Association of Substance Use Pattern and Family Factors With Use-Related Problems According to Arabic Drug Abuse Screening Test-10: A Cross-Sectional Study

Abstract

Background

Examining associations of substance use (SU) pattern and family factors with severity of SU-related problems is crucial for designing effective interventions. This study was designed to address this under-researched topic in the Arab societies, utilizing the validated Arabic Drug Abuse Screening Test-10 (DAST-10).

Methods

This observational cross-sectional study enrolled 360 young adult drug users from Alamal Complex for Mental Health, Saudi Arabia. The questions were about SU pattern and family-related variables.

Results

Parental divorce, family problems, low family emotional support, poor family control, recent SU (during the past year), polysubstance use, and frequent SU showed significant correlations with more severe DAST-categories. Sociodemographic differences, financial capacity, age of starting use, and duration of use showed non-significant correlations with DAST-categories. The groups of complete family, parental death, and no recent SU were associated with significantly lower odds ratios (OR: 0.51, 0.31, 0.14) (p: 0.013, 0.001, 0.010) indicating associations with lower DAST-categories compared with parental divorce and recent SU groups, respectively. In contrast, groups of no and limited emotional family support, polysubstance use, and SU less than one year were associated with significantly higher odds ratios (OR: 3.00, 3.20, 14.53, 1.78) (p: 0.005, 0.003, 0.004, 0.031) indicating associations with higher DAST-categories compared with constant emotional family support, single-substance use, and SU more than one year groups respectively. The users with parental divorce, family problems, no and limited family emotional support, no and limited family control, recent SU, frequent use, and polysubstance use showed significantly higher distributions in substantial and severe DAST categories.

Conclusions

The associations observed are statistically significant, but modest. However, we believe that they remain clinically relevant, as even small associations may have practical significance. The study findings could support designing and implementing culturally tailored, family-centered preventive and therapeutic strategies and interventions, particularly for young adults, in Arab communities.

Introduction

Substance use disorder (SUD), specifically in adolescents, is a maladaptive behaviour which can lead to other problem behaviours, severe adverse health outcomes, and detrimental social consequences. It is a major contributor to the worldwide disease burden and therefore, effective interventions are mandatory to combat this burden. ¹ Designing targeted and culturally suitable educational and preventive programs about SUD for vulnerable populations like students help combat misconceptions and improve preventive awareness. ² Adolescence is an important stage of risk for SU initiation and related consequences. Implementation of targeted SU interventions could benefit certain youth populations combined with wider population-level prevention programs that aim to decrease risk factors and enhance protective factors related to youth SU. ³ Early initiation of SU in adolescence is a definite risk factor for the later development of SUD in adulthood. Several factors influence adolescent initiation of SU such as peer norms, parental surveillance, community background, and also changes due to continuing brain maturation such as enhanced reward sensitivity, decreased inhibitory control, and changed brain network engagement in decision-making.^4,5 Recognizing these early factors enables identification of at-risk adolescents and helps in designing more effective and targeted prevention programs. ⁶

Most universal SU prevention efforts target early adolescents aiming to delay or prevent its onset. The “Life Skills Training” is a school-based prevention program that uses cognitive/behavioral skills-training techniques to augment social and personal competence skills and drug refusal skills. In a large-scale randomized trial, the “Life Skills Training” program was implemented on junior high school students, and then after 13 years, the rates of overall lifetime illegal drug use were found to be lower among young adults who received the program during junior high school compared with the control participants. ⁷ The “keepin’ it REAL” program is an evidence-based SU prevention curriculum designed for youth. REAL is an acronym for four resistance strategies (Refuse, Explain, Avoid, Leave). The delivery of elementary school “keepin’ it REAL” by the Drug Abuse Resistance Education (D.A.R.E.) America officers have deterred the onset of alcohol use and vaping. ⁸ The “Communities That Care” (CTC) is a community-level prevention system that trains and assists community alliances to build evidence-based and data-driven conclusions on local prevention efforts allowing community-wide and sustained positive youth development. A clinical trial reported that implementation of the CTC prevention system in early adolescence promoted positive development and decreased health-risking behavior into young adulthood. ⁹

Early interventions including those conducted in school settings have been shown to reduce SU-related problems among adolescents. ¹⁰ A prospective study on young Australian adults concluded that problem behaviours in early adolescence can predict long-term SUD. Therefore, prevention strategies should target adolescents with early manifestations of problem behaviours. ¹¹ The family management factors (including parental discipline, monitoring, behavioural control, and rewards set by parents to support good behaviours) showed either protective or predisposing effects on the adolescent SU. ¹² There is a vicious circle between the family problems, SU, and criminal conduct. Adolescents whose parents are justice-involved are more likely to be involved in SU and illegal acts. Positive and supportive relationships with parents could decrease these risks. Consequently, clinical interventions for at-risk adolescents should be multidimensional focusing more on the family context, for instance, family-based approach therapy for preventing and treating SU and criminal behavior among youth. However, there was inconclusive empirical evidence in the assessment of the long-term efficacy and the sustainability of SU programs for adolescents. ¹³ Family is central at the confluence of several social systems (e.g., school, community, and peer), thus evidence-based family programs were more effective than several other approaches. ¹⁴

In the Arab region, about 60% of the population are under 30 years old, highlighting a need for economic opportunities and safe environments. ¹⁵ Globally, alcohol use disorders are more prevalent than SUDs, but in the Middle East they are less prevalent compared with other regions. SUDs are more prevalent in the Western countries than in the Middle East, Asia, Africa, and South America. ¹⁶ The Arab countries enforce strict prohibitions on the consumption and distribution of alcohol and illicit drugs; however, SUDs are recognized by the authorities as a public health problem. ¹⁷ The cultural attitude and legal rules against substance consumption may have resulted in underreporting on SUD. The magnitude of SU in the Arab countries is still indefinite because most studies have focused on the students and SU patients, not the general population. ¹⁸ The sociodemographic risk factors for developing SUD include young age, male gender, being single, lower levels of education, lower income, family problems, psychiatric disorders, and traumatic events.^19,20 In Saudi Arabia, use of alcohol, amphetamine, fenethylline (captagon), and khat constitutes a substantial part of SU. ²⁰ In Morocco, Egypt, and Yemen, use of cannabis, tramadol, and khat are prevalent respectively. Use of prescription drugs in excess of the medical directions demands attention by health authorities. Prevention and treatment interventions for high-risk groups like students and patients are needed to decrease drug related complications. ¹⁸ The social and generational changes have led to an increase in SU among young adults in the Arab world. Tobacco and hashish are being used more frequently and more openly in the urban areas. ²¹ The burden of SUD has increased in the last three decades in the Middle East and North Africa (MENA) countries in contrast to the global trend. The use of opioids constitutes the main burden on MENA region in contrast to that in the Western countries which face substantial use of alcohol and cannabis. ²² A recent meta-analysis among school children in the Arab and African countries, revealed that the prevalence of use for tobacco, alcohol, stimulants, khat, and cannabis were 16%, 15%, 11.4%, 10%, and 8% respectively. The varying prevalence rates in different countries underscore necessity for designing interventions tailored to the specific challenges and resources of each country. It is essential to address socio-environmental factors and to enhance preventive strategies through educational and guidance programs to reduce SU. Early intervention, specifically against the gateway substances such as tobacco and alcohol, is fundamental for preventing the use of more harmful substances. ²³ Data from the Saudi National Mental Health Survey has revealed that SUD is more prevalent than previously thought, treatment seeking is still inadequate, and culturally adapted prevention and intervention programs are needed. ²⁴

There is lack of studies addressing association of the SU pattern and family-related factors with the degree of use-related problems in Arab societies. A study conducted at Al-Amal Hospital in Jeddah, Saudi Arabia showed that adolescents started using tobacco and drugs at younger ages compared with adults and showed a different sequence of SU progression. This could have an implication in prevention programs. ²⁵ Family history of SU, loss of a close family member, and the educational level of parents were found to be risk factors for SU. ²⁶ Moreover, a recent study reported that treatment seeking for SUD and its related psychiatric comorbidities in Saudi Arabia is inadequate. ²⁴ A retrospective analysis of SU among female psychiatric patients in Saudi Arabia recommended screening of risk factors for SUD and building rehabilitation programs. ²⁷ In the United Arab Emirates, substance users face a significant risk of relapse due to many factors including decreased family communication. ²⁸ A study conducted in Tunisia concluded that implementing preventive strategies for addictive behaviors in youth such as SU is needed to prevent violence perpetration. ²⁹

Taken together, there is a need for developing SU prevention and intervention programs that are tailored to the Arabic culture. Therefore, the current study aimed to evaluate the associations of the SU pattern and family factors with severity of SU-related problems according to the categories identified by the validated Arabic Drug Abuse Screening Test-10 (DAST-10).

Materials and Methods

Study Design, Setting, and Participants

This is an observational cross-sectional study which was conducted at Alamal Complex for Mental Health, Jeddah, Saudi Arabia. The study involved responses obtained from 360 young adult Arabic-speaking substance users (18-35 years old) recruited from Alamal Complex for Mental Health. Ethical approval was obtained from the Institutional Review Board of the Saudi Arabian Ministry of Health in February 2020 (No. 01169), and the study was conducted in accordance with the Helsinki Declaration. To reduce selection bias, every consecutive eligible substance user presenting during the study period, from March 2020 to September 2020, was included in the study. Substance users with neuropsychiatric disorders and those under the drug effects or having drug withdrawal were excluded. The refusal rate in the current study was 28% of eligible individuals which is comparable to that reported in the health-related research. ³⁰ Informed written consents were obtained from all participants.

Variables and Measures

Previously, the Arabic DAST-10 version was developed and validated as a reliable screening tool for SU-related problems in the Arabic-speakers. Its categories were determined based on scores of 0.0, 1–2, 3–5, 6–8, and 9–10 corresponding to none, low, intermediate, substantial, and severe levels of the SU problems respectively. The cut-off point was selected as the point closest to the upper left corner of the Receiver Operating Characteristic (ROC) curve, reflecting an optimal balance between sensitivity and specificity.^31,32 In the current study, the Arabic DAST-categories represented the outcome variable. These categories are consistent with those of the original English test. ³³ Furthermore, in a primary care setting the original English DAST-10 version showed a cutoff score of ≥ 3 for identifying the problems of current SU in adults. ³⁴ Moreover, Spanish and Turkish DAST-10 versions validated in substance users and non-users reported cutoff scores equal to four.^35,36 A Korean DAST-10 version validated in non-user adults showed a cutoff score of two. ³⁷

The questionnaire used in the current study was not validated; however, its items were developed based on reviewing the relevant literature and were checked carefully to ensure clarity, relevance, and content appropriateness. As with both the original English DAST-10 version and the Arabic DAST-10 version, the items of the current questionnaire did not include alcohol drinks. The questionnaire included the following three sections:

• (I) Sociodemographic information: Gender, age, marital status, and education level.

• (II) Family-related factors: Family structure (complete/incomplete), causes of family incompleteness (parental death, parental divorce), and family problems (yes/no). Moreover, there were three questions about family emotional support, family control, and financial capacity where the responses were scored on a 5-point scale (never, rarely, sometimes, often, always) corresponding to (no, limited, moderate, frequent, constant).

• (III) SU pattern factors to identify chronic, regular, and recreational users: Age of starting SU, recent SU (during the past year), duration of SU, type of the substance(s) used, and frequent SU (at least once weekly).

Statistical Analysis

Analyses were performed using SPSS 22 software (SPSS Inc., IL, USA) by individuals who were not involved in data collection to minimize bias. The study included all eligible users who attended the clinic during the specified study period and consented to participate. For calculating the sample size, the significance level was set at p < 0.05, and statistical power of 80% was assumed which is commonly acceptable to detect a significant association between two variables, if it exists. ³⁸ The effect size and standard deviation were acquired from previous literature. Moreover, to avoid the need for a larger sample size and to ensure obtaining full response to all questions from each participant, the questionnaires were distributed personally by the researchers. Descriptive statistics included frequencies and percentages to summarize the sociodemographic characteristics, SU pattern, and distribution of substance users in the different DAST-categories for each family and SU pattern factors. The chi-square test was used to examine significance between categorical variables. The Spearman’s rho test (a bivariate analysis) was used to evaluate correlations of SU pattern and family-related factors with DAST-10 categories. The ordinal logistic regression (a multivariable analysis) was used to express associations between the variables and DAST-10 categories. A p value < 0.05 was considered significant. To validate use of the ordinal logistic regression, the multicollinearity and proportional odds assumption were assessed by variance inflation factors (VIF) and the test of parallel lines respectively.

Results

Table 1 shows that the sociodemographic differences among the substance users did not significantly account for the variations of the DAST-categories. As shown in Table 2, parental divorce, family problems, recent SU, polysubstance use, and frequent SU showed significant positive correlations indicating associations with more severe DAST-categories (p < 0.001 except for frequent SU where p = 0.007). In contrast, family emotional support and family control showed significant negative correlations (p < 0.001) indicating that low support and poor supervision were associated with more severe DAST-categories. The financial capacity, age of starting SU, and duration of SU showed non-significant correlations.

Table 1.

Sociodemographic Characteristics of Study Participants (360 Substance Users)

Gender	Percentage	Education level	Percentage
Male	91.7%	Under high school	18.6%
Female	8.3%	High school and above	81.4%
Age	Percentage	Substances used	Percentage
18-24 years old	33.9%	Captagon, Amphetamine, Khat	38.6%
25-35 years old	66.1%	Cannabis, Marijuana, Hashish	16.4%
Marital status	Percentage	Opiates, Heroin, Methadone	0.8%
Single	60.8%	Methamphetamine	0.6%
Married	24.4%	Tramadol	0.6%
Divorced	13.1%	Other substances	3%.
Widowed	1.7%	Multiple substances	40%

The p values for Gender, Age, Marital status, Education level, and Substances used equals 0.903, 0.708, 0.229, 0.309, and 0.207 respectively.

Table 2.

Spearman’s Rho Correlations of the Substance Use (SU) Pattern and Family Factors With the DAST-10 Categories

Factor	Correlation coefficient
Parental divorce	0.247 **
Family problems	0.215 **
Family emotional support	-0.306 **
Family control	-0.260 **
Recent SU	0.228 **
Polysubstance use	0.187 **
Frequent SU	0.142 *

^*Significance at P < 0.01.

^**Significance at P < 0.001.

The use of the ordinal logistic regression was validated by checking for multicollinearity and proportional odds assumption. The variance inflation factors (VIF) were lower than five indicating absence of multicollinearity and the test of parallel lines was non-significant (p = 0.285) implying that the proportional odds assumption was met. As shown in Table 3, the regression analysis revealed that the groups of complete family, parental death, and no recent SU showed negative estimates and lower odds ratios indicating associations with lower DAST-categories compared with the reference groups (parental divorce and recent SU) respectively. In contrast, the groups of no and limited family emotional support, polysubstance use, and SU less than one year demonstrated positive estimates and higher odds ratios indicating associations with higher DAST-categories compared with the reference groups (constant emotional family support, single- substance use, and SU more than one year) respectively. The groups with no family problems, no and limited family control, financial capacity, infrequent SU, and age of starting SU were not significantly associated with SU severity. The ordinal logistic regression analysis showed a significant model fitting test and a non-significant goodness-of-fit test indicating that the model explains a significant amount of variation in the outcome and fits the observed data adequately.

Table 3.

Ordinal Logistic Regression Analysis Between the Substance Use (SU) Pattern and Family-Related Variables, and the DAST-10 Categories

Variables (groups)	Estimate	Odds ratio (OR)	p	95% confidence interval (CI)
				Lower bound	Upper bound
Complete family A	-0.659	0.518	0.013 *	-1.177	-0.141
Parental death A	-1.152	0.316	0.001 **	-1.803	-0.501
No family problems B	-0.399	0.671	0.103	-0.878	0.081
No family emotional support C	1.101	3.007	0.005 **	0.326	1.876
Limited family emotional support C	1.165	3.207	0.003 **	0.395	1.935
No family control D	0.380	1.463	0.370	-0.451	1.212
Limited family control D	0.503	1.654	0.190	-0.249	1.255
No financial capacity E	-0.221	0.802	0.716	-1.408	0.967
Age of starting SU (less than 24 years old) F	-0.205	0.815	0.544	-0.868	0.458
No recent SU G	-1.959	0.141	0.010 *	-3.442	-0.476
SU less than one year H	0.581	1.787	0.031 *	0.053	1.109
Polysubstance use I	2.676	14.531	0.004 **	0.855	4.497
Infrequent SU J	-0.393	0.675	0.114	-0.880	0.094

^*Significance at P < 0.05 and.

^**Significance at P < 0.01 compared with the references variables (groups).

^AParental divorce.

^BFamily problems.

^CConstant family emotional support.

^DConstant family control.

^EConstant financial capacity.

^FMore than 24 years old.

^GRecent SU.

^HSU more than one year.

^ISingle-substance use.

^JFrequent use.

Table 4 shows the relation between percentage of substance users in the substantial and severe DAST categories compared with their percentage in the none, low, and intermediate DAST categories. The users with parental divorce, family problems, no and limited family emotional support, no and limited family control, and recent SU showed higher significant distributions (p < 0.001). The frequent users and polysubstance users also showed higher distributions, but less significant (p = 0.001), in the substantial and severe DAST categories. The users with duration of SU more than one year showed a non-significantly higher distribution.

Table 4.

Percentage Distributions of Substance Users in the Different DAST-Categories With Each Family and Substance Use Pattern Factor

Factor	DAST-10 categories					None + Low + Intermediate	Substantial + Severe
	None	Low	Intermediate	Substantial	Severe
Parental divorce	0.00%	3.10%	8.30%	22.80%	8.90%	11.40%	31.70%
Family problems	0.60%	4.70%	16.70%	28.30%	11.40%	22.00%	39.70%
No family emotional support	0.00%	0.60%	2.80%	11.40%	3.30%	3.40%	14.70%
Limited family emotional support	0.00%	0.60%	5.60%	11.70%	5.30%	6.20%	17.00%
No family control	0.00%	0.60%	1.90%	9.70%	2.20%	2.50%	11.90%
Limited family control	0.00%	0.00%	4.40%	11.10%	3.10%	4.40%	14.20%
Recent SU	0.30%	8.10%	31.10%	40.30%	14.70%	39.50%	55.00%
SU more than one year	0.80%	6.10%	21.10%	26.70%	8.60%	28.00%	35.30%
Frequent SU	0.30%	4.70%	18.30%	26.10%	10.00%	23.30%	36.10%
Polysubstance use	0.60%	2.80%	11.40%	20.00%	8.30%	14.80%	28.30%

Discussion

The SUD can be induced by numerous factors including family factors, influence of peers, curiosity, tension release, personal problems, and other issues. ³⁹ According to the degree of SU-related problems (none, low, intermediate, substantial, and severe), the American Society of Addiction Medicine (ASAM) determined five levels of the medical service needed which are: (1) Monitor, (2) Brief counseling (outpatient), (3) Outpatient service (intensive), (4) Intensive in a residential setting (the patient lives on-site, and staff are present 24/7), and (5) Intensive in a hospital setting such as acute care units (for patients with severe biomedical, behavioral, or cognitive deterioration) respectively. ⁴⁰ Therefore, assessing degree of SU-related problems and understanding SU risk and protective factors are essential to ensure appropriate medical care. In Arab societies, there is a lack of studies addressing effects of SU pattern and family-related factors on degree of use-related problems; therefore, this study was designed to cover this research gap.

The current results showed that the sociodemographic differences did not significantly account for the variability of the DAST categories. Previously, it was reported that socioeconomic risk factors for SU included male sex, young age, low education levels, parental divorce, and the jobless or fully employed mothers. ¹² The current findings showed that parental divorce, family problems, low family emotional support, poor family supervision, recent SU, polysubstance use, and frequent SU significantly correlated with the SU severity. In contrast, family structure, financial capacity, age of starting SU, and duration of SU showed non-significant correlations with SU problem categories. In our analysis, most variables showed consistent results between Spearman correlation and the ordinal logistic regression model. However, family problems, poor family supervision, and frequent SU showed significant Spearman correlations but non-significant associations in the regression model, while duration of SU showed the reverse. This does not mean that there are no effects, but it means that the data do not provide sufficient evidence that the odds ratio differs from one. This discrepancy happens because the two tests use the data differently and therefore, significant variables are not automatically good predictors. ⁴¹

The present statistical analysis revealed that the two key model assumptions for applying the ordinal logistic regression were met, where the VIF was lower than five and the test of parallel lines was non-significant. Previously it was reported that a VIF lower than five and tolerance (reciprocal of VIF) higher than 0.2 indicated that the independent variables were not highly correlated with each other and that multicollinearity was not a concern. ⁴² Moreover, satisfaction of the proportional odds assumption indicates that the effects of the independent variables were constant across the outcome thresholds. ⁴³ A significant correlation between the SU frequency during the past year and the DAST score was previously reported. ⁴⁴ The impact of the financial status on SU severity is not constant because some used drugs e.g., synthetic cathinone drugs (widely known as bath salts) are cheap and so easily obtainable, but they are highly dangerous causing severe adverse consequences. ⁴⁵ Moreover, SU severity significantly correlated with parental divorce, but not with parental death which may be due to the kind support that orphans receive from their relatives in Arab communities. Previously, it was reported that divorce, parental death, low parental surveillance, and poor family emotional relations caused significant differences between the substance users and normal controls. ⁴⁶ A study in a rehabilitation centre in Malaysia revealed that individual’s SU is caused by a combination of several factors including family factors (like poverty and inadequate emotional support) and peer influence. ⁴⁷ An incomplete family is a factor of increased crimes in adolescents and youth. ⁴⁸ In contrast, family support protected adolescents against use of common inhalants such as glues and paints. ⁴⁹ The good parent-child relationships prevent, while poor relationships may lead to, negative emotions and problem behaviours including SU. ⁵⁰ It has been shown that paternal and maternal rearing styles have different impacts on adolescents’ problem behaviours, and that adolescents’ self-control exerted a mediating role in these various relationships. ⁵¹ Parental divorce correlated to higher alcohol and smoking among Lebanese adolescents, therefore children whose parents are separated should be followed up by their parents and healthcare providers to avoid slipping into SU. ⁵² A study in Qatar reported that in Arab families, the relationship between family dynamics and adolescent SU is bidirectional, with each potentially affecting the other. ⁵³ In the United Arab Emirates, the risk of relapse in substance users was found to be mainly due to craving and negative social experiences. Factors such as societal support, job availabilities, and extended rehabilitation programs efficiently enhanced resilience and mitigated the risk of relapse. Therefore, it has been recommended to: (1) Develop and implement family-based interventions tailored to the local context, (2) Promote family ties, (3) Optimize healthcare systems to effectively support substance users in all healthcare settings, and (4) Develop early detection and intervention strategies involving families and schools. ²⁸

Evidence indicates that SU prevention programs, whether community-based, school-based, or clinical interventions, can be effective across a broad range of populations and settings including schools, healthcare systems, communities, workplaces, and criminal justice environments. Previously, it was reported that the parental behavioral control (regulations set by parents to manage children’s behaviors) protects against adolescent SU, while excessive parental psychological control (handling children’s emotions and thoughts through for example, guilt induction and love withdrawal) makes adolescents vulnerable to SU. ⁵⁴ Extreme parental psychological control weakens adolescent resilience to SU. ⁵⁵ A study in Hong Kong, reported that the parental behavioural control was a negative predictor of SU, while the maternal behavioural control predicted a slower increase of SU. Moreover, the parental psychological control was not a significant predictor of SU. ⁵⁶ A recent study reported that low parental supervision, poor emotional family relations, parental divorce, low socio-economic status, parental SU, and child abuse are the main family factors encouraging SU in teenagers. ⁵⁷ Family factors, especially family cohesion, play important roles in individuals’ SU. Children look up to their parents as role models, therefore parents should set a positive example through adopting healthy behaviors. ⁵⁸ Intervention efforts aiming at socio-cognitive-emotional regulatory processes can be designed to optimize the neurodevelopment of cognitive skills, emotional control, and behavioral self-regulation, thus postponing initiation of adolescent alcohol use which is a gateway for more harmful SU. Further, improving neurological dysfunction via behavioral therapy, psychoeducation, and functional training are useful approaches. ⁵⁹ In fact, many students are already using drugs and have undergone both the beneficial and adverse effects of SU, therefore they refuse prevention notes that highlight the most severe drawbacks. Instead, these student desire to learn about real experiences with SU such as stories with actual negative experiences. Consequently, using adapted versions of the “keepin’ it REAL” prevention program would have an impact on their behaviors. Therefore, school professionals could potentially integrate this experience in a prevention program without normalizing SU. ⁶⁰ A language-adapted form of the school-based “keepin’ it REAL” universal prevention program was evaluated in primary schools in Kenya. The study suggested the potential of the program as an effective method for SU prevention; however, it recommended conducting larger trials. ⁶¹ In contrast, a trial in students of 32 Australian secondary schools concluded that the universally implemented pragmatic school-based intervention was found neither effective in decreasing the use of tobacco, alcohol, and illegal substances nor in enhancing the protective factors. ⁶²

The SU initiation, defined as trying any non-prescribed substance, in early adolescence increases the risk of developing SUD and psychosocial problems in adulthood. ⁶³ The most commonly reported substances used by youths were alcohol, followed by cannabis and nicotine. ⁶⁴ The top sociodemographic predictors included parental endorsement of a religious preference, white race, and lower income. The top cultural and environmental predictors included history of detention and school suspension. Including the resource-intensive measures such as including hormones and neurocognitive assessment did not enhance prediction of SU initiation. Implementation of these findings in clinical practice could help tailor prevention and early intervention programs. ⁶⁵ A study on healthy, substance-naïve adolescents aged 13-14 years found that diminished engagement of the left lateral frontoparietal networks during negative emotional contexts was associated with earlier SU initiation, pointing to large-scale activation patterns as potential early markers of vulnerability. ⁶⁶ Furthermore, anxiety can increase the risk of SU initiation among the adolescents. Therefore, early screening and treatment of anxiety symptoms could delay or prevent the onset of the SU initiation. ⁶⁷ School connectedness protected against SU including cigarette smoking, marijuana use, and binge drinking. ⁶⁸ However, school connectedness was not associated with less SU for emotionally maltreated teens. Therefore, it is important to discover the unique interplay between risk and protective factors for SU in adolescents. ⁶⁹ Also, the prevention and early intervention efforts may benefit from focusing on more adjustable risk factors that can increase the likelihood of SU initiation such as substance availability and peer use of alcohol and nicotine. ⁷⁰ Evidence-based family-centered interventions for SUD aim to enhance family dynamics and resilience, and to reduce SU among affected individuals. ⁷¹ The rationale for tailored SU prevention programs arises from differences in the risk factors, predictors, and prevalence of SU across racial/ethnic groups. For instance, peer influences are strong among White Americans, while parental influences are stronger among African Americans. ⁷² To effectively determine the characteristics of culturally specific interventions for SU and to measure the intervention outcomes, it is important to educate researchers, health practitioners and policymakers on the specific needs of the community. ⁷³ In Arab countries, implementation and impact of family-centered interventions for SU remain underexplored. To reduce SUD and its consequences, a study in Saudi Arabia recommended that healthcare professionals and policymakers must develop culturally relevant effective strategies, policies, and early interventions such as: (1) Enhancing education programs that target adolescents, (2) Training healthcare providers on emerging SU trends, (3) Incorporating SU screenings into clinical assessments to help early detection, (4) Developing specialized protocols to manage psychotic symptoms associated with SU, and (5) Conducting nation-wide studies to establish a national database on SU. ²⁰ Another study in SA reported that most substance users started taking drugs at 19-23 years old with school friends, mainly due to curiosity and joy-seeking. It recommended that young adults must be educated about risks and consequences of SU through conducting awareness campaigns in schools and public places, creating trusted media platforms, and delivering workshops. ⁷⁴

No gender variation in SU severity was detected in the current study; however, this may be due to low reporting of SU by females in Arab populations which is a critical issue that can affect generalizability. To overcome this problem, future studies in similar cultural contexts should consider certain methodological adjustments. Presence of a female researcher ⁷⁵ and strict assurance of privacy and confidentiality ⁷⁶ enhance females’ participation in research. Asking direct frequency questions rather than using yes/no filters, makes it more likely that participants report SU. ³ Online surveys on sensitive topics such as SUD allow quick and low-cost data collection from large samples because participants perceive greater anonymity and privacy. ⁷⁷ In the Black Women’s Health Study, utilizing web-based questionnaires reduced costs, improved response completeness irrespective of the question sensitivity, and increased response rates among younger individuals. ⁷⁸ Electronic self-administered surveys were associated with higher rates of reporting SU among youth compared with face-to-face interviews because they are confidential and more comfortable. ⁷⁹

The Spearman’s correlations observed in the present study are statistically significant, but weak in magnitude. They do not provide strong evidence of substantial effects and should be interpreted with caution. However, we believe that they remain clinically relevant because even small associations may have practical or public health significance when considered at the population level. In clinical research, the statistical significance indicates reliability of the findings, while the clinical relevance reflects their impact on clinical settings. Statistically significant results may not be clinically important and vice versa, clinically relevant results may not be statistically significant. Clearly, clinical significance is the most important and the effect size forms a basis for evidence of substantial significance. ⁸⁰ An expert researcher who possesses an analytical mind is in the best place to assess research findings and hence employing them to practice evidence-based medicine. ⁸¹

The study has several strengths including: (1) Addressing an important gap in the literature, which is the association of SU pattern and family factors with severity of SU problems in Arabic-speaking populations. Therefore, the study is regionally valuable, (2) Applying the validated Arabic DAST-10 to address such under-researched topic, (3) Linking family factors to SU severity which is highly relevant for designing targeted interventions, and (4) Guiding healthcare professionals and decision-makers in crafting targeted policies and programs. However, the study has several limitations including (1) Single-center design, (2) Lack of validation of the questionnaire used, (3) The associations were of modest strength, (4) The relatively small number of females (8.3% of the participants), but this is due to underreporting of SU among females in Arab populations, (5) Cross-sectional design which limits causal interpretations, and (6) Inclusion of several types of SUD but this is due to non-specific nature of the original English DAST-10. Moreover, confining the study to a single type of SUD would decrease number of the participants and generalizability of the results.

Conclusion

The current study highlights the association of substance use (SU) pattern and family factors with use-related problems, an under-researched area in the Arab countries. It revealed that parental divorce, family problems, low family emotional support, poor family supervision, recent SU, polysubstance use, and frequent SU were significantly associated with more severe DAST-categories. The users with parental divorce, family problems, no and limited family emotional support, no and limited family control, recent SU, frequent SU, and polysubstance use showed higher significant distributions in the substantial and severe DAST categories. The associations observed were statistically significant, but modest in magnitude. However, we believe that they remain clinically relevant, as even small associations may have practical or public health significance when considered at the population level. Understanding the family-related risk and protective factors for SU is crucial for designing family-based, cost-effective, and practical intervention programs against SU and its consequences. The present study used the validated Arabic DAST-10 version to generate recommendations that inform SU policies and strategies for young adults, with potential long-term benefits for public health and socio-economic stability in Arab communities. Consequently, the following recommendations are suggested: (1) Developing family-based early detection, prevention and intervention programs tailored to the Arab context, (2) Enhancing family ties and emotional support to protect adolescents against SUD, (3) Training healthcare professionals to effectively support SUD patients in all healthcare settings, and (4) Conducting further studies, especially longitudinal prospective cohort research, to provide deeper insights, expand the current findings, and enhance clinical applications.

ORCID iD

Hussam Aly Sayed Murad https://orcid.org/0000-0002-8406-4946

Ethical Considerations

This study was approved by the Institutional Review Board of the Saudi Arabian Ministry of Health in February 2020 (No. 01169).

Consent to Participate

Informed consents were obtained from all participants in the study.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.*