Trends in Substance Use and Related Disorders
Analysis of the Epidemiological Survey of Substance Abuse 1995 to 2018
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Background: Changes in the use of psychoactive substances and medications and in the occurrence of substance-related disorders enable assessment of the magnitude of the anticipated negative consequences for the population.
Methods: Trends were analyzed in the consumption of tobacco, alcohol, cannabis and other illegal drugs, analgesics, and hypnotics/sedatives, as well as trends in substance-related disorders, as coded according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The data were derived from nine waves of the German Epidemiological Survey of Substance Abuse (Epidemiologischer Suchtsurvey, ESA) from 1995 to 2018. The data were collected in written form or by means of a combination of paper and internet-based questionnaires or telephone interviews.
Results: The estimated prevalence rates of tobacco and alcohol consumption and the use of hypnotics/sedatives decreased over time. On the other hand, increasing prevalence rates were observed for the consumption of cannabis and other illegal drugs and the use of analgesics. The trends in substance-related disorders showed no statistically significant changes compared to the reference values for the year 2018, except for higher prevalence rates of nicotine dependence, alcohol abuse and dependence, analgesic dependence, and hypnotic/sedative dependence in the year 2012 only.
Conclusion: Trends in tobacco and alcohol consumption imply a future decline in the burden to society from the morbidity, mortality, and economic costs related to these substances. An opposite development in cannabis use cannot be excluded. No increase over time was seen in the prevalence of analgesic dependence, but the observed increase in the use of analgesics demands critical attention.
In the years 2006 and 2016, tobacco use was the leading global risk factor for early death and loss of life years due to disability (e1). In 1990, tobacco had occupied third place among 86 comparable risk factors. Alcohol consumption was the fourth most important risk factor in 2016 (fifth in 1990), while illegal drugs were listed in 18th place (21st in 1990). In the USA the prescription of pain-relieving drugs has been debated in connection with the threefold increase in opioid overdoses between 2010 and 2014 (1, 2) and a related decrease in life expectancy (3).
Observations of changes in the use of psychoactive substances and medications and in the occurrence of substance-related disorders enable assessment of the magnitude of the anticipated negative consequences for the population and are thus of wide-reaching importance for health policy (e2). Given the causal connection between use and negative consequences such as illness and death, trends in indicators of consumption permit conclusions regarding the future development of such consequences. In Germany, the Epidemiological Survey of Substance Abuse (Epidemiologischer Suchtsurvey; ESA) has been conducting regular cross-sectional surveys of substance use and related disorders in the adult population (18 to 64 years) since 1995 (4).
The study reported here was designed to analyze:
- Trends in use of tobacco, alcohol, cannabis, and other illegal drugs together with intake of analgesics and hypnotics/sedatives
- Trends in substance-related disorders as coded according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
The data came from nine ESA surveys carried out between 1995 and 2018 (every 3 years from 1997 onwards). Owing to changes in the age range surveyed during the observation period, all analyses were restricted to the age range 18 to 59 years. (Information on the individual ESA surveys can be found in the eMethods.) The data were collected in written form or by means of a combination of paper and internet-based questionnaires or telephone interviews. (For details of the complex sampling techniques, see the eMethods.) Information was collected on consumption and patterns of use (amount) of tobacco and alcohol, the use of cannabis, the use of at least one other illegal drug, and the intake of medications (details of the survey instruments are given in the eMethods). Documentation of substance-related disorders was adapted from the Munich Composite International Diagnostic Interview (M-CIDI, [5, 6]). Diagnoses were assigned according to the criteria of DSM-IV (7).
Sex-specific analyses of the trends in substance use and related disorders were based on binomial logistic regression models. (For details of the statistical analyses, see the eMethods.) With time as predictor, the trend with regard to tendency and course was assessed. A statistical test to ascertain any difference between the sexes was carried out only if men and women showed similar trends. The prevalences, mean predicted prevalences, and 95% confidence intervals for each survey year and sex are shown in the Figures. Analyses of trends in substance-related disorders were performed on the whole sample—with the year 2018 as reference—for the categorical variable survey year. (For sex-specific data and a detailed presentation of the findings, see the eFigures and eTables.) Because of the complexity of the sample design (see the eMethods for details), weights were used in every survey year. These involved, among others, the distribution by federal state, community size, sex, and year of birth across the German population. Standard errors based on Taylor series were calculated to take account of the effects of the multistage selection procedure (8). The level of significance was set at 5%.
The results of the regression models for the trends in substance use are presented in shortened form for the sake of readability. A comprehensive account of the statistical analyses and findings can be found in the eMethods supplement and in the eFigures and eTables.
The prevalence of tobacco use shows a decreasing trend in both sexes, more so in women than in men. A comparable trend can be observed for the prevalence of daily smoking by women and men (Figure 1, Table 1).
The prevalence of alcohol use shows a decreasing trend in both sexes, more so in women than in men. The prevalence of episodic heavy drinking displays an increasing trend in women but a decreasing trend in men (Figure 2, Table 1).
The prevalence of cannabis consumption shows an increasing trend in both sexes, with a tendency towards a higher increase in men than in women. The prevalence of use of at least one other illegal drug (amphetamine/methamphetamine, ecstasy, LSD, heroin/other opiates, or cocaine/crack) is constant in men and increases in women (Figure 3, Table 1).
In both men and women the prevalence of weekly intake of analgesics shows an increasing trend and that of hypnotics/sedatives a decreasing trend (Figure 4, Table 1).
Among the substance-related disorders (Table 2), nicotine dependence shows the highest prevalence and the greatest fluctuation over time in both sexes. The prevalence was significantly higher in 2006 (men 11.1%, women 8.5%) and 2012 (men 10.4%, women 7.7%) than in 2018 (men 7.8%, women 5.7%).
The prevalence of alcohol abuse in men was statistically significantly lower in 2018, at 4.0%, than in 2006 (6.3%) and 2012 (5.3%). The same was true for women comparing 2018 (1.5%) with 2012 (1.8%). The prevalence of alcohol dependence reached a statistically significant peak in 2012 (men 5.2%, women 2.1%) but returned to a level comparable with previous years in 2018.
The prevalence of cannabis-related disorders shows a generally constant trend in men, with the exception of the year 2000 (0.5%).
In 2018, the prevalence of analgesic and hypnotic/sedative dependence fell back to the levels in 2000. For both classes of drugs, the prevalence of dependence was higher in 2012 than in 2018 for both men (analgesics 2.5%, hypnotics/sedatives 1.3%) and women (analgesics 3.4%, hypnotics/sedatives 1.5%).
The observed distinct decrease in the 30-day prevalence of both tobacco use and daily smoking is confirmed by the findings of studies in adults (9), young adults (10), and adolescents (11). Studies from other European countries and North America also show clear reductions in the prevalence of (daily) smoking (12, 13). However, a recent meta-analysis has shown that the greatest part of the risk for coronary heart disease and stroke is attributable to the use of just a few cigarettes per day, that there is no threshold below which tobacco use is safe, and that the risk can be avoided only by giving up tobacco entirely (e3). When one includes all tobacco, electronic inhalation, and heat-not-burn products, as well as water pipes, the proportion of current smokers in the 18 to 64 age group in Germany is still high, at around 25% (7).
A number of policy measures have been credited with the observed decrease in the prevalence of smoking in Germany (14), for example:
- Increased taxation of tobacco
- Amendments of the Workplace Ordinance and the German Protection of Young Persons Act
- Restriction of tobacco advertising
- The passing of the Non-Smokers’ Protection Act in 2007
- Introduction of smoking bans in the individual federal states .
However, a considerable time lag can be expected before there are any major effects of decreasing tobacco use on morbidity and mortality, and thus on economic costs (e4).
The question of whether the changes in the prevalence of nicotine dependence between 2012 and 2018 represent a decrease or merely fluctuations around a constant trend cannot be answered at the present moment. Continuation of the positive trend towards reduced tobacco use in Germany will require strict implementation of the measures contained in the WHO Framework Convention and thus restrictive tobacco policies (e5). Prevention of tobacco use by children and adolescents will continue to be key (15, 16), together with expansion of smoking cessation programs (17).
Alongside a slight reduction in the prevalence of alcohol use, a decrease in risky patterns of use in the form of episodic heavy drinking can be observed, at least in men. Alcohol is not only drunk less often, it is also less frequently imbibed in large amounts, and the average consumption has gone down (18). Nevertheless, Germany is still one of the countries where the most alcohol is drunk (19). One reason for this is inconsistent implementation of preventive measures to effectively reduce the availability of alcohol and thus lower the demand (20). The need for the implementation and application of appropriate measures to be at the forefront of evidence-based alcohol policy in Germany has not changed substantially since publication of an analysis in 2008 (21).
Positive trends, however, can be seen with regard to alcohol consumption by adolescents. A number of studies point to a general reduction in adolescents’ alcohol consumption in Germany (22) and especially in other European countries (13), North America (23), and Australia (24). Because behavior in adolescence molds the drinking patterns in later life, this development can be expected to lead to a generation-related reduction in alcohol use as the respective age cohorts grow older (25).
The finding of practically unchanged prevalence of alcohol-related disorders is no surprise. Estimates of the uptake of addiction care services show clearly that overall only 16% of persons with alcohol dependence-related illness seek outpatient or inpatient help, including rehabilitation (26). The aim should therefore be to increase the uptake of professional addiction care services. The major cornerstones of such a campaign are alcohol screening programs and short-term interventions, in primary health care by general practitioners, the efficacy of which has been demonstrated in a number of studies (e6, 27). To avoid negative alcohol-related consequences, it is essential to strengthen efforts to prevent hazardous drinking patterns such as heavy use and binge drinking.
In contrast to the decreasing trend in use of legal substances, the use of cannabis, and to a lesser extent the use of at least one other illegal drug, increased during the observation period. However, this trend is not reflected in the prevalence of cannabis-related disorders. The trends in consumption are confirmed in studies of adolescents. For example, the 12-month prevalence and the prevalence of regular use increased in 12- to 17-year-olds. The prevalence of use in the age group 18 to 25 years also increased statistically significantly between 2008 and 2016 (28). An increase in the prevalence of cannabis use by adolescents and young adults is likewise reported for most European countries (29) and for the USA (30). The current debate on recent changes in cannabis legislation in Uruguay (31), some states of the USA (32), and recently in Canada (33) is viewed as a reason for the increase in recent years (34). Changes in the subjective perception of the health risks associated with cannabis use have been discussed as a possible mediating factor. For instance, adult residents of the USA judged cannabis to be less dangerous for health in 2014 than they had done 10 to 15 years earlier (35).
The prevalence of use of at least one other illegal drug is relatively stable, so it can be assumed that the number of persons using other illegal substances has remained largely unchanged over time. Because drug users with intensive patterns of use are very likely to be greatly underrepresented in population surveys, the majority of positive cases are broadly socially integrated occasional consumers (36). It can thus be assumed that the prevalence of illegal drug use is regularly underestimated in surveys. However, evidence of a constant rate of opioid dependence over the past 20 years (37) suggests that the number of high-risk users of illegal hard drugs has also hardly changed.
Prescription data provide external validation of the trends in medication intake (38). They show that total numbers of prescriptions of opioid analgesics and non-opioid analgesics, in terms of defined daily doses, increased in parallel from 2008 to 2017. A recent study evaluating prescription data from statutory health insurance records shows, however, that the number of persons receiving prescriptions for opioid pain relievers increased only slightly between 2006 and 2016 (e7). The available data on trends in the use of analgesics do not permit separate analysis of opioid- and non-opioid-containing painkillers, because they were not distinguished at all time points. Under the assumption that the proportions of consumed opioid and non-opioid analgesics—including over-the-counter medications—have not changed dramatically over time, the constant prevalence of analgesic dependence indicates that the abuse of opioid painkillers has not increased in general. It can therefore be concluded, from the trends in opioid prescribing, the near-constant numbers of opioid addicts contacting the addiction care services (37), and the minor increase in the numbers of fatal overdoses involving opioids (39), that there is no opioid epidemic in Germany comparable with that in the USA. As for the intake of analgesics, it is important to improve the information supplied to the population and intensify the training of primary care physicians and personnel in medical and geriatric institutions, with regard to the prescription of these drugs.
The decreasing trend in the intake of hypnotics/sedative and the small amount of fluctuation in the numbers of associated dependence disorders point to a possible delayed positive effect. This development is confirmed by a recent study based on an evaluation of prescriptions supplied to statutorily insured patients (40). According to the authors, the numbers of persons receiving prescriptions for benzodiazepines and z-drugs and the numbers of prescriptions that deviate from guidelines are decreasing in the statutorily insured population.
Prevalence figures that rely on self-reported data on substance use can be underestimated in cross-sectional analyses due to the influence of socially desired response behavior. If one assumes that the impact of these variables remains constant across repeated cross-sectional analyses, bias introduced by response behavior plays no part in the analysis of trends over time, although the true prevalence is unknown.
Bias may arise from heterogeneity in sampling procedures and in the characteristics of the sample population. However, this bias was minimized by matching the distribution of the sample to the respective characteristics of the general population.
The decreasing trends in use of tobacco and alcohol are a positive development. To avoid reversal of these trends in the future, steps to promote prevention and early detection are required. An increasing trend in cannabis consumption cannot be excluded, and appropriate preventive measures must be intensified. The prevalence of dependence on analgesics has shown no discernible increase over time. However, the increased use of analgesics should be monitored closely. In general, it can be assumed that effective steps to reduce substance use lead to decreased population-wide burdens in terms of morbidity, mortality, and economic costs.
The Epidemiological Survey of Substance Abuse was supported by funding from the German Federal Ministry of Health (project no. ZMVI1–2517DSM200). The funder imposed no conditions.
Conflict of interest statement
Dr. Pfeiffer-Gerschel has received lecture fees from Sanofi.
The remaining authors declare that no conflict of interest exists.
Manuscript received on 4 April 2019, revised version accepted on
6 June 2019
Translated from the original German by David Roseveare
Dr. phil. Nicki-Nils Seitz
IFT Institut für Therapieforschung
80804 München, Germany
Cite this as:
Seitz NN, Lochbühler K, Atzendorf J, Rauschert C, Pfeiffer-Gerschel T, Kraus L: Trends in substance use and related disorders—analysis of the Epidemiological Survey of Substance Abuse 1995 to 2018. Dtsch Arztebl Int 2019; 116: 585–91. DOI: 10.3238/arztebl.2019.0585
For “e-References” please refer to:
eMethods, eTables, eFigures:
an estimate of consumption and substance-related disorders in Germany. Dtsch Arztebl Int 2019; 116: 577–84.
Dr. phil. Kirsten Lochbühler, Dipl.-Soz., B.Sc. Psych. Josefine Atzendorf,
M.Sc. Public Health Christian Rauschert, Dr. hum. biol. Tim Pfeiffer-Gerschel,
Prof. Dr. phil. Ludwig Kraus
Department of Public Health Sciences, Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden and Institute of Psychology, ELTE, Eötvös Loránd University, Budapest, Hungary: Prof. Dr. phil. Ludwig Kraus
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