals and researchers understand which motivators are most prevalent in specific age groups and how those motivators influence individuals’ decisions to enter treatment.

Methods

Data

Public use data files made available online from the 2019 National Survey on Drug Use and Health (NSDUH) were used (CBHSQ, 2020). This dataset is free to download from SAMHSA’s website under data sources. This is an annual survey that aims to provide current information on the state of substance use, mental health, and physical health in America. The survey is conducted by RTI International via computer assisted personal interviewing (CAPI) and audio computer-assisted self-interviewing (ACASI) (CBHSQ, 2020). The survey’s target population was American civilians aged 12 or older that are not institutionalized (CBHSQ, 2020). To survey a population generalizable to the American population, “an independent, multistage area probability sample” was used in all 50 states and the District of Columbia (CBHSQ, 2020). In 2019, 67,625 people completed the survey and 56,136 of those interviews were published in the public use file (CBHSQ, 2020).

Measures

The dependent variable in our analysis was “TXYRRCVD2”, which included everyone that received some form of treatment at any location for illegal drugs or alcohol in the past year (CBHSQ, 2020). This variable includes treatments in pastoral, medical, and even self-help settings and is different from the variable that describes treatment in a specialty setting that is frequently used in analyses using this dataset.

There were several independent variables created for this analysis. Two of the independent variables that were created combined the data from questions that were identical except for the substance being mentioned. The first variable combined the data from every question that asked participants, “During the past 12 months, did you have any problems with family or friends that were probably caused by your use of (insert substance)?” The second variable combined the data from every question that asked participants, “During the past 12 months, did you have any physical health problems that were probably caused or made worse by your use of (insert substance)?” Both variables were created by making the dichotomous versions of the original questions in which yes (and any answer that could be logically assigned to yes) was equal to 1 and no (and any answer that could be logically assigned to no) was equal to 0. The third variable is a dichotomous version of the variable for the question, “Not counting minor traffic violations, how many times during the past 12 months have you been arrested and booked for breaking a law?” This new version of this variable assigned everyone that had been arrested at least once to 0 and everyone that had not been arrested to 1. The final variable that was created is comprised of the “yes” answers of the three previously mentioned variables and it is named “anyproblem”. The “yes” answers to the first variable are equal to 1, the “yes” answers to the second variable are equal to 2, and the “yes” answers to third variable are equal to 3.

Analysis

The data analyses were conducted using StataBE v. 17.0. Descriptive statistics for the proportion of survey respondents who met the following criteria were calculated: reported needing treatment for illegal drug or alcohol misuse in the last year, reported receiving treatment for drugs or alcohol at any location in the past year, and reported experiencing problems with friends or family, physical health problems, and/or being arrested. A logistic regression was conducted with the dependent variable of receiving treatment and independent variables of interest being an interaction between age category and “anyproblem” with income, sex, and race as control variables. These demographic factors included age as a categorical variable (age 12–17, 18–25, and 26 or older), sex as a dichotomous variable (male and female), income as a categorical variable (less than $20,000, $20,000-$49,999, $50,000-$74,999, and over $75,000), and race as a categorical variable (Non-Hispanic White, Non-Hispanic Black/African American, Non-Hispanic Native American/Alaskan Native, Non-Hispanic Native Hawaiian/Other Pacific Islander, Non-Hispanic Asian, Non-Hispanic more than one race, and Hispanic). The analysis was run on a subpopulation of individuals that needed addiction treatment. This was done using a variable that included everyone that needed treatment for illegal drug or alcohol misuse in the last year. Their need for treatment was determined based on the DSM-4 criteria for dependence on or misuse of substances as well as whether they received treatment for their substance use in the last year (American Psychiatric Association, 2000).

The regression was used to determine how age interacted with people’s motivations (family problems, physical problems, and being arrested) to initiate treatment for the group of people that needed treatment. All analyses were survey weighted.

Results

Based on the data from the 56,136 respondents that was published in the public use file for the 2019 National Survey on Drug Use and Health, we estimated that people who needed addictions treatment and had been arrested in the twelve months prior to the survey had 14.01 (95% CI, 7.78%−25.23%) times greater odds of receiving treatment when compared to someone that did not report experiencing any of the three motivators. Individuals that needed addictions treatment and experienced problems with family members or friends had 3.23 (95% CI, 2.08%−5.01%) times greater odds of receiving treatment than someone that did not experience one of the three motivator categories. The results for individuals of all ages that need treatment after experiencing physical health problems were insignificant.

Adolescents (12–17) that needed treatment and experienced problems with friends and family had about 0.15 times the odds of receiving treatment when compared to emerging adults (18–25). The odds that someone that needs treatment will receive treatment after experiencing problems with family and friends are around 0.43 times smaller in older adults (26+) when compared to 18-to-25-year-olds. Individuals over the age of 26 that are experiencing physical health problems and need treatment have about 0.31 times lower odds of receiving treatment when compared to people between the ages of 18 and 25. Results comparing an adolescent’s odds of receiving treatment after experiencing health problems to that of emerging adults and older adults were insignificant. People aged 26 years or older that are involved in the criminal justice system and need treatment have almost 0.41 times smaller odds of receiving treatment when compared to 18-to-25-year-olds. Results comparing an adolescent’s odds of receiving treatment after becoming involved in the criminal justice system to emerging adults and older adults were insignificant.

Discussion

Effect of Arrests as a Motivator by Age Category

The individuals that were arrested had far greater odds of receiving treatment than people with other reported motivators. This is most likely because treatment is often mandated for individuals entering the criminal justice system with a SUD. Comparing emerging adults and older adults that had been arrested, the older adults had 0.41 times smaller odds of receiving treatment. This finding is important because it informs behavioral health professionals of the heightened influence criminal justice involvement has on emerging adults compared to older adults. More research is necessary to determine the factors that contribute to this finding.

Social Relationships a Motivator by Age Category

Individuals of all ages that needed treatment and reported having problems with family and friends had 3.23 times greater odds of receiving treatment than individuals that were not motivated by any of the three categories. This finding suggests that problems with family and friends are not as motivating as criminal justice involvement.

The data regarding problems with family and friends presented some interesting findings when factoring in the age categories. Adolescents (12–17) that were experiencing problems with friends and family and needed treatment had 0.15 times the odds of receiving treatment when compared to emerging adults. For older adults that needed treatment and were experiencing problems with family members and friends, the odds of receiving treatment were 0.43 times smaller than that of the 18-to-25-year-olds. This is an important finding because it informs behavioral health professionals of the substantially decreased influence that emphasizing an adolescent’s or older adult’s problems with their friends or family would have on their motivation to initiate treatment in comparison to an emerging adult. More research is needed to determine the cause of this finding.

Physical Health as a Motivator by Age Category

The findings pertaining to treatment receipt while experiencing physical health problems placed this motivator at the bottom of the three because there was no association between having physical health problems and treatment receipt in individuals of all ages that need treatment. The results for physical health problems contained one interesting finding between age groups. Older adults that needed treatment and had physical health problems had about 0.31 times the odds of receiving treatment when compared to emerging adults. This result is logical because physical health problems seem more concerning and unexpected when individuals are younger because it suggests an increased severity of SUD. This is an important piece of information for behavioral health professionals because it suggests that emphasizing a patient or client’s physical health problems is much more effective when the individual is an adolescent.

Limitations

The NSDUH Survey is limited to populations that are not institutionalized. This excludes people that are hospitalized, in residential treatment, or incarcerated. The survey also does not include a significant portion of the homeless population.

A limitation produced by the method of variable creation used for “anyproblem” is that the participants that answered “yes” to more than one of the three motivator category variables end up being assigned to just one of the three categories within “anyproblem.” There was an overlap of about 10% that could be shifted between the three categories depending on the order of the input of the categories when creating “anyproblem.” The order of the categories during the creation of “anyproblem” did not affect any of the significant findings when the regression was run.

Conclusion

The data produced some results that were obvious and others that were surprising. Involvement in the criminal justice system was the most influential motivator of the three categories, which was to be expected given prior research. The results showed that problems with family and friends are more influential in terms of motivating individuals to receive treatment when compared to physical health problems, which produced insignificant results. Based on the results of this study and the previously discussed research concerning physical health as a motivator, familial issues may be more influential than health problems when it comes to treatment initiation.

Due to the insignificance of most of the results pertaining to physical health as a motivator, it seems as though physical health is not an effective motivator to receive treatment. However, there was one significant finding which suggested that physical health is a much more effective motivator for emerging adults when compared to older adults. This may be due to the increased concern that arises when an emerging adult has a SUD that is severe enough to produce physical health problems at a young age.

When it comes to receiving treatment, problems with friends and family were more influential for emerging adults and older adults than it was for adolescents. More research is necessary to determine the explanation for this finding. As previously hypothesized, the relative effect of physical health, social relationships and criminal justice involvement did vary for emerging adults compared to adolescents and older adults. This kind of information can be useful for behavioral health professionals because the findings suggest that focusing on the problems someone has with family and friends due to their substance use may be far more effective in adults than it would be in adolescents.

In future studies, it may be worthwhile to include more motivator categories to see how the motivators outside of criminal justice involvement compare. Some examples of additional categories could be financial difficulties or issues relating to employment. While this study did provide insight into some of the motivators outside of the criminal justice system, adding those other categories would provide a more complete understanding of how motivators separate from mandated treatment influence treatment receipt.

3.1 Table 1:

Proportion of the subpopulation of people needing treatment that received or did not receive it categorized by sex or race

Survey Weighted Population Proportions	Men	Women	White	Black	Native American/Alaskan Native	Native Hawaiian/Pacific Islander	Asian	Other Race	Hispanic
Received Treatment	14.80%	14.10%	15.60%	14.10%	18.40%	33.00%	4.10%	17.50%	10.90%
Did Not Receive Treatment	85.20%	85.90%	84.40%	85.90%	81.60%	67.00%	95.90%	82.50%	89.10%

3.2 Table 2:

Proportion of the subpopulation of people needing treatment that received or did not receive it categorized by age, income, or motivator category.

Survey Weighted Population Proportions	Under 18 y/o	Age 18–25	Age 26 and older	Income below 20,000	Income $20000–49999	Income $50000–74999	Income above $75000	No/Other Motivator	Arrested	Family or Friend Problems	Health Problems
Received Treatment	10.30%	9.60%	16.40%	24.50%	14.70%	13.40%	9.30%	10.60%	44.20%	14.50%	8.00%
Did Not Receive Treatment	89.70%	90.40%	83.60%	75.50%	85.30%	86.60%	90.70%	89.40%	55.80%	85.50%	92.00%

3.3 Table 3:

Multivariate logistic regression model showing the interaction between three age categories and three motivator categories (family/friend problems, physical health problems, and being arrested) as well as the associations between receiving treatment and income, sex, and race among the subpopulation of U.S. participants aged 12 and older that needed treatment (N=56,136)

Received Treatment in Past 12 Months		Odds Ratio	95% Confidence interval
Sex	Male	Ref
	Female	0.98	0.77	1.25
Race	Non-Hispanic White	Ref
	Non-Hispanic Black/African American	0.61	0.41	0.92
	Non-Hispanic Native American/Alaskan Native	0.88	0.40	1.93
	Non-Hispanic Native HI/Pacific Islander	2.98	1.03	8.60
	Non-Hispanic Asian	0.30	0.12	0.74
	Non-Hispanic More Than One Race	1.16	0.53	2.53
	Hispanic	0.64	0.41	0.98
Income	< $20000	Ref
	$20000 – $49999	0.51	0.38	0.68
	$50000 – $74999	0.48	0.33	0.70
	≥ $75000	0.32	0.23	0.47
Motivator	None	Ref
	Family/Friend Problems	3.23	2.08	5.01
	Physical Health Problems	1.91	0.93	3.92
	Arrested	14.01	7.78	25.23
Age	18–25	Ref
	12–17	2.84	1.36	5.92
	26+	3.79	2.50	5.76
Motivator by Age	18–25	Ref
	Family/Friend Problems: 12–17	0.15	0.06	0.37
	Family/Friend Problems: 26+	0.43	0.24	0.78
	Physical Health Problems: 12–17	0.82	0.21	3.26
	Physical Health Problems: 26+	0.31	0.13	0.75
	Arrested: 12–17	0.45	0.14	1.41
	Arrested: 26+	0.41	0.18	0.91
_cons		0.09	0.06	0.14