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. Author manuscript; available in PMC: 2015 Nov 16.
Published in final edited form as: J Subst Use. 2011 Jan 10;16(3):213–229. doi: 10.3109/14659891.2010.545857

The association between substance use disorders and early and combined use of alcohol and marijuana in two American Indian populations

JOAN M O'CONNELL 1, DOUGLAS K NOVINS 1, JANETTE BEALS 1, NANCY R WHITESELL 1, PAUL SPICER 2; THE AI-SUPERPFP TEAM2
PMCID: PMC4645988  NIHMSID: NIHMS710125  PMID: 26582968

Abstract

Objective

To study the relationships between early and combined use of alcohol and marijuana with diagnoses of alcohol and marijuana use disorders in two American Indian (AI) populations.

Method

Data were drawn from a psychiatric epidemiologic study of 3084 AIs living on or near two reservations. We analysed data for adults aged 18–54 years at the time of interview (n = 2739). Logistic regression models were estimated to examine associations between early and combined use of alcohol and marijuana with lifetime diagnoses of abuse and dependence.

Results

Overall, younger AIs (18–29 years old) were more likely than older AIs (40–54 years old) to initiate substance use early and initiate use with marijuana, with or without alcohol. Persons who initiated alcohol use before age 14 were more than twice as likely as those who initiated use at older ages to meet criteria for alcohol or marijuana use disorders (p < 0.01). The odds of abuse or dependence were two to five times higher among persons who reported combined use of alcohol and marijuana (p < 0.01) than among those who reported use of either substance.

Conclusions

These findings document the need to address both early and combined use of alcohol and marijuana in prevention and treatment programmes.

Keywords: American Indians, alcohol, marijuana

Introduction

Recent national studies have documented the substantial burden of alcohol and drug use among American Indian and Alaska Native (AI/AN) populations (Stinson et al., 2006; Gilman et al., 2008; U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2010). AI/ANs were found to have the highest rates of lifetime alcohol dependence and marijuana use disorders among all racial/ethnic groups (Stinson et al., 2006; Gilman et al., 2008). Findings from an epidemiologic study of reservation-based American Indians (AIs) indicate that their rates of lifetime alcohol dependence are 40–100% higher than those of the US general population (Spicer et al., 2003; Beals et al., 2005). These high rates of lifetime alcohol dependence are in stark contrast to rates of current alcohol use, which among reservation-based AIs are often lower than US population rates (Beals et al., 2003b; O'Connell et al., 2005). At the same time, rates of marijuana use among AI youth may be higher than US rates as a whole (Plunkett & Mitchell, 2000; Wallace et al., 2002; Shaughnessy & Jones, 2003; Whitesell et al., 2007; U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration Office of Applied Studies, 2008). In one study of primarily reservation-based AI high school students, the prevalence of lifetime marijuana use was reported to be more than double the rate for US students in similar geographic areas (62.1% as compared to 34.5%; Plunkett and Mitchell, 2000).

The burden of substance use and its related mental, physical and social costs is exceedingly high among AI/ANs. For example, Naimi et al. (2008) reported that alcohol-attributable deaths accounted for 11.7% of all AI/AN deaths between 2001 and 2005. Furthermore, these authors reported that the age-adjusted rate for alcohol-attributable deaths among AI/ANs was approximately twice that of the US general population, and years of potential life lost due to such deaths among AI/ANs exceeded that of the US population by 6.4 years (36.3 vs. 29.9; Naimi et al., 2008). Understanding the nature of both alcohol and marijuana initiation and their relationship to abuse and dependence can inform efforts aimed at reducing this burden.

Numerous studies have documented that early substance use is associated with subsequent substance use disorders, mental health problems, lower educational attainment, work impairment, driving under the influence and poor health in the US general population (Kessler & Frank, 1997; Kessler, 2004; Breslau et al., 2008; Falk et al., 2008) as well as among AIs (Beals et al., 1997; Duclos et al., 1998; Robin et al., 1998; Borowsky et al., 1999; O'Connell et al., 2006). Research indicates early age of first substance use and combined use of multiple substances are associated with the development of substance use disorders in non-AI populations (Grant & Dawson, 1998; Wu et al., 2005; Hingson et al., 2006, 2008).

Few studies have assessed the relationships between early and combined substance use with use disorders among AI/ANs. However, several studies suggest the average age of first use of alcohol and marijuana among AIs is younger than for comparison populations, rates of combined alcohol and marijuana use are higher, and many initiate marijuana use before or at the same age as alcohol use (U.S. Congress Office of Technology Assessment, 1990; Beauvais, 1992b; Novins et al., 2001; Beauvais et al., 2004; Novins & Barón, 2004; O'Connell et al., 2007; Whitesell et al., 2007). These same studies indicate substance use differs by age, gender and tribe (Novins et al., 2001; O'Connell et al., 2007; Whitesell et al., 2007), yet little is known about how such patterns of substance use relate to the development of substance use disorders.

The purpose of this article is to study the relationships between early onset and combined use of alcohol and marijuana and the development of alcohol and marijuana use disorders using data drawn from an epidemiologic study of two reservation-based populations: the American Indian Service Utilization Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) (Beals et al., 2003). We focus on marijuana as it is the most commonly used drug reported by AIs in this and other studies (Beauvais, 1992a; Johnston et al., 2002; Mitchell et al., 2003; Novins et al., 2001).

Method

Data

Data were drawn from AI-SUPERPFP, the first large-scale, population-based psychiatric epidemiologic study of reservation-based AIs which was designed to allow estimation of prevalence rates of substance use, DSM-based psychiatric disorders and service utilisation. AI-SUPERPFP worked with two closely affiliated Northern Plains (NP) tribes and one Southwest (SW) tribe. Selection of these tribal groups provided an opportunity to account simultaneously for both the diversity and common experiences among AIs. The NP and SW tribes have distinct and different histories (migration patterns, traditional forms of subsistence, cultural and linguistic heritages), yet they share, along with other AI groups, similar histories of colonisation, military resistance, imposed governance, mandatory boarding school education and active missionary movements.

The AI-SUPERPFP populations of inference were enrolled members of these tribes who lived on or within 20 miles of their reservations. Once located and found to be eligible, 73.7% of SW and 76.8% of NP AIs agreed to participate. Respondents (n = 3084) ranged in age from 15 to 57 years and were interviewed between 1997 and 1999. AI-SUPERPFP methods are described in greater detail elsewhere (Beals et al., 2003a).

We included AI-SUPERPFP respondents who were aged 18–54 years at the time of interview in the statistical analyses (n = 2739). Participants who were aged 15–17 years (n = 157) were excluded from these analyses, as they may not have initiated substance use by the age of interview or had time to develop substance use disorders (Spicer et al., 2003; Whitesell et al., 2007). Participants who were aged 55–57 years also were excluded, as only two of the 56 adults in this age group reported marijuana use. In addition, they were more likely than younger adults to be a biased sample because of substance-related deaths (Naimi et al., 2008). For these two reasons we felt their inclusion would obscure key findings for the other age groups. A small percentage of respondents (n = 132, 4.6%) were excluded from the analyses due to missing data regarding their substance use.

Measures

Demographic

Measures were created from the survey data for age, gender and tribe.

Substance use

AI-SUPERPFP used the University of Michigan version of the Composite International Diagnostic Interview (UM-CIDI). Cultural concerns necessitated modification of the wording for some UM-CIDI questions (Beals et al., 2003a). Questions about alcohol and marijuana use were similar and organised hierarchically. With regard to alcohol, respondents were asked first about their age of first alcohol use and if they ever consumed 12 or more drinks during any 1 year. Those answering yes to the second question were classified as lifetime alcohol users. Similarly, respondents who reported consuming marijuana six times or more in their life were classified as lifetime marijuana users and information on their age of first marijuana use was obtained. These definitions of lifetime use excluded persons who rarely used alcohol or marijuana or only experimented with use. We refer to lifetime use of both substances as combined use.

Early substance use

We defined early use of alcohol and marijuana as use initiated before age 14. This definition was based on the fact that most individuals in the United States enter high school at this age, as well as on published findings concerning early substance use and use disorders (Libby et al., 2004; Degenhardt et al., 2007; Hingson et al., 2006) and the age distributions of first use of alcohol and marijuana among AI-SUPERPFP respondents (O'Connell et al., 2007; Whitesell et al., 2007). Among those who reported use of either or both substances, early substance use was defined as initiating use of at least one substance before age 14.

Type of initiating substance

In our previous studies, we found many AIs reported their first use of marijuana before or at the same age as their first use of alcohol; we refer to this pattern of substance use initiation as atypical initiation (Novins et al., 2001; Novins & Barón, 2004; O'Connell et al., 2007). We therefore classified persons with histories of both alcohol and marijuana use by initiating substance as follows: (1) alcohol alone or (2) atypical initiation.

Substance abuse and dependence

Using questions from the UM-CIDI, substance abuse and dependence were defined using diagnostic criteria published in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV (American Psychiatric Association, 1987). We examined lifetime alcohol and marijuana abuse and dependence separately and then together, as the overwhelming majority (93.5%) of persons who used marijuana also used alcohol.

Analytic methods

Variable construction was completed using the SPSS (Norusis, 2001) and SAS (SAS Institute Inc., 2001) statistical packages; descriptive and inferential analyses were conducted in STATA (Stata, 2001) using sample and non-response weights. We first examined bivariate associations between substance use, substance use initiation and substance use disorders by age, gender and tribe. Significant differences among gender/tribal groups were identified by non-overlapping confidence intervals. Significant differences across the three age groups within the same gender/tribal group were identified using logistic regression. Differences at the level of p < 0.01 are noted for both types of comparisons.

Second, we estimated multivariate logistic regressions to evaluate associations between patterns of early and combined substance use and age with lifetime abuse and dependence among substance users. The estimated coefficients are reported in the form of adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Lifetime use of alcohol and marijuana

The prevalence of lifetime alcohol and lifetime marijuana use was similar among NP and SW males and NP females. Rates of alcohol use ranged from 67.1% to 74.6% and marijuana use ranged from 33.6% to 43.3% (see Table I). In contrast, lifetime use of alcohol and marijuana was significantly lower (p < 0.01) among SW females: 38.7% reported alcohol use and 18.0% reported marijuana use. Differences in age-specific prevalence rates for alcohol and marijuana use by gender and tribe were for the most part similar to those reported for all ages.

Table I.

Lifetime use of alcohol and marijuana by gender, tribe and age.

Males
 Females
Northern plains
 Southwest
 Northern plains
 Southwest
Number Number Number Number
Age
    <30 years 262 167 310 252
    30–39 years 214 152 198 188
    40+ years 226 218 248 304
    All ages 702 537 756 744
% CI % CI % CI % CI
Lifetime use alcohol
    <30 years 74.2 66.3–80.8sf 58.8 48.7–68.2sf,t 60.4 52.8–67.6sf 38.8 31.2–47.1nm,sm,nf
    30–39 years 70.9 61.6–78.6sf 63.9 58.9–78.0sf,t 73.0 63.7–80.7sf 38.7 30.0–48.2nm,sm,nf
    40+ years 79.5 70.6–86.2sf 75.5 67.1–82.4sf,t 69.2 60.8–76.6sf 38.5 31.2–46.3nm,sm,nf
    All ages 74.6 69.7–78.9sf 68.1 62.6–73.2sf 67.1 62.3–71.5sf 38.7 34.0–43.5nm,sm,nf
Lifetime use marijuana
    <30 years 46.6 38.4–55.lsf 44.8 35.2–54.9t 36.5 29.4–44.3t 29.5 22.7–37.5nm,t
    30–39 years 42.3 33.5–51.7sf 39.0 29.3–50.0sf,t 38.7 29.8–48.4sf,t 16.8 10.9–25.0nm,sm,nf,t
    40+ years 40.6 32.0–49.8sf 25.8 18.6–34.9sf,t 24.9 18.0–33.3sf,t 7.8 4.4–13.5nm,sm,nf,t
    All ages 43.3 38.2–48.5sf 36.2 30.9–41.8sf 33.6 29.0–38.6sf 18.0 14.6–22.1nm,sm,nf
Lifetime use of alcohol and/or marijuana
    <30 years 76.9 69.2–83.2sf 66.1 56.0–74.8 66.5 59.0–73.2sf 48.8 40.7–57.0nm,nf
    30–39 years 73.7 64.6–81.2sf 74.6 64.5–82.6sf 75.7 66.6–83.0sf 42.9 33.9–52.4nm,sm,nf
    40+ years 82.4 73.8–88.6sf 77.5 69.3–84.1sf 71.6 63.3–78.7sf 40.0 32.7–47.8nm,sm,nf
    All ages 77.4 72.7–81.5sf 72.9 67.6–77.6sf 71.0 66.3–75.2sf 43.9 39.2–48.8nm,sm,nf
Lifetime combined substance use
    <30 years 43.9 35.8–52.3sf 37.6 28.5–47.7sf,t 30.5 23.7–38.2 19.6 13.9–26.9nm,sm,t
    30–39 years 39.5 30.9–48.8sf 33.6 24.5–44.1sf,t 36.0 27.3–45.7sf 12.6 7.6–20.2nm,sm,nf,t
    40+ years 37.8 29.4–46.9sf 23.8 16.8–32.4sf,t 22.4 15.9–30.7sf 6.2 3.2–11.6nm,sm,nf,t
    All ages 40.4 35.5–45.6sf 31.4 26.4–36.9sf 29.8 25.3–34.6nm,sf 12.8 9.8–16.4nm,sm,nf
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Note: CI indicates confidence intervals calculated at the 99% level. The superscripts nm, sm, nf and sf indicate American Indian Northern Plains and Southwest males and Northern Plains and Southwest females, respectively, and are used to indicate significant (p < 0.01) pairwise comparisons between gender/culture groups. Statistically significant differences (p < 0.01) within one gender/culture group among the three age groups (<30 years, 30–39 years, 40+ years) are indicated through use of the superscript t. Lifetime combined substance use is lifetime use of both alcohol and marijuana.

As only a small percentage of the sample reported lifetime use of marijuana without any alcohol use, rates of use of either substance were similar to those for alcohol use, and rates of combined use were similar to those for marijuana use. The prevalence of combined substance use among NP and SW males was 40.4% and 31.4%, respectively. NP females were significantly less likely than NP males to use both substances (29.8%, p < 0.01), and only 12.8% of SW females reported combined substance use.

Within gender/tribal groups, we observed little variation in alcohol use rates by age except among SW males. Lifetime alcohol use was 75.5% among SW males aged 40 years and older and 58.8% among SW males less than 30 years old (p < 0.01). However, rates of lifetime marijuana use did vary by age among SW males and females and NP females. Among these AIs, lifetime marijuana use among the youngest age group (persons less than 30 years old) ranged from 29.5% to 44.8%; these rates were statistically higher (p < 0.01) than those of AIs age 40 years and older.

Age of first use of alcohol and marijuana

Approximately 30% of NP and SW male drinkers initiated alcohol use before age 14 years (see Table II). The percent of NP female drinkers who reported first use of alcohol before age 14 did not differ from that reported by males (26.1% for NP females as compared to 33.9% and 29.5% for NP and SW males, respectively). Only 15.6% of SW female drinkers reported early alcohol use. Although age of first alcohol use did not vary by age group among male drinkers, the percent of NP and SW female drinkers who reported initiating alcohol use before age 14 was higher (p < 0.01) in the youngest age group. For example, the prevalence of early use was 16.8% among NP female drinkers aged 40 years and older and 35.2% among NP female drinkers less than 30 years old.

Table II.

Age of first substance use and atypical progression of use among lifetime substance users by gender, tribe and age.

Males
 Females
Northern plains
 Southwest
 Northern plains
 Southwest
% CI % CI % CI % CI
Lifetime alcohol users
    First used alcohol <14 years
        <30 years 31.3 23.0–40.9 29.5 19.1–42.7 35.2 26.2–45.5t 25.3 15.6–38.2t
        30–39 years 34.7 25.3–45.6 29.6 19.4–42.2 25.6 16.9–36.7t 13.2 5.9–26.9t
        40+ years 35.6 26.6–45.7nf,sf 29.3 20.8–39.7sf 16.8 10.2–26.3nm,t 8.2 3.5–17.7nm,sm,t
        All ages 33.9 28.5–39.7sf 29.5 23.6–36.1sf 26.1 21.0–31.9 15.6 10.8–22.1nm,sm
Lifetime marijuana users
    First used marijuana < 14 years
        <30 years 29.0 19.1–41.3t 27.8 16.5–42.9t 32.6 21.4–46.2t 13.0 5.8–26.6
        30–39 years 21.3 12.1–34.8sf,t 20.3 9.9–37.0sf,t 21.8 11.4–37.8sf,t 5.8 0.9–29.0
        40+ years 3.8 0.6–20.1t 6.7 15.1–25.2sf,t 2.8 2.1–28.0t 0.0 0.0–11.9sm
        All ages 19.1 13.7–26.1 19.8 13.3–28.6 22.0 15.3–30.4 9.0 4.3–17.9
Lifetime users of alcohol and/or marijuana
    First used either substance <14 years
        <30 years 38.2 29.4–47.8 35.3 24.6–47.8 40.3 31.2–50.1t 24.2 15.6–35.6t
        30–39 years 37.6 28.0–48.2 29.3 19.5–41.4 28.8 19.8–39.8t 13.0 6.1–25.7t
        40+ years 34.9 26.2–44.8 28.6 20.2–38.7 17.5 10.9–27.1t 7.8 3.4–17.0t
        All ages 36.9 31.5–42.7 30.8 25.0–37.2 29.4 24.2–35.2 15.7 11.1–21.7
Lifetime combined substance use
    First used either substance <14 years
        <30 years 43.0 31.0–55.9 41.5 26.7–57.9 54.9 40.5–68.6t 35.9 20.6–54.7
        30–39 years 42.9 29.3–57.6 49.0 31.7–66.7 40.4 25.7–57.0t 24.0 8.5–51.6
        40+ years 39.3 25.8–54.6 37.3 21.3–56.7 29.4 15.0–49.5t 6.4 0.5–49.9
        All ages 41.9 34.1–50.1 43.0 33.2–53.3 43.5 34.4–53.0 27.3 16.9–40.9
Lifetime combined substance use
    Atypical initiation
        <30 years 55.0 37.4–62.6t 48.8 33.1–64.7t 54.1 39.6–67.9t 53.0 35.0–70.3
        30–39 years 45.9 31.9–60.5t 39.1 23.4–57.5t 52.6 36.6–68.1t 63.1 36.3–83.6
        40+ years 13.5 6.1–27.3t 10.8 3.4–29.7t 23.5 10.9–43.5t 39.6 14.2–72.2
        All ages 38.2 30.7–46.4 35.2 26.1–45.6 46.5 37.2–56.0 53.7 40.0–66.9
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Note: CI indicates confidence intervals calculated at the 99% level. The superscripts nm, sm, nf and sf indicate American Indian Northern Plains and Southwest males and Northern Plains and Southwest females, respectively, and are used to indicate significant (p < 0.01) pairwise comparisons between gender/culture groups. Statistically significant differences (p < 0.01) within one gender/culture group among the three age groups (<30 years, 30–39 years, 40+ years) are indicated through use of the superscript t. Lifetime combined substance use is lifetime use of both alcohol and marijuana. Atypical initiation among lifetime combined substance users refers to initiating substance use with marijuana, with or without alcohol, as compared to initiating substance use with alcohol alone.

Approximately 20% of NP and SW male and NP female marijuana users reported initiating use before age 14. Although only 9.0% of SW female marijuana users reported early use of marijuana, the prevalence of early use among SW females did not differ statistically from the prevalence among NP and SW males or NP females. Among NP and SW males and NP females, differences across age groups were significant (p < 0.01) with one-third of the marijuana users in the youngest age group reporting early marijuana use.

Rates of early substance use among persons who reported use of either substance were similar to those of drinkers. Approximately 40% of NP and SW males and NP females who reported combined use initiated use of alcohol and/or marijuana by age 14; the rate among SW females with combined use was 27.3. Age group differences were significant among the NP females who reported combined use (p < 0.01); 54.9% in the youngest age group reported early substance use.

Type of initiating substance

Among all persons who reported combined substance use, the prevalence of atypical substance use initiation (initiating substance use with marijuana with or without alcohol, rather than alcohol alone) ranged from 35.2% to 53.7% (see Table II). There were no significant differences by gender or tribe. The prevalence of atypical initiation varied by age among NP and SW males and NP females and was generally highest in the youngest age group (p < 0.01). For example, the percent of respondents in the youngest age group who reported atypical initiation ranged from 48.8% to 55.0%, compared to 10.8% to 23.5% for the oldest age group.

Lifetime substance use disorders

For both tribal groups, the prevalence of lifetime alcohol disorders among lifetime drinkers was significantly higher (p < 0.01) for males than females. Over half of NP and SW male drinkers met criteria for a lifetime alcohol use disorder. The prevalence of an alcohol use disorder among NP and SW female drinkers was 42.9% and 32.1%, respectively (see Table III).

Table III.

The prevalence of lifetime dependence and abuse among lifetime substance users by gender, tribe and age.

Males
 Females
Northern plains
 Southwest
 Northern plains
 Southwest
% CI % CI % CI % CI
Lifetime alcohol users
    Lifetime alcohol dependence/abuse
        <30 years 55.7 45.9–65.1sf 57.8 44.6–70.0sf 39.3 29.8–49.7 31.4 20.7–44.5nm,sm
        30–39 years 54.8 43.9–65.2 61.0 48.2–72.4sf 44.3 33.5–55.6 31.8 19.5–37.3sm
        40+ years 58.3 48.2–67.7sf 61.0 50.5–70.5sf 45.3 35.2–55.8 33.0 22.2–45.9nm,sm
        All ages 56.2 50.3–62.0nf,sf 60.1 53.2–66.6nf,sf 42.9 36.9–49.1nm,sm 32.1 25.2–39.8nm,sm
Lifetime marijuana users
    Lifetime marijuana dependence/abuse
        <30 years 41.9 30.4–54.4t 38.1 25.0–53.2 26.6 16.7–39.5 24.0 13.7–38.6
        30–39 years 25.8 15.4–39.9t 23.8 12.4–40.9 29.6 17.2–45.9 19.5 7.0–43.9
        40+ years 22.3 12.3–37.2t 29.5 15.5–48.7 21.2 10.3–38.7 23.0 6.5–56.1
        All ages 30.7 23.9–38.4 30.9 22.8–40.4 26.5 19.4–35.0 22.6 14.4–33.6
Lifetime users of alcohol and/or marijuana
    Lifetime alcohol and/or marijuana dependence/abuse
        <30 years 58.7 49.1–67.8nf,sf 58.7 46.2–70.2sf 39.1 30.1–48.9nm 33.4 23.5–45.1nm,sm
        30–39 years 54.8 44.1–65.0 61.1 48.8–72.2sf 44.5 33.9–55.6 33.8 21.7–48.4sm
        40+ years 56.8 46.8–66.2sf 60.2 49.9–69.7sf 45.2 35.2–55.6 32.9 22.2–45.6nm,sm
        All ages 56.7 50.9–62.4nf,sf 60.1 53.4–66.4nf,sf 42.8 37.0–48.8nm,sm 33.3 26.8–40.6nm,sm
Lifetime combined substance users
    Lifetime alcohol and/or marijuana dependence/abuse
        <30 years 71.6 59.0–81.6 72.4 55.7–84.6 58.5 43.9–71.8 51.0 33.2–68.5
        30–39 years 71.4 56.8–82.6 76.5 58.0–88.4 58.4 42.0–73.1 46.1 22.8–71.2
        40+ years 80.1 66.3–89.2 80.3 60.6–91.5 54.0 35.5–71.4 68.3 35.0–89.6
        All ages 73.9 66.3–80.4 75.9 66.1–83.6 57.4 47.9–66.4 52.5 38.9–65.8
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Note: CI indicates confidence intervals calculated at the 99% level. The superscripts nm, sm, nf and sf indicate American Indian Northern Plains and Southwest males and Northern Plains and Southwest females, respectively, and are used to indicate significant (p < 0.01) pairwise comparisons between gender/culture groups. Statistically significant differences (p < 0.01) within one gender/culture group among the three age groups (<30 years, 30–39 years, 40+ years) are indicated through use of the superscript t. Lifetime combined substance use is lifetime use of both alcohol and marijuana. Atypical initiation among lifetime combined substance users refers to initiating substance use with marijuana, with or without alcohol, as compared to initiating substance use with alcohol alone.

In contrast to the prevalence of lifetime alcohol use disorders, the prevalence of lifetime marijuana use disorders among lifetime marijuana users did not vary by gender. Prevalence rates ranged from a low of 22.6% among SW females to 30.9% among SW males. We observed only one significant difference in the prevalence of alcohol or marijuana use disorders related to age group; younger NP males who used marijuana were more likely to report a marijuana use disorder than were the oldest NP male users (p < 0.01).

The prevalence of lifetime use disorders among AIs who reported lifetime use of either substance was similar to that of alcohol use disorders among drinkers. Nearly half of AIs who reported use of either substance had a lifetime alcohol and/or marijuana use disorder (48.5%, n = 866). Among those with a disorder, nearly three-quarters had alcohol abuse or dependence, 6.6% had marijuana abuse or dependence and 25.5% had both. However, approximately three-quarters of males and over half of females with combined substance use had alcohol and/or marijuana abuse or dependence.

Correlates with lifetime substance use disorders

We estimated multivariate logistic regressions by gender to examine the associations between patterns of alcohol and marijuana initiation, age and tribe with lifetime alcohol and marijuana abuse and dependence (see Table IV). Correlates of alcohol use disorders were remarkably similar across gender. Drinkers who initiated alcohol use before age 14 years were more than twice as likely to have an alcohol use disorder as those who initiated use at older ages (ORs of 2.31 for male and female drinkers, p < 0.01). Combined substance use, as compared to use of alcohol alone, was associated with significantly higher odds of alcohol abuse and dependence. The odds among females who used both substances were 1.82 (p < 0.05) for those who initiated use with alcohol first and 3.33 (p < 0.01) for those who reported atypical initiation.

Table IV.

Correlates of lifetime alcohol and marijuana dependence and abuse among lifetime substance users by gender.

Male lifetime drinkers
 Female lifetime drinkers
Lifetime alcohol dependence/abuse OR CI OR CI
First used alcohol <14 years 2.31** 1.63–3.27 2.31** 1.51–3.52
First used alcohol at an older age 1.00 1.00
First used marijuana <14 years 1.01 0.54–1.91 1.37 0.67–2.81
First used marijuana at an older age or non-user 1.00 1.00
Combined substance use, initiated with alcohol 3.04** 2.14–4.30 1.82* 1.20–2.77
Combined substance use, atypical initiation 3.93** 2.44–6.35 3.33** 2.07–5.36
Used only alcohola 1.00 1.00
Northern Plains 0.74 0.55–1.00 1.37 0.98–1.91
Southwest 1.00 1.00
Age <30 years 0.88 0.60–1.29 0.71 0.47–1.07
Age 30–39 yearsa 1.00 1.00
Age 40+ years 1.31 0.92–1.89 1.42 0.94–2.15
Male lifetime marijuana users
 Female lifetime marijuana users
Lifetime marijuana dependence/abuse OR CI OR CI
First used alcohol <14 years 1.39 0.83–2.33 1.87 0.97–3.59
First used alcohol at an older age or non-user 1.00 1.00
First used marijuana <14 years 1.16 0.64–2.08 1.06 0.49–2.26
First used marijuana at an older age 1.00 1.00
Combined substance use, initiated with alcohol 1.00 1.00
Combined substance use, atypical initiation 1.33 0.80–2.22 3.48** 1.79–6.79
Used only marijuanaa 0.86 0.40–1.83 2.45* 1.12–5.35
Northern Plains 0.99 0.65–1.50 1.23 0.71–2.14
Southwest 1.00 1.00
Age <30 years 2.03** 1.24–3.32 0.92 0.50–1.68
Age 30–39 yearsa 1.00 1.00
Age 40+ years 1.10 0.62–1.97 1.04 0.48–2.26
Male lifetime users of alcohol and/or marijuana
 Female lifetime users of alcohol and/or marijuana
Lifetime alcohol and/or marijuana dependence/abuse OR CI OR CI
First used alcohol <14 years 2.27** 1.61–3.21 2.16** 1.45–3.24
First used alcohol at an older age or non-user 1.00 1.00
First used marijuana <14 years 1.22 0.64–2.33 1.23 0.63–2.42
First used marijuana at an older age 1.00 1.00
Combined substance use, initiated with alcohol 3.22** 2.26–4.57 1.96** 1.30–2.96
Combined substance use, atypical initiation 4.81** 2.94–7.88 4.12** 2.58–6.58
Used only marijuana 0.44* 0.21–0.93 0.98 0.51–1.88
Used only alcohola 1.00 1.00
Northern Plains 0.70* 0.52–0.95 1.24 0.90–1.70
Southwest 1.00 1.00
Age <30 years 0.96 0.65–1.40 0.76 0.51–1.12
Age 30–39 yearsa 1.00 1.00
Age 40+ years 1.23 0.86–1.76 1.35 0.91–2.02
Male lifetime combined substance users
 Female lifetime combined substance users
Lifetime alcohol and/or marijuana dependence/abuse OR CI OR CI
First used alcohol <14 years 1.46 0.83–2.56 1.42 0.74–2.70
First used alcohol at an older age or non-user 1.00 1.00
First used marijuana <14 years 1.74 0.83–3.65 1.66 0.73–3.77
First used marijuana at an older age 1.00 1.00
Combined substance use, initiated with alcohola 1.00 1.00
Combined substance use, atypical initiation 1.37 0.79–2.39 1.71 0.96–3.03
Northern Plains 0.90 0.56–1.43 1.14 0.67–1.93
Southwest 1.00 1.00
Age <30 years 0.91 0.54–1.54 0.96 0.54–1.69
Age 30–39 yearsa 1.00 1.00
Age 40+ years 1.77 0.95–3.28 1.40 0.69–2.82
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Note: OR indicates odds ratio and CI indicates confidence intervals calculated at the 95% level. Combined substance use is lifetime use of both alcohol and marijuana. Atypical initiation among lifetime alcohol and marijuana users refers to initiating substance use with marijuana with or without alcohol as compared to initiating substance use with alcohol alone.

a

The referent groups in the logistic regressions were chosen to identify the risks associated with atypical patterns of use. The logistic regressions of alcohol dependence and abuse were estimated with the referent group being users of only alcohol. The referent group in the regression of marijuana dependence and abuse were respondents who reported combined substance use and initiating use with alcohol. We chose age 30–39 years as the referent group for the age variables to distinguish patterns of use between this age group and the youngest age group.

*

Significance at the 0.05 and 0.01 level, respectively.

**

Significance at the 0.05 and 0.01 level, respectively.

Correlates of lifetime marijuana use disorders differed by gender. Among males, age was significantly associated with marijuana use disorders while among females, patterns of substance use were. More specifically, male marijuana users less than 30 years old were twice as likely as males users aged 30–39 years to have a marijuana use disorder (OR = 2.03, p < 0.01). For females, atypical initiation, as compared to initiating use with alcohol alone, increased the odds of a marijuana use disorder (OR = 3.48, p < 0.01). The odds of a marijuana use disorder among female marijuana users who did not drink were 2.45 times higher than among females who reported combined substance use and initiating use with alcohol alone (p < 0.05).

Early marijuana use was not found to be significantly associated with alcohol or marijuana use disorders among males or females, but it is noteworthy that early use of marijuana was correlated with atypical initiation (phi coefficient of 0.30). Equally important is that we were unable to identify a relationship between age and disorder in any of the other regressions. This finding indicates that substance users less than 30 years old were just as likely as older users to be diagnosed with an alcohol or marijuana use disorder after controlling for other variables in the regression model.

Correlates of lifetime substance use disorders among AIs who reported use of either alcohol or marijuana were very similar to those of alcohol use disorders noted above for males and females. However, the odds of either type of disorder were two to five times higher among persons who reported combined use of alcohol and marijuana (p < 0.01) than among those who reported use of either alcohol or marijuana. The odds of a use disorder among males who reported marijuana use, yet not alcohol use, were approximately half of those who reported only alcohol use (p < 0.05). In addition, NP males who reported use of either substance were less likely (p < 0.05) than SW males to have a use disorder, controlling for other correlates of substance use. Among those who reported lifetime combined use of alcohol and marijuana, none of the correlates included in the logistic regression significantly influenced the risk of lifetime abuse or dependence.

Discussion and conclusions

That early alcohol use, combined use of alcohol and marijuana and atypical initiation (initiating use with marijuana with or without alcohol) were associated with a greater likelihood of abuse and dependence in this study highlight the need to increase the effectiveness of substance use prevention and treatment programs for AIs, especially among youth. This is particularly important as findings for the US general population suggest early age of onset of alcohol use is associated with multiple and longer episodes of dependence, and meeting a wider range of dependence symptoms (Hingson et al., 2006).

In general, the AIs in the youngest age group (less than 30 years old) were more likely than those in the oldest age group to initiate substance use early and more likely to initiate substance use with marijuana with or without alcohol. These patterns of substance use initiation place them at greater risk of developing alcohol and marijuana use disorders. When we also consider that the younger AIs already had rates of substance use disorders comparable to those of their older counterparts, despite having less time between substance use initiation and age of interview, the burden of substance use among AIs with early age of onset may far exceed that among those who initiate use at older ages and may place a greater burden on substance use treatment services over time.

Although patterns of substance use among males did not differ between NP and SW males, NP males who reported use of either alcohol or marijuana were less likely than SW males to be diagnosed with a substance use disorder. Tribal differences among females were not observed. It may be that perceptions of the psychological, behavioural and physical consequences of alcohol and marijuana use differ by tribe and gender and NP males are less likely to endorse symptoms of abuse or dependence than SW males.

These findings have a number of important implications for prevention and treatment. First, patterns of early and combined substance use indicate that prevention efforts should not only target younger adolescents and their families but also focus on both alcohol and marijuana. The prevalence of lifetime alcohol or marijuana use disorders among NP and SW males and females who reported combined substance use ranged from a low of 52.5% among SW females to a high of 75.9% among SW males. Second, methods to improve early identification of youth with substance use issues should be enhanced to reduce the onset of substance use disorders and related hazards. As sovereign nations, federally recognised tribes may examine policies aimed at reducing the burden of substance use in their communities. Many statutes address the legality of sales and consumption as well as taxation (Kovas et al., 2008). Tribes may evaluate their policies concerning driving under the influence and other violations related to substance use to identify persons in need of treatment. Finally, treatment programs for youth and young adults should be evaluated with regard to access, utilisation, cultural appropriateness and comprehensiveness (Beauvais et al., 2004; Hawkins et al., 2004; Novins et al., 2004; Fickenscher et al., 2005). Comprehensive outpatient and residential programs for youth with substance use disorders are costly, and financing of such programmes is limited. Research concerning the long-term mental, physical and social outcomes of programmes is needed to inform policies concerning increasing access and resources for such services.

Limitations of the AI-SUPERPFP study design, instrumentation and sample are published elsewhere (Beals et al., 2003a). They include reliance on self-reports of psychiatric symptoms using structured protocols to assess the prevalence of substance use disorders. Retrospective reporting of age of first use may be subject to reporting bias, particularly for older persons who are reporting about events that may have occurred decades ago (Labouvie et al., 1997). This bias may account for some of the differences in age of onset observed in this study. Of note is that retrospective reporting of the rank ordering of first use of different substances was found to be more reliable than the actual specific age of first use (Labouvie et al., 1997), suggesting that our examination of combined use and atypical initiation may be particularly relevant when considering these findings among the older age groups included in this study. It is important to note that, in studies of the US population, high rates of dependence among younger adults (age 18–23 years), as compared to older adults, may be explained in part by younger adults’ higher reports of dependence symptoms related to “increased tolerance” and “using more than intended”; these symptoms may mean something different to younger adults than older adults (Harford et al., 2005; Caetano & Babor, 2006; Degenhardt et al., 2007). Additional research is needed to examine symptoms of abuse and dependence reported by younger and older AIs to better understand their treatment needs (Harford et al., 2005; Caetano & Babor, 2006; Degenhardt et al., 2007). Finally, the population of inference was two reservation-based tribes, but there are over 500 federally designated tribes in the United States with considerable heterogeneity among them (U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 2001). Additionally, the majority of AIs do not live on tribal lands (U.S. Census Bureau, 2003), and they may experience patterns of substance use that differ from those reported here (Beauvais, 1996; O'Connell et al., 2005). Consequently, the results of this study may not extend to other AI populations.

Despite these limitations, our findings point to three important factors related to substance use disorders: early use of alcohol, combined use of both marijuana and alcohol and initiating substance use with marijuana with or without alcohol. All of these factors should be considered in the development of prevention and treatment programmes for these communities. As younger AIs were more likely to report these patterns of use and may, therefore, be at greater risk for developing substance use disorders, the burden on treatment services – and the need for improved prevention efforts – may grow considerably as these younger AIs enter middle adulthood.

Acknowledgements

AI-SUPERPFP would not have been possible without the significant contributions of many people. The following interviewers, computer/data management and administrative staff supplied energy and enthusiasm for an often difficult job: Anna Barón, Antonita Begay, Amelia Begay, Cathy Bell, Phyllis Brewer, Nelson Chee, Mary Cook, Helen Curley, Mary Davenport, Rhonda Dick, Pearl Dull Knife, Geneva Emhoolah, Roslyn Green, Billie Greene, Fay Flame, Jack Herman, Tamara Holmes, Shelly Hubing, Cameron Joe, Louise Joe, Cheryl Martin, Jeff Miller, Robert Moran, Natalie Murphy, Melissa Nixon, Ralph Roanhorse, Margo Schwab, Jennifer Settlemire, Donna Shangreaux, Matilda Shorty, Selena Simmons, Wileen Smith, Tina Standing Soldier, Jennifer Truel, Lori Trullinger, Arnold Tsinajinnie, Marvine Two Eagle, Jennifer Warren, Intriga Wounded Head, Dawn Wright, Jenny Yazzie and Sheila Young. We also acknowledge the contributions of the Methods Advisory Group: Margarita Alegria, Evelyn Bromet, Peter Guarnaccia, Steve Heeringa, Ron Kessler, R. Jay Turner and William Vega. Finally, we thank the tribal members who so generously answered all the questions asked of them. Relevant ethical safeguards have been met in relation to the confidentiality and consent of the tribal members involved in the research. The university and the tribal institutional review boards approved the study protocol.

Footnotes

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References

  1. American Psychiatric Association . Diagnostic and statistical manual of mental disorders, third edition, revised (DSM-III-R) American Psychiatric Association; Washington, DC: 1987. [Google Scholar]
  2. Beals J, Manson SM, Mitchell CM, Spicer P, The AI-SUPERPFP Team Cultural specificity and comparison in psychiatric epidemiology: Walking the tightrope in American Indian research. Culture, Medicine and Psychiatry. 2003a;27:259–289. doi: 10.1023/a:1025347130953. [DOI] [PubMed] [Google Scholar]
  3. Beals J, Novins DK, Whitesell NR, Spicer P, Mitchell CM, Manson SM. Prevalence of mental disorders and utilization of mental health services in two American Indian reservation populations: Mental health disparities in a national context. American Journal of Psychiatry. 2005;162(9):1723–1732. doi: 10.1176/appi.ajp.162.9.1723. [DOI] [PubMed] [Google Scholar]
  4. Beals J, Piasecki J, Nelson S, Jones M, Keane E, Dauphinais P, Shirt RR, Sack WH, Manson SM. Psychiatric disorder among American Indian adolescents: Prevalence in Northern Plains youth. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36(9):1252–1259. doi: 10.1097/00004583-199709000-00018. [DOI] [PubMed] [Google Scholar]
  5. Beals J, Spicer P, Mitchell CM, Novins DK, Manson SM, The AI-SUPERPFP Team Racial disparities in alcohol use: Comparison of two American Indian reservation populations with national data. American Journal of Public Health. 2003b;93(10):1683–1685. doi: 10.2105/ajph.93.10.1683. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Beauvais F. Characteristics of Indian youth and drug use. American Indian and Alaska Native Mental Health Research. 1992a;5:50–67. doi: 10.5820/aian.0501.1992.51. [DOI] [PubMed] [Google Scholar]
  7. Beauvais F. Comparison of drug use rates for reservation Indian, non-reservation Indian and Anglo youth. American Indian and Alaska Native Mental Health Research. 1992b;5(1):13–31. doi: 10.5820/aian.0501.1992.13. [DOI] [PubMed] [Google Scholar]
  8. Beauvais F. Trends in drug use among American Indian students and dropouts, 1975 to 1994. American Journal of Public Health. 1996;86:1594–1599. doi: 10.2105/ajph.86.11.1594. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Beauvais F, Jumper-Thurman P, Helm H, Plested B, Burnside M. Surveillance of drug use among American Indian adolescents: Patterns over 25 years. Journal of Adolescent Health. 2004;34(6):493–500. doi: 10.1016/j.jadohealth.2003.07.019. [DOI] [PubMed] [Google Scholar]
  10. Borowsky IW, Resnick MD, Ireland M, Blum RW. Suicide attempts among American Indian and Alaska Native youth: Risk and protective factors. Archives of Pediatric and Adolescent Medicine. 1999;153:573–580. doi: 10.1001/archpedi.153.6.573. [DOI] [PubMed] [Google Scholar]
  11. Breslau J, Lane M, Sampson N, Kessler R. Mental disorders and subsequent educational attainment in a US national sample. Journal of Psychiatric Research. 2008;42(7):708–716. doi: 10.1016/j.jpsychires.2008.01.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Caetano R, Babor TF. Diagnosis of alcohol dependence in epidemiological surveys: An epidemic of youthful alcohol dependence or a case of measurement error?. Addiction. 2006;101(Suppl. 1):111–114. doi: 10.1111/j.1360-0443.2006.01599.x. [DOI] [PubMed] [Google Scholar]
  13. Degenhardt L, Chiu WT, Sampson N, Kessler RC, Anthony JC. Epidemiological patterns of extra-medical drug use in the United States: Evidence from the National Comorbidity Survey Replication, 2001–2003. Drug and Alcohol Dependence. 2007;90:210–223. doi: 10.1016/j.drugalcdep.2007.03.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Duclos CW, Beals J, Novins DK, Martin C, Jewett CS, Manson SM. Prevalence of common psychiatric disorders among American Indian adolescent detainees. Journal of the American Academy of Child and Adolescent Psychiatry. 1998;37(8):866–873. doi: 10.1097/00004583-199808000-00017. [DOI] [PubMed] [Google Scholar]
  15. Falk DE, Yi H, Hilton ME. Age of onset and temporal sequencing of lifetime DSM-IV alcohol use disorders relative to comorbid mood and anxiety disorders. Drug and Alcohol Dependence. 2008;94(1–3):234–245. doi: 10.1016/j.drugalcdep.2007.11.022. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Fickenscher A, Novins DK, Beals J. A pilot study of motivation and treatment completion among American Indian adolescents in substance abuse treatment. Addictive Behaviors. 2005;31(8):1402–1414. doi: 10.1016/j.addbeh.2005.11.001. [DOI] [PubMed] [Google Scholar]
  17. Gilman WE, Breslau J, Conron KJ, Koenen KC, Subramanian SV, Zaslavsky AM. Education and race-ethnicity differences in the lifetime risk of alcohol dependence. Journal of Epidemiology and Community Health. 2008;62:224–230. doi: 10.1136/jech.2006.059022. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Grant BF, Dawson DA. Age of onset of drug use and its association with DSM-IV drug abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse. 1998;10(2):163–173. doi: 10.1016/s0899-3289(99)80131-x. [DOI] [PubMed] [Google Scholar]
  19. Harford TC, Grant BF, Yi H, Chen CM. Patterns of DSM-IV alcohol abuse and dependence criteria among adolescent and adults: Results from the 2001 National Household Survey on Drug Abuse. Alcoholism, Clinical and Experimental Research. 2005;29(5):810–828. doi: 10.1097/01.alc.0000164381.67723.76. [DOI] [PubMed] [Google Scholar]
  20. Hawkins EH, Cummins LH, Marlatt GA. Preventing substance abuse in American Indian and Alaska Native youth: Promising strategies for healthier communities. Psychological Bulletin. 2004;130(2):304–323. doi: 10.1037/0033-2909.130.2.304. [DOI] [PubMed] [Google Scholar]
  21. Hingson RW, Heeren T, Edwards EM. Age at drinking onset, alcohol dependence, and their relationship to drug use and dependence, driving under the influence of drugs, and motor-vehicle crash involvement because of drugs. Journal of Studies on Alcohol and Drugs. 2008;69:192–201. doi: 10.15288/jsad.2008.69.192. [DOI] [PubMed] [Google Scholar]
  22. Hingson RW, Heeren T, Winter MR. Age of drinking onset and alcohol dependence: Age at onset, duration, and severity. Archives of Pediatric and Adolescent Medicine. 2006;160:739–746. doi: 10.1001/archpedi.160.7.739. [DOI] [PubMed] [Google Scholar]
  23. Johnston LD, O'Malley PM, Bachman JG. Monitoring the future national survey results on drug use, 1975–2001. Volume I: Secondary school students. National Institute on Drug Abuse; Bethesda, MD: 2002. [Google Scholar]
  24. Kessler RC. The epidemiology of dual diagnosis. Biological Psychiatry. 2004;56:703–713. doi: 10.1016/j.biopsych.2004.06.034. [DOI] [PubMed] [Google Scholar]
  25. Kessler RC, Frank RG. The impact of psychiatric disorders on work loss days. Psychological Medicine. 1997;27(4):861–873. doi: 10.1017/s0033291797004807. [DOI] [PubMed] [Google Scholar]
  26. Kovas AE, McFarland BH, Landen MG, Lopez AL, May PA. Survey of American Indian alcohol statutes, 1975–2006: Evolving needs and future opportunities for tribal health. Journal of Studies on Alcohol and Drugs. 2008;69:183–191. doi: 10.15288/jsad.2008.69.183. [DOI] [PubMed] [Google Scholar]
  27. Labouvie E, Bates M, Pandina R. Age of first use: Its reliability and predictive utility. Journal of Studies on Alcohol. 1997;58:638–643. doi: 10.15288/jsa.1997.58.638. [DOI] [PubMed] [Google Scholar]
  28. Libby AM, Orton HD, Novins DK, Spicer P, Buchwald D, Beals J, Manson SM, AI-SUPERPFP Team Childhood physical abuse and sexual abuse and subsequent alcohol and drug use disorders in two American Indian tribes. Journal of Studies on Alcohol. 2004;65(1):74–83. doi: 10.15288/jsa.2004.65.74. [DOI] [PubMed] [Google Scholar]
  29. Mitchell CM, Beals J, Novins DK, Spicer P, The AI-SUPERPFP Team Drug use among two American Indian populations: Prevalence of lifetime use and DSM-IV substance disorders. Drug and Alcohol Dependence. 2003;69:29–41. doi: 10.1016/s0376-8716(02)00253-3. [DOI] [PubMed] [Google Scholar]
  30. Naimi TS, Cobb N, Boyd D, Jarman DW, Brewer R, Nelson DE, Holt J, Espey D, Snesrud P, Chavez P. Alcohol-attributed deaths and years of potential life lost among American Indians and Alaska Natives – United States, 2001–2005. Morbidity & Mortality Weekly Report. 2008;57(34):938–940. [PubMed] [Google Scholar]
  31. Norusis MJ. SPSS 10.0 for Windows user's guide. SPSS, Inc.; Chicago, IL: 2001. [Google Scholar]
  32. Novins DK, Barón A. American Indian adolescent substance use: The hazards for substance use initiation and progression for adolescents aged 14 to 20. Journal of the American Academy of Child and Adolescent Psychiatry. 2004;43:316–324. doi: 10.1097/00004583-200403000-00013. [DOI] [PubMed] [Google Scholar]
  33. Novins DK, Beals J, Mitchell CM. Sequences of substance use among American Indian adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 2001;40:1168–1174. doi: 10.1097/00004583-200110000-00010. [DOI] [PubMed] [Google Scholar]
  34. Novins DK, Spicer P, Beals J, Manson SM. Preventing underage drinking in American Indian and Alaska Native communities: Contexts, epidemiology, and culture. In: Division of Behavioral and Social Sciences and Education, editor. National Research Council and Institute of Medicine, Reducing underage drinking: A collective responsibility, background papers [CD ROM] The National Academies Press; Washington, DC: 2004. pp. 678–696. [Google Scholar]
  35. O'Connell JM, Novins DK, Beals J, Croy CD, Barón AE, Spicer P, Buchwald D, American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project Team The relationship between patterns of alcohol use and mental and physical health disorders in two American Indian populations. Addiction. 2006;101(1):69–83. doi: 10.1111/j.1360-0443.2005.01308.x. [DOI] [PubMed] [Google Scholar]
  36. O'Connell JM, Novins DK, Beals J, Spicer P. Disparities in patterns of alcohol use among reservation-based and geographically dispersed American Indian populations. Alcoholism: Clinical and Experimental Research. 2005;29(1):107–116. doi: 10.1097/01.alc.0000153789.59228.fc. [DOI] [PubMed] [Google Scholar]
  37. O'Connell JM, Novins DK, Beals J, Whitesell NR, Libby A, Orton H, Croy CD, AISUPERPFP Team Childhood characteristics associated with stage of substance use of American Indians: Family background, traumatic experiences, and childhood behaviors. Addictive Behavioirs. 2007;32:3142–3152. doi: 10.1016/j.addbeh.2007.07.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Plunkett M, Mitchell CM. Substance use rates among American Indian adolescents: Regional comparisons with Monitoring the Future high school seniors. Journal of Drug Issues. 2000;30(3):593–620. [Google Scholar]
  39. Robin RW, Long JC, Rasmussen JK, Albaugh B, Goldman D. Relationship of binge drinking to alcohol dependence, other psychiatric disorders, and behavioral problems in an American Indian tribe. Alcoholism, Clinical and Experimental Research. 1998;22(2):518–523. [PubMed] [Google Scholar]
  40. SAS Institute Inc . SAS language (Version 8.2) SAS Institute; Cary, NC: 2001. [Google Scholar]
  41. Shaughnessy L, Jones SE. Tobacco, alcohol, and other drug use among high school students in Bureau of Indian Affairs-funded schools – United States, 2001. Morbidity & Mortality Weekly Report. 2003;52:1070–1072. [PubMed] [Google Scholar]
  42. Spicer P, Beals J, Mitchell CM, Novins DK, Croy CD, Manson SM, Moore L, The AI-SUPERPFP Team The prevalence of DSM-III-R alcohol dependence in two American Indian reservation populations. Alcoholism: Clinical and Experimental Research. 2003;27(11):1785–1797. doi: 10.1097/01.ALC.0000095864.45755.53. [DOI] [PubMed] [Google Scholar]
  43. Stata . Stata statistical software: Release 7.0 (Version 7) Stata Corporation; College Station, TX: 2001. [Google Scholar]
  44. Stinson FS, Ruan WJ, Pickering R, Grant B. Cannabis use disorders in the USA: Prevalence, correlates and co-morbidity. Psychological Medicine. 2006;36:1447–1460. doi: 10.1017/S0033291706008361. [DOI] [PubMed] [Google Scholar]
  45. Census Bureau US. Characteristics of American Indians and Alaska Natives by tribe and language: 2000. US Government Printing Office; Washington, DC: 2003. [Google Scholar]
  46. U.S. Congress Office of Technology Assessment . Indian adolescent mental health. U.S. Congress; Washington, DC: 1990. [Google Scholar]
  47. U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services . Mental health: Culture, race, and ethnicity – a supplement to mental health: A report of the surgeon general (SMA01-3613) U.S. Department of Health and Human Services; Rockville, MD: 2001. [PubMed] [Google Scholar]
  48. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies . Results from the 2007 National Survey on Drug Use and health: Detailed tables. U.S. Department of Health and Human Services; Rockville, MD: 2008. [Google Scholar]
  49. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies . The NSDUH report, substance use among American Indian or Alaska Native adults. U.S. Department of Health and Human Services; Rockville, MD: 2010. [Google Scholar]
  50. Wallace JM, Jr., Bachman JG, O'Malley PM, Johnston LD, Schulenberg JE, Cooper SM. Tobacco, alcohol, and illicit drug use: Racial and ethnic differences among U.S. high school seniors, 1976–2000. Public Health Reports. 2002;117(Supplement 1):S67–S75. [PMC free article] [PubMed] [Google Scholar]
  51. Whitesell NR, Beals J, Mitchell CM, Novins DK, Spicer P, O'Connell J, Manson SM. Marijuana initiation in two American Indian reservation communities: Comparison to a national sample. American Journal of Public Health. 2007;97(7):1311–1318. doi: 10.2105/AJPH.2005.071266. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Wu L, Pilowsky DJ, Schlenger WE. High prevalence of substance use disorders among adolescents who use marijuana and inhalants. Drug and Alcohol Dependence. 2005;78:23–32. doi: 10.1016/j.drugalcdep.2004.08.025. [DOI] [PubMed] [Google Scholar]

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