Family structure and youth illicit drug use, use disorder, and treatment services utilization

Journal Pre-proofs Family Structure and Youth Illicit Drug Use, Use Disorder, and Treatment Services Utilization Saijun Zhang, Younghee Lim, Javier F. Boyas, Viktor Burlaka PII: DOI: Reference:

S0190-7409(19)31349-0 https://doi.org/10.1016/j.childyouth.2020.104880 CYSR 104880

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Children and Youth Services Review

Received Date: Revised Date: Accepted Date:

22 November 2019 18 February 2020 18 February 2020

Please cite this article as: S. Zhang, Y. Lim, J.F. Boyas, V. Burlaka, Family Structure and Youth Illicit Drug Use, Use Disorder, and Treatment Services Utilization, Children and Youth Services Review (2020), doi: https:// doi.org/10.1016/j.childyouth.2020.104880

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Family Structure and Youth Illicit Drug Use, Use Disorder, and Treatment Services Utilization Running Head: FAMILY STRUCTURE AND YOUTH ILLICIT DRUG USE Family Structure and Youth Illicit Drug Use, Use Disorder, and Treatment Services Utilization Saijun Zhang (Corresponding author)1 Younghee Lim 2 Javier F. Boyas 3 Viktor Burlaka 4

Author Note 1 University

of Mississippi, School of Applied Sciences, Department of Social Work, 315

Garland Hall, University, MS, 38677-1848, Phone: 662-915-2593, Email: [email protected] 2 University

of Mississippi, School of Applied Sciences, Department of Social Work, 215

Garland Hall, Oxford, MS, 38677-1848 3 University 4Wayne

of Georgia, School of Social Work, 279 Williams Street, Athens, GA 30602

State University, School of Social Work, 5447 Woodward Avenue, Detroit, MI,

48202

Compliance with Ethical Standards: The study was partially funded by a Summer Research Program funding from the University of Mississippi School of Applied Sciences. No potential conflicts of interest are known to the authors. The study used publicly available secondary data from the National Survey on Drug Use and Health, so the study itself did not involve human participants and/or animals and informed consent was not applicable.

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Family Structure and Youth Illicit Drug Use, Use Disorder, and Treatment Services Utilization Abstract Objectives: The study aimed to examine family structure’s relation to youth illicit drug use, use disorders, and treatment service utilization. Methods: Using pooled data from the 2015 to 2017 National Survey on Drug Use and Health, we examined the prevalence of youth (12—17 years old) past-year and lifetime illicit drug use (N=41,579), drug use disorders among each type of drug users (n=149 to 5,445), and treatment service usage among drug use disorders (n = 1,335) across two-parent, one-parent, and no-parent families. Bivariate analyses and logistic regression models were used to compare disparities across family structure. Results: On average about 25% youth ever used illicit drugs, 20% of the past-year users had a drug use disorder, and less than 10% of the past-year use disorders received treatment services. Family structure was associated with drug use prevalence, in particular, the use of marijuana, heroin/cocaine/methamphetamine, and hallucinogens, but was not related to the rate of drug use disorders and treatment service utilization, even after adjusting for covariates. Conclusions: The findings suggest that family structure is associated with youth drug use initiation but not drug use disorders or service utilization. Youth in single and non-parent families are especially vulnerable to drug use initiation and should be specifically targeted by programs aimed at preventing such initiation. Keywords: illicit drug use; drug use disorders; treatment services utilization; family structure

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Background Youth illicit drug use has been a serious public health concern (Degenhardt, Stockings, Patton, Hall, & Lynskey, 2016). Despite a declining trend in drug use and drug dealing among youth (Vaughn, Abinader, Salas-Wright, Oh, & Holzer, 2018), illicit drug involvement among youth remains prevalent. Recent statistics show that one in four (23.9%) youth aged 12 to 17 used illicit drugs in their lifetime and about one in six (16.3%) in the past year, with most of them being marijuana users. Additionally, roughly one in five youth who had used illicit drugs (18.2%) had developed drug use disorders (dependence or abuse) (Center for Behavioral Health Statistics and Quality [CBHSQ], 2018). Furthermore, recent estimates based on the Monitoring the Future national data show that about 50% of high school students have used illicit drugs at the time of their graduation (Johnston et al., 2018). Youth are especially vulnerable to the detrimental impacts of illicit drug use (Hall, Patton, Stockings, Weier, & Morley, 2016), because illicit drug use puts them at elevated risks of cognitive impairment, mental health problems, traffic accidents, and other injuries (Governors Highway Safety Association, 2018; Volkow, Baler, Compton, Weiss, & Susan, 2014). They are also more likely to experience academic failure, crimes, delinquency, poor health and other problems (Hall et al., 2016; National Institute on Drug Abuse [NIDA], 2014; Pardini et al., 2015; Volkow et al., 2016). Additionally, youth who misuse prescription opioids are about 50% more likely to experience suicidality (Baiden, Graaf, Zaami, Acolatse, & Adeku, 2019). Youth drug use also imposes enormous financial costs to the families and society due to health care, crime, and loss of work productivity (Birnbaum et al., 2011; National Drug Intelligence Center, 2011;

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NIDA, 2019), and such costs have been rising rapidly (Florence, Zhou, Luo, & Xu, 2016; NIDA, 2019). The etiology of youth drug use is multifaceted, but family contexts have been identified as one of the salient factors associated with youth drug use and abuse prevention outcomes (Gavazzi, 2011). Family is a critical socialization agent that imparts values, beliefs, and social connections that ultimately help shape individual behaviors (Desmond & Turley, 2009; UmañaTaylor, Alfaro, Bámaca, & Guimond, 2009). However, few studies have systematically examined family structure’s relation with youth illicit drug use, use disorder, and treatment services jointly and distinguished the pattern by drug types. Further, studies usually do not distinguish youth in non-parent families, despite their sizable proportion and unique status. Using nationally representative data, the present study assessed whether youth illicit drug use, use disorder, and treatment services utilization are associated with the family structures including two-parent, single-parent, and non-parent families. Theoretical Framework to Infer Linkage Between Family Structure and Youth Drug Issues Various theories have suggested potential linkage between family structure and youth drug problems. For example, social control theories suggest that individuals refrain from deviant behaviors because of social ties (Hirschi, 1969). Family bonds are important sources of social control, because family serves as a socialization agent which communicates values and beliefs that ultimately shape individual behaviors, including refraining from substance use (Parke & Buried, 1998; Umaña et al., 2009). The family-driven socialization process may occur through enforcement of parental attitudes, behavior modeling, and family network structure development (Desmond & Lopez Turley, 2009). As a result, the family socialization processes may exert a more powerful influence on prevention of drug involvement among youth in two-parent families

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compared to youth growing in single-parent families, in part because the messages are transmitted by two parents as opposed to one (Boyas, Villarreal-Otálora, & Marsiglia, 2019; Guilamo-Ramos, Bouris, Jaccard, Lesesne, & Ballan, 2009). Social learning theory suggests that youth in non-two-parent families as opposed to youth in two-parent families are more likely to be affiliated with and exposed to the influence of deviant peer groups, which increases their risk of illicit drug use through the “social learning” process from deviant peers (Akers, Krohn, Lanza-Kaduce, & Radosevich, 1979; Bahr, Hoffmann, & Yang, 2005; Bandura, 1977). Additionally, youth in non-two-parent families are more likely to face resource limitation and other life stresses, which may jeopardize their coping responses and increase risks of illicit drug use and other delinquent behaviors (Rhodes & Jason, 1990). Research findings show that compared to non-two-parent families, youth in two-parent families have higher levels of parental monitoring (Blustein et al., 2015), parental warmth (Donaldson, Nakawaki, & Crano, 2015), beneficial parent-child interactions and secure attachment (Barfield-Cottledge, 2015), and positive parenting skills (Lussier, Laventure, & Bertrand, 2010), which lends support to family structure-related social control and social learning theories. Given the theoretical framework linking family structure and youth drug use, the current study examined the potential variation of youth drug use, use disorder, and service utilization across family structure. Empirical Evidence Concerning Family Structue and Youth Drug Issues Previous research suggests that family structure is associated with youth illicit drug use, use disorder, and treatment. Compared to youth in two-parent families, youth in other families are more likely to use illicit drugs and use them more frequently (Eitle, 2001; Hoffmann, 2018; Scales et al., 2014), and are at a higher risk of experiencing drug use disorders (Vaughan,

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Waldron, De Dios, Richter, & Cano, 2017). Studies examining the use of specific types of illicit drugs have revealed similar patterns in terms of the relationship between family structure and youth drug use. For example, youth in non-two-parent families are more likely to use marijuana (Bartle-Haring, Slesnick, & Murnan, 2017; Hoffmann, 2018), cocaine and crack (Palamar & Ompad, 2014), and misuse prescription drugs or experience prescription drug use disorders (Vaughan et al., 2017) than youth in two-parent families. Similarly, Lac and Crano's (2009) meta-analysis of 17 studies concluded that higher levels of parental monitoring, defined as parental knowledge of the child’s whereabouts, activities, and relations, was associated with a lower level of marijuana use. Findings from path analyses further suggest the linkage between family structure and youth illicit drug use via parental monitoring or similar family processes. Studies using cross sectional (Wagner et al., 2010) and longitudinal (Hemovich, Lac, & Crano, 2012) data both showed that youth living in single- or non-parent families received lower levels of parental monitoring, which subsequently predicted higher levels of drug use. Nakawaki and Crano's (2015) study using national data showed that the level of parental monitoring was lower in nontwo-parent families than in two-parent families, which was associated with higher risks of affiliation with deviant peer groups that subsequently led to higher risks of drug use. Ewing et al. (2015) showed that compared to youth in non-two-parent families, youth in two-parent families were less likely to be exposed to parental drug use, which in turn was linked to reduced illicit drug use and abuse. Treatment services use among youth to address drug use problems has been low. It is estimated that about 11% of individuals who were identified as needing treatment for substance including drug use in the past year received specialty treatment services, while the rate for youth

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of 12 to 17 was only about 9% (SAMHSA, 2019). Few studies have examined whether family structure is related to treatment services use. Dennis et al.'s (2004) study examined a sample of about 600 youth who were admitted for treatment of cannabis use at multi-state treatment centers. These researchers found that about half of the youth were from single-parent or nonparent families. It is less clear how family structure may be related to treatment service use among youth with drug problems. It is possible that youth in non-two-parent families experiencing drug use problems are more likely to seek formal treatment services than youth in two-parent families, because their caregivers may lack time and recourses to accommodate the needs alternatively (Nanninga, Jansen, Knorth, & Reijneveld, 2015). However, the opposite may be true too, because the duty-stressed caregivers in single parent and non-parent families may not have the time and other recourses needed for youth service seeking (Gallo et al., 2018; Zhang, Cain, & Liao, 2019) or to urge the youth to look for services, which was found to be an important cause for youth service initiation (Cleverley, Grenville, & Henderson, 2018). Family structure is also regarded as a marker of unequal distribution of risk and protective factors associated with youth drug use problems (Barrett & Turner, 2005). To assess the extent to which the relation between family structure and youth drug use problems is independent of commonly associated factors, it is important to examine potential confounders such as youth age, gender, race, health status, antisocial behavior, depression, family poverty status, insurance coverage, and region. These confounders are commonly included in studies predicting youth drug use problems (Barrett & Turner, 2005; Fuller et al., 2001; Lankenau et al., 2012). Knowledge Gaps and the Present Study

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Despite extensive research on family structure and youth illicit drug use, existing knowledge is limited in several ways. First, little is known about potential differences across drug types. Indeed, few studies have examined the relationship between family structure and the use of a comprehensive list of illicit drug types rather than focusing on a combination or a set of selected drugs (e.g., Barfield-Cottledge, 2015; Berge et al., 2015; Hemovich & Crano, 2009; Hoffmann, 2018). Second, existing studies usually focused on one of the sequential processes from drug use, use disorder, to treatment service utilization, which cannot explain whether the family structure influences one of the processes or imposes a consistent influence throughout. To achieve an in-depth understanding between family structure and youth drug involvement, it is essential to examine the relationship along the sequential process from youth illicit drug use to use disorder and finally to treatment seeking. Finally, earlier studies mostly distinguished youth in single-parent families from youth in non-single-parent families, without identifying youth in non-parent families in which the biological parents are not present. Currently, about 5% youth live with grandparents or other caregivers in non-parent families (U.S. Census Bureau, 2018). Thus, youth in non-parent families may be at a greater risk of drug use and use disorder and deserve equal attention in the drug involvement study literature. The present study attempted to address the knowledge gaps. Because caregivers in nontwo-parent families may have less capacity and resources to closely monitor and support youth than caregivers in two-parent families (Boyas et al., 2019; Fosco, Stormshak, Dishion, & Winter, 2012; Guilamo-Ramos et al., 2009), we hypothesized that: a) youth in two-parent families are less likely to use illicit drugs than youth in non-two-parent families; and b) youth in two-parent families who are drug users are less likely to develop drug use disorders than their counterparts in non-two-parent families. We did not set a hypothesis regarding the relation between youth

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family structure and treatment services use, because the limited literature in this area did not support a clear hypothesis. Method Data Source and Sample The present study used pooled data (2015—2017) from the National Survey on Drug Use and Health (NSDUH), which annually surveys noninstitutionalized individuals 12 years and older in the U.S. civilian population across all 50 states and the District of Columbia. The study focused on youth who were 12 to 17 years old, and multiple samples were used to assess the prevalence of illicit drug use, use disorder, and treatment services use. We first used total youth (n=41,579) for the estimation of the prevalence of illicit drug use in the past year and lifetime; we then estimated the prevalence of drug use disorders corresponding to the past-year users of each type of drug (n=149 to 5,445), and finally we estimated the rate of treatment seeking among youth with a drug use disorder in the past year (n=1,335). Measures Any illicit drug use includes the use of any cocaine, hallucinogen, heroine, methamphetamine, marijuana, and the misuse of pain reliever, sedative, stimulant, and tranquilizer, whereas the drug misuse refers to the use of the drugs in any way that is not directed by doctors, including using the drugs without a prescription for self, in larger amount, more frequent, longer than being directed, or in any other way not directed by the doctor (NSDUH, 2016). Based on whether and when the respondents used any of the illicit drugs, respondents were indicated by whether having lifetime illicit drug use (1 = yes, 0 = no) and past-year illicit drug use (1 = yes, 0 = no). Furthermore, a hierarchical list was created to indicate the use of specific types of drugs in the past year and lifetime. First, the use of marijuana and illicit drugs

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other than marijuana was distinguished; second, the use of specific types of non-marijuana illicit drugs including cocaine/heroin/methamphetamine, hallucinogens, inhalants, and any prescription misuse was distinguished; and finally, the misuse of specific types of prescription including pain relievers, tranquilizers, stimulants, and sedatives was distinguished. All illicit drug use or misuse variables were dummy coded (1 = yes, 0 = no). Youth drug use disorder included drug dependence and abuse which were assessed based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (American Psychiatric Association, 2000). Family structure was derived from two questions that asked youth whether their biological mother or father lived at home to indicate three types of families: two-parent families, single-parent families, and non-parent families. Other independent variables included age (12 to 13, 14 to 15, and 16 to 17), gender (male vs. female), race/ethnicity (non-Latinx White, African American, Latinx, and Other), self-rated health status (1 = excellent or very good, 0 = good, fair, or poor), family poverty status (1 = living in poverty based on the federal poverty line, 0 = not in poverty), health insurance coverage (1 = yes, 0 = no), region (large metro, medium metro, and non-metro), and survey year (2015, 2016, and 2017). Any antisocial behavioral problems (1 = yes, 0 = no) indicated whether youth reported any of the following antisocial behaviors: involved in a serious fight at school or work, took part in group fight, carried a handgun, sold illegal drugs, stole or tried to steal an item worth more than $50, and attacked someone with intent to seriously harm them. Analytic Methods Descriptive statistics were first used to present sample characteristics across three types of family structure. Secondly, the bivariate analysis was performed using chi-square (χ2) to

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assess the prevalence of youth lifetime and past-year illicit drug use, use disorders, and treatment services seeking cross family structure based on hierarchical samples. Thirdly, binomial logistic regression models were used to assess the likelihood of youth illicit drug use and use disorders by comparing youth in single-parent and non-parent families with youth in two-parent families, while adjusting for confounding factors, which may be associated with both family structure and the outcome variables to increase the confidence that the relation between family structure and the outcome variables is not attributed to the confounding factors. Finally, both unadjusted and adjusted probabilities of treatment services seeking were estimated through bivariate analyses and a logistic regression model to present family structure’s relation with treatment services seeking among youth with drug use disorders. Following weighting strategies suggested for NSDUH (Center for Behavioral Health Statistics, 2018; Substance Abuse and Mental Health Data Archive, 2014), STATA svyset and svy procedures were used to account for the complex survey design so that the estimates were representative of the non-institutionalized youth population in the U.S. Results Sample Characteristics Table 1 displays the general characteristics of the sample based on bivariate analysis. Overall, youth were largely evenly distributed across three age groups and gender. The majority (53.18%) of the youth were non-Latinx White, followed by Latinx (23.51%), African American (13.74%), and Other (9.58%). Over half (56.18%) of the youth had a family income greater than $50,000, three quarters (75.53%) rated their health as very good or excellent, a small fraction (4.45%) of them did not have insurance coverage, about one quarter (26.06%) reported presenting antisocial behaviors, and most of them resided in large metro (57%) or small metro

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(29.22%). Each of the three years’ NSDUH contributed an even proportion of cases to the sample. When examining the difference of sample characteristics across families structure, youth in non-parent and single-parent families than youth in two-parent families were generally more likely to be 16 to 17 years old (40.19% for youth in non-parent families, 34.43% for youth in single-parent families, and 33.66% for youth in non-parent families; the order of youth in family types applied below in the presentation of Table 1 results), to be African American (27.87%, 26%, and 8.3%), to live in poverty (39.06%, 36.1%, and 15.71%), to report having no insurance coverage (7.77%, 4.66%, and 4.18%), to have antisocial behavior (33.9%, 29.85%, and 24.18%), and reside in non-metro area (22.17%, 13.53%, and 13.38%, p < .001 for all the comparisons), but less likely to rate themselves as having very good or excellent health status (68.14%, 71.18%, and 77.6%). Illicit Drug Use in Lifetime and Past Year The Table 2 left panel presents the prevalence of youth illicit drug use in lifetime and past year, while the right panel presents the comparisons of prevalence across family structure by adjusting various confounding factors. As shown in the left panel on table 2, about one quarter (24.15%) of youth used some type of illicit drugs, with youth in non-parent families (34.16%) having a substantially higher rate than youth in single-parent (28.39%) and two-parent families (21.97%, p < .001) families. This pattern largely remained for lifetime marijuana use (25.08% in non-parent families, 19.42% in single-parent families, and 13.31% in two-parent families, p < .001; numbers below would be presented in the same order across family structure unless otherwise specified) and use of illicit drugs other than marijuana (19.49%, 16.49%, and 14.18%, p < .001), or the use of specific types of non-marijuana illicit drugs such as inhalants (11.13%,

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9.1%, and 8.1%, p < .001), hallucinogens (5.53%, 3.75%, and 2.58%, p < .001), prescription misuse (8.78%, 8.08%, and 6.7%), and cocaine, heroin, or methamphetamine (2.08%, 1.36%, and 0.83% p < .001). The pattern of illicit drug use was generally the same as lifetime use, but the corresponding rate was lower than that of the lifetime use. As shown in the right panel of Table 2, the difference of youth lifetime illicit drug use across family structure in the bivariate analysis largely remained even after adjusting for covariates. Youth in single-parent families (OR = 1.34, 95% CI = 1.25 to 1.44) and non-parent (OR = 1.61, 95% CI = 1.38 to 1.86) were more likely to use any illicit drugs in lifetime than youth in two-parent families. More specifically, when compared with youth in two-parent families, youth in single-parent (OR = 1.59, 95% CI = 1.47 to 1.71) and non-parent families (OR =2, 95% CI = 1.69 to 2.37) had a substantially higher likelihood of using marijuana, but a mildly higher likelihood of using non-marijuana illicit drugs (OR =1.11 to 1.24, 95% CI = 1.02 to 1.49). When further examining the use of specific types of non-marijuana drugs, youth in single-parent and non-parent families had a moderately higher likelihood of using cocaine/heroin/methamphetamine (OR = 1.63 to 1.78, 95% CI = 1.21 to 2.71) and hallucinogens (OR = 1.45 to 1.83, 95% CI = 1.22 to 2.44) than youth in two-parent families. Although youth did not show differences in the misuse of prescriptions as a whole, when specific types of prescriptions were examined, youth in single-parent families had a moderately higher likelihood of misusing tranquilizers (OR = 1.32, 95% CI = 1.12 to 1.56) and stimulants (OR = 1.23, 95% CI = 1.01 to 1.51) than youth in two-parent families. There were no differences across family structure in the use of inhalants and misuse of pain relievers and sedatives after adjusting for covariates. The pattern across family structure based on past-year illicit drug use was largely consistent with that based on the lifetime illicit drug use as presented above (Table 2).

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Illicit Drug Use Disorder among Past-Year Users Table 3 left panel presents the risk of drug use disorder (dependence or abuse) among youth who had used illicit drugs in the past year. Among youth who used any illicit drugs in the past year, roughly one in five (19.42%) had a drug use disorder, which was nearly identical with the rate for past-year marijuana users (19.43%) while slightly higher than the rate for past-year users of non-marijuana illicit drugs (14.85%). The risk of having a drug use disorder was nearly one quarter (23.77%) for past-year cocaine/heroin/methamphetamine users, followed by the misusers of prescriptions (16.35%), users of hallucinogens (12.93%), and users of inhalants (7.36%). When further examining specific types of prescription misused, those who misused sedatives had the highest risk of having a use disorder (26.78%), followed by those who used tranquilizers (18.4%), pain relievers (14.7%), and stimulants (11.79%). The risk of having a drug use disorder among the past-year illicit drug users generally did not vary across family structure based on the bivariate analysis. The right panel of Table 3 presents the comparison of the risk of having a drug use disorder among past-year youth drug users after controlling for various covariates. The results were largely consistent with that from the bivariate analysis. Generally, the risk of having a drug use disorder among past-year drug users did not vary across family structure and drug types, except that past-year inhalant users in single-parent families (OR = .49, 95% CI = .25 to .98) and tranquilizer misusers in non-parent families (OR = .28, 95% CI = .13 to .58) were less likely to experience a use disorder than their counterparts in two-parent families. Treatment Services Use among Youth with Drug Use Disorders Figure 1 presents the probability of treatment services use among youth who were identified as having a drug use disorder in the past year, based on both the bivariate and

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multivariate analysis that adjusted for covariates. The results show that the probability of treatment services use ranged from 8.3% to 11.3% (bivariate analysis) or from 5.5% to 8.6% (multivariate analysis) among youth with a past year drug use disorder across family structure, with the highest probability for those in single-parent families, followed by those in non-parent families and two-parent families. Discussion The present study systematically examined the variation of youth illicit drug use and use disorder across family structure by drug type, as well as the variation of treatment services use among youth with past-year drug use disorders. Overall, findings show that about one quarter of youth ever used illicit drugs, with about one in six ever using marijuana. Among non-marijuana illicit drugs, use of inhalants (8.55%) and misuse of pain relievers (5.36%) were most likely, while the use or misuse of other drugs were in the range of less than 1% to about 3%. Although youth illicit drug use slightly declined over the past decades (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018), it is concerning because of its harm to youth during this time and across the lifespan. For example, Choi, Marti, and DiNitto's (2019) study using national data found that marijuana was the most commonly substantiated substance among youth suicide decedents, and the rate of marijuana-positive toxicology more than doubled from 2005-2011 to 2012–2015. Family Structure and Youth Illicit Drug Use The findings show that family structure is strongly associated with youth’s overall illicit drug use, even after controlling for various covariates. Counting any type of drugs, youth in nonparent and single-parent families had about 30% to 60% higher odds of using illicit drugs than youth in two-parent families. Such a difference was mainly reflected in the use of marijuana,

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heroin/cocaine/methamphetamine, hallucinogens, and the misuse of tranquilizers and stimulants, but not in the use of inhalants and misuse of pain relievers. The findings show that first hypothesis is generally supported, and they may lend support to social control and social learning theories, which suggest youth in two-parent families may receive more close parental supervision and are less likely to “learn” deviant behaviors from peers than youth in other family structures (Akers et al., 1979; Bahr et al., 2005; Bandura, 1977). Consistent with previous research (SAMHSA, 2018), findings show that pain reliever misuse was the second most likely illicit drug use among youth. Pain reliever misuse is a special concern because it accounts for over 90% of the opioid misuse that characterizes the current opioid crisis and is responsible for more than one third of the opioid-related overdose deaths (NIDA, 2016; SAMHSA, 2018; Scholl et al., 2019). However, youth pain reliever misuse did not differ across family structure possibly because of its seemly legality. Unlike the use of other major illicit drugs, pain reliever misuse is often associated with a reason such as reducing physical pains, relaxing tension, or helping with sleep (SAMHSA , 2018), and individuals typically obtain pain relievers from friends, relatives, or a doctor (Lipari & Hughes, 2017). However, youth in single-parent families were more likely to misuse tranquilizers and stimulants than youth in two-parent families. It is possible that youth in single-parent families are more likely to have access to such drugs, because anxiety and depression, which likely correspond to the usage of such drugs, is more prevalent among single parents than other parents (Liang, Berger, & Brand, 2019; Manuel, Martinson, Bledsoe-Mansori, & Bellamy, 2012). About 10% of the youth ever used inhalants in their lifetime, which was second only next to the lifetime use of marijuana. However, only about 2% youth used inhalants in the past year, which was substantially smaller than that of youth who used marijuana or misused prescriptions

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in the past year. This discrepancy likely is because inhalants are typically used by younger children (Nonnemaker, Crankshaw, Shive, Hussin, & Farrelly, 2011), and there is a high discontinuation rate of its use (Garland, Howard, Vaughn, & Perron, 2011; Nakawaki & Crano, 2015; Nonnemaker et al., 2011). The findings that only about 7% of youth inhalant users relative to about 10% to 30% of other drug users had drug use disorders also lend support to such claims. Youth inhalant use is similar across family structure. It is possible that parents are less aware of its consequences and do not monitor it closely (Ahern & Falsafi, 2013). Therefore, in addition to family structure, other factors such as drug availability and parental awareness may play a role in youth drug use. Family Structure and Youth Drug Use Disorders The examination of drug use disorders among youth who used drugs in the past year provides a way to approximate the estimation of drug addictiveness. About 7% to 27% of pastyear drug users had a use disorder based on drug types (Table 3). However, there is generally no variation across family structure, thus the second hypothesis is not supported. This suggest that once youth start illicit drug use, they are similarly likely to develop use disorders regardless of potential variation in family resources and monitoring. It is alarming that about 20% of youth who used marijuana in the past year experienced drug use disorders, given that marijuana is the most widely used illicit drug among youth. Youth illicit drug use has been stable and has even slightly declined over the past decade (SAMHSA, 2019), which may ease concerns about the influence of recent marijuana legalization expansion (Dills, Goffard, & Miron, 2017). However, marijuana legalization across the nation may create a more challenging environment for programs aimed at stabilizing and further reducing youth illicit drug use, which requires future programs to consider novel strategies to overcome such

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challenges. Attention is also needed for youth pain reliever misuse. Youth pain reliever misuse was the second most common illicit drug use type in the past year, and the likelihood for youth who misused pain relievers to have a use disorder was not much different from that of the marijuana users. Kapadia and Bao's (2019) recent study showed that youth who misused pain relievers were much less likely to perceive trying heroine as a great risk than adult counterparts, which may further indicate the risk of their pain reliever misuse. It is important to provide interventions aimed at increasing the awareness of the harm of youth pain reliever misuse and other illicit drug use. Family Structure and Treatment Services Use Only about 10% or less of youth who were identified as having a drug use disorder in the past year received treatment services, and youth treatment services use was not significantly different across family structure (Figure 1). The decision of treatment seeking for needy youth may be a jointed consideration of parental time and other resources to afford the services, the urgency of relying on the services for support, and perceptions toward the services (Gallo et al., 2018; Nanninga et al., 2015; Zhang et al., 2019), which may finally balance out across family structure. Treatment services use is not only low among youth who are identified as having the need, but similarly low among older age groups (SAMHSA, 2019), despite the documented treatment effectiveness (Tanner-Smith, Wilson, & Lipsey, 2013). Lack of motivation or awareness may underlie low treatment service use. Recent data show that among youth who were identified as needing treatment for substance use problems in the past year but did not receive the services, nearly all (98%) of them did not perceive a need for services (SAMHSA, 2019). Outreach and other effective strategies aimed to promote treatment utilization for needy youth are important given its currently mediocre success.

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Limitations There are several limitations in the current study that should be acknowledged. First, data from the NSDUH were cross-sectional, which only allowed the examination of association rather than causation concerning the relation between family structure and youth drug related issues. Second, despite the large pooled dataset, the breakdown across family structure by drug types has diminished cases in some cells to a small number. Therefore, the estimation related to some illicit drugs were unavailable (e.g., youth with sedative use disorders), and estimation based on a small number of participants should be taken with caution. Third, the NSDUH only contained two questions that asked whether youth’ birth mom and dad were at home to construct the family structure variable. The lack of detailed family structure information, such as whether a stepparent was present, restricted more in-depth investigation of the relation between family structure and youth illicit drug use issues. Finally, parental behavior problems such as parental substance use and mental health problems have been found to be strongly associated with youth’s illicit drug use (Ewing et al., 2015; Nonnemaker et al., 2011). The lack of such information in the NSDUH database does not allow further partial out the potential influence from family structure when examining youth drug use related outcomes. Despite the limitations, the current study provides valuable insights to advance the understanding concerning the relation between family structure and youth drug use, use disorder, and treatment services use. Conclusion Overall, the findings underscore the importance of taking family structure into account when developing policies and programs targeting youth drug prevention. Our findings show that youth in two-parent families generally are less likely to use marijuana, heroin/cocaine/methamphetamine, and hallucinogens than youth in other families. This may be

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because two-parent families are more likely to monitor youth closely and have lower risks of exposing youth to deviant peers. Two-parent families also tend to be financially better off (Elliott, Powell, & Brenton, 2015), and financial restrains in non-two-parent families are a noticeable risk factor for youth drug use (Oh, DiNitto, & Kim, 2018). However, youth inhalant use and pain reliever misuse are not related to family structure, which may be because of the similarity of youth access to and parental low awareness of these drugs across family structure. Our findings underscore the need to identify distinct drug prevention strategies for youth based on drug types. Quality afterschool programs that provide effective supervision support to youth (Lowe Vandell, Stewart, & Foundation, 2007), campaigns aimed at increasing parental awareness of youth inhalant use and prescription misuse, and community-change focusing programs that target low socioeconomic families (Peterson et al., 2019) are some promising options to advance youth anti-drug prevention efforts. The risks of youth drug users having drug use disorders do not vary across family structure. However, the fact that an average of about one in five youth who used illicit drugs in the past year had a drug disorder raises an important concern. It urges the need of further advancing youth drug use prevention programs to curtail youth drug use, especially marijuana use and pain reliever misuse, given their prevalence and the high likelihood of evolving into drug use disorders. The rate of only about 10% of the youth in need of treatment for drug use disorders actually receiving treatment is excessively low. Enhanced efforts are needed to increase awareness of drug use consequences, promote treatment motivation and engagement, reduce treatment related stigma, and increase treatment services’ visibility to promote treatment services utilization among youth (Ballon, Kirst, & Smith, 2004; Wisdom, Cavaleri, Gogel, & Nacht, 2011).

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31 Table 1 Sample Description (N=41,579) Two-parent Age*** 12 to 13 14 to 15 16 to 17 Male Race*** Non-Latinx White African American Latinx Other Family in poverty*** Health status excellent or very good*** No insurance*** Having antisocial behavior*** Region*** Large metro Small metro Non-metro Year 2015 2016 2017

Single-parent

Non-parent

Total

%

SE

%

SE

%

SE

%

SE

31.68 34.65 33.66 50.91

(0.32) (0.40) (0.37) (0.42)

31.05 34.53 34.43 50.82

-0.49 -0.52 -0.56 -0.55

25.97 33.83 40.19 52.23

(1.65) (1.74) (1.70) (1.39)

31.28 34.59 34.13 50.94

(0.28) (0.33) (0.33) (0.34)

58.6 8.3 23.19 9.91 15.71

(0.47) (0.22) (0.36) (0.30) (0.38)

40.6 26 24.82 8.58 36.10

-0.58 -0.69 -0.57 -0.39 (0.82)

41.17 27.87 20.66 10.3 39.06

(1.79) (1.46) (1.39) (1.10) (1.52)

53.18 13.74 23.51 9.58 22.00

(0.43) (0.29) (0.28) (0.21) (0.42)

77.6 4.18 24.18

(0.37) (0.18) (0.30)

71.18 4.66 29.85

-0.63 -0.27 -0.52

68.14 7.77 33.9

(1.62) (0.84) (1.39)

75.53 4.45 26.06

(0.30) (0.15) (0.27)

57.78 28.84 13.38

(0.50) (0.53) (0.30)

56.43 30.04 13.53

-0.72 -0.75 -0.51

47.34 30.49 22.17

(1.66) (1.47) (1.29)

57 29.22 13.78

(0.44) (0.45) (0.30)

33.32 33.32 33.36

(0.45) (0.40) (0.48)

33.59 33.23 33.19

-0.78 -0.73 -0.55

31.41 33.81 34.77

(1.51) (1.57) (1.37)

33.31 33.31 33.38

(0.40) (0.33) (0.37)

Note. Chi-square tests were used to assess the difference across family structure in bivariate analysis. Data were weighted for national representation.

32 Table 2 Prevalence of Illicit Drug Use in Lifetime and Past Year (N=41,579) Bivariate Analysis Two-parent %

SE

Single-parent %

SE

Adjusted OR

Non-parent %

SE

Total %

SE

Two-parent Single-parent p value Ref. OR 95% CI

Non-parent OR

95% CI

Lifetime use Any illicit drug Marijuana Illicit drugs other than marijuana

(0.33) 28.39 (0.25) 19.42 (0.23) 16.49

(0.44) 34.16 (0.50) 25.08 (0.38) 19.49

(1.30) 24.15 (1.21) 15.39 (1.10) 15

(0.27) <.001 (0.24) <.001 (0.17) <.001

1 1 1

1.34 1.59 1.11

[1.25, 1.44] [1.47, 1.71] [1.02, 1.22]

1.61 2 1.24

[1.38, 1.89] [1.69, 2.37] [1.04, 1.49]

Cocaine/heroin/methamphe 0.83 tamine

(0.08) 1.36

(0.13) 2.08

(0.28) 1.02

(0.07) <.001

1

1.63

[1.21, 2.2]

1.78

[1.18, 2.71]

Hallucinogens Inhalants Any prescription misuse

2.58 8.2 6.7

(0.11) 3.57 (0.23) 9.1 (0.17) 8.08

(0.20) 5.53 (0.30) 11.13 (0.31) 8.78

(0.62) 2.96 (0.86) 8.55 (0.71) 7.15

(0.09) <.001 (0.19) <.001 (0.14) <.001

1 1 1

1.45 1.04 1.1

[1.22, 1.73] [0.94, 1.16] [0.98, 1.24]

1.83 1.23 1.05

[1.38, 2.44] [0.99, 1.51] [0.83, 1.33]

4.97 1.82 2.03 0.61

(0.15) (0.08) (0.10) (0.05)

(0.27) (0.17) (0.17) (0.11)

(0.58) (0.53) (0.43) (0.23)

(0.13) (0.08) (0.08) (0.04)

<.001 <.001 0.238 0.929

1 1 1 1

1.06 1.32 1.23 1

[0.93, 1.2] [1.12, 1.56] [1.01, 1.51] [0.68, 1.49]

1.05 1.39 1.29 0.85

[0.83, 1.33] [0.9, 2.13] [0.89, 1.89] [0.39, 1.85]

14.94 10.9 7.69

(0.26) 19.92 (0.21) 15.35 (0.19) 9.45

(0.45) 23.15 (0.43) 19.51 (0.35) 9.67

(1.34) 16.58 (1.30) 12.42 (0.66) 8.23

(0.22) <.001 (0.19) <.001 (0.16) <.001

1 1 1

1.4 1.53 1.18

[1.28, 1.52] [1.39, 1.67] [1.04, 1.33]

1.53 1.84 1.05

[1.26, 1.87] [1.48, 2.3] [0.87, 1.28]

Cocaine/heroin/methamphe 0.58 tamine

(0.06) 0.96

(0.10) 1.59

(0.24) 0.72

(0.05) <.001

1

1.64

[1.18, 2.27]

2.01

[1.25, 3.21]

Hallucinogens Inhalants Any prescription misuse

(0.10) 2.45 (0.13) 2.61 (0.16) 6.19

(0.17) 3 (0.19) 2.54 (0.26) 6.31

(0.43) 2.06 (0.33) 2.39 (0.54) 5.37

(0.07) 0.001 (0.11) 0.255 (0.13) <.001

1 1 1

1.41 1.07 1.15

[1.15, 1.74] [0.86, 1.34] [1.02, 1.31]

1.35 0.97 1.02

[0.9, 2.03] [0.69, 1.37] [0.81, 1.28]

Pain reliever misuse Tranquilizer misuse Stimulant misuse Sedative misuse Past-year use Any illicit drug Marijuana Illicit drugs other than marijuana

21.97 13.31 14.18

1.86 2.3 5.01

6.15 2.51 2.23 0.65

6.9 3.13 2.66 0.68

5.36 2.05 2.11 0.63

33 Pain reliever misuse Tranquilizer misuse Stimulant misuse Sedative misuse

3.27 1.55 1.77 0.33

(0.14) (0.08) (0.09) (0.04)

4.07 2.17 1.94 0.39

(0.21) (0.15) (0.16) (0.08)

4.4 2.5 2.29 0.37

(0.43) (0.40) (0.39) (0.18)

3.52 1.75 1.83 0.35

(0.11) (0.07) (0.08) (0.03)

0.001 <.001 0.304 0.769

1 1 1 1

1.07 1.35 1.24 1.13

[0.92, 1.24] [1.12, 1.63] [1.01, 1.53] [0.7, 1.82]

1.02 1.3 1.31 0.86

[0.81, 1.29] [0.88, 1.93] [0.89, 1.95] [0.31, 2.38]

Note. Chi-square tests were used to assess the difference of the dependent variables (as shown in the first column) across family structure in the bivariate analysis. Binominal logistic regression models were used to obtain the adjusted odds ratios while adjusting for youth age, gender, race, health status, family poverty status, insurance coverage, antisocial behavior, depression, region, and year of survey. Data were weighted for national representation.

34 Table 3 Drug Use Disorder (Abuse or Dependence) among Past-Year Users Bivariate Analysis Two-parent Any Illicit drugs abuse or dependence (n=7,158) Marijuana (n=5,445) Illicit drugs other than marijuana (n=3,522) Cocaine/heroin/ methamphetamine (n=313) Hallucinogens (n=902) Inhalants (n=1,063) Prescription misuse (n=2,269) Pain reliever (n=1,506) Tranquilizer (n=728) Stimulant (n=769) Sedative (n=149)

Single-parent

Non-parent

Adjusted OR Total

p value

Two-parent

% SE % SE % SE 18.87 (0.73) 20.06 (0.90) 21.87 (2.68)

% SE 19.42 (0.53)

0.385

Ref. 1

19.06 (0.88) 20.14 (0.96) 19.35 (2.87) 15.04 (1.24) 13.99 (1.27) 18.02 (3.39)

19.43 (0.65) 14.87 (0.90)

0.732 0.528

23.88 (4.36) 23.85 (4.91) 22.79 (10.26) 23.77 (2.66) 14.25 (1.89) 9.17 (2.26) 18.51 (5.98) 7.99 (1.27) 5.22 (1.22) 11.68 (4.79) 16.5 (1.62) 16.54 (1.99) 13.08 (3.39) 14.95 19.04 11.25 31.33

(1.87) (2.62) (1.68) (6.51)

14.88 18.74 12.93 20.44

(1.96) (4.04) (2.66) (6.90)

10.61 9.78 12.62 NA

(3.65) (2.73) (6.64) NA

Single-parent

Non-parent

OR 95% CI 1.09 [0.93, 1.27]

OR 95% CI 1.04 [0.72, 1.49]

1 1

1.11 0.81

[0.95, 1.3] [0.59, 1.1]

0.93 0.9

[0.61, 1.41] [0.53, 1.52]

0.995

1

0.89

[0.36, 2.18]

1.1

[0.22, 5.58]

12.93 (1.27) 7.36 (0.95) 16.35 (1.14)

0.183 0.180 0.758

1 1 1

0.56 0.49 0.82

[0.25, 1.26] [0.25, 0.98] [0.54, 1.25]

1.17 1.34 0.55

[0.37, 3.66] [0.52, 3.46] [0.26, 1.14]

14.7 18.4 11.79 26.78

0.694 0.434 0.860 0.214

1 1 1 1

0.73 0.88 0.98 0.43

[0.44, 1.21] [0.46, 1.69] [0.47, 2.03] [0.1, 1.89]

0.5 0.28 0.96 NA

[0.18, 1.35] [0.13, 0.58] [0.22, 4.11] NA

(1.27) (1.87) (1.33) (5.15)

Note. Chi-square tests were used to assess the difference of the dependent variables (as shown in the first column) across family structure in the bivariate analysis. Binominal logistic regression models were used to obtain the adjusted odds ratios while controlling for youth age, gender, race, health status, family poverty status, insurance coverage, antisocial behavior, depression, region, and year of survey. Data were weighted for national representation.

35

11.3

12 10

9.8 8.6

8.3

%

8 6

7.7

5.5

4 2 0 Two parent

Single-parent Unadjusted

Non-parent

Adjusted

Figure 1: Probability of receiving treatment among youth identified as having drug use disorders in the past year (n = 1,335) Note. Unadjusted probability was based on bivariate analysis; adjusted probability was based on marginal effects from a binominal logistic regression model that controlled for youth age, gender, race, health status, family poverty status, insurance coverage, antisocial behavior, depression, region, and year of survey. No statistical differences were found for the probabilities across family structure based on both bivariate and multivariate analyses. Data were weighted for national representation.

36

Highlights: 1. Family structure is associated with youth drug use but not drug use disorders or treatment service utilization. 2. Family structure’s association with youth drug use varies by drug types. 3. Youth drug users’ risks of evolving into use disorders vary by drug types and are high for marijuana users and prescription misusers.

37

Conflict of Interest: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors do not have conflict of interest to declare.

38

Author statement: Dr. Saijun Zhang conceptualized the study, conducted data analyses, and wrote the initial draft of the paper. Drs. Yonghee Lim, Javier Boyas, and Viktor Burlaka thoroughly reviewed and revised the paper, and wrote part of the paper. Dr. Younghee Lim and Javier Boys also offered valuable inputs in the conceptualization of the study.