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Youth with Substance Use Disorders Should Be Screened for Overdose Risk Factors

Key findings

  • Close to one-third of patients ages 16 to 26 seeking treatment for substance use disorder had a history of overdose
  • Alcohol, cocaine and amphetamine use disorders, but not opioid or benzodiazepine use disorders, were associated with overdose
  • Psychopathy associated with overdose included depressive, anxiety and eating disorders, but not ADHD or other impulsivity-related disorders
  • The best predictors of overdose were alcohol use disorder, eating disorder, blackouts, intravenous drug use and psychiatric hospitalization
  • Young adults seeking treatment of substance abuse or dependence should be screened for a history of overdose and associated risk factors

The past 15 years have seen a substantial increase in overdoses, both fatal and nonfatal, in the United States. However, while a growing body of literature has identified risk factors for overdose among adults, only one previous study has investigated these factors associated in young adults who report substance misuse. Understanding the risk factors for overdose in young people is essential to improving screening and intervention strategies to prevent overdoses.

A team of investigators in the Addiction Recovery Management Service (ARMS) at Massachusetts General Hospital led by medical director Amy M. Yule, MD, and Timothy Wilens, MD, chief of the Division of Child and Adolescent Psychiatry, conducted a community-based investigation of overdoses among urban youth seeking treatment for substance use disorders (SUDs). The team is the first to assess relationships between overdose and psychiatric disorders in this population and the first to investigate intentionality of overdose. Their findings appear in the Journal of Clinical Psychiatry.

The team reviewed the intake records of consecutive patients who were first seen at ARMS, Mass General’s youth outpatient addiction clinic, between January 2012 and June 2013. They selected the records of 200 patients who were 16 to 26 years of age at intake and had a diagnosis of substance abuse or dependence.


The lifetime prevalence of overdose involving any substance was 29%. Of those 58 patients, 36 (62%) reported only an unintentional overdose, 18 (31%) reported only an intentional overdose (suicide attempt), and four (7%) reported both. Twenty-four patients (12% of the entire cohort) had a history of more than one overdose.

The only significant demographic difference between groups was gender. Young women were more likely than males to have a history of overdose, and among patients who reported an overdose, females were more likely than males to have been attempting suicide.

Patients with two or more SUDs were about three times more likely than those with one SUD to have a history of overdose. Likewise, those with a history of overdose had significantly more severe SUDs than those without such a history (average scores of 11.0 vs. 8.6, on the Leeds Dependence Questionnaire, respectively).

Common Risk Factors Among Youth Who Overdose

The researchers found that certain factors were significantly more common among overdosers than non-overdosers:

  • Current alcohol, cocaine or amphetamine use disorder
  • History of blackouts
  • History of intravenous drug use
  • Current depressive, anxiety or eating disorder
  • History of self-injurious behavior or suicide attempt
  • History of psychiatric hospitalization
  • History of emotional, physical or sexual abuse

The researchers had suspected that attention deficit hyperactivity disorder might be related to overdose, but did not see this association in this sample.

On regression analysis, the following factors predicted a 2- to 5-fold greater risk of overdose:

  • Alcohol use disorder
  • Eating disorder
  • Blackouts
  • Intravenous drug use
  • Psychiatric hospitalization

Among young patients who reported an overdose, those who said it was a suicide attempt were eight times more likely to have a history of self-harm than those who reported unintentional overdose. They were also twelve times more likely to have had an inpatient psychiatric hospitalization.

Importance of Screening for Overdose Risk Factors

The authors recommend that when clinicians assess young adults for substance use disorders, they should carefully screen for overdoses and the risk factors identified in this study. Considering the attention that is being focused lately on opioids, they remind their colleagues to assess for misuse of all substances, including alcohol, cocaine and benzodiazepines.

Lifetime prevalence of OD among patients included in the review

Patients with multiple ODs among those with any history of OD

Increase in likelihood of OD history with two or more SUDs

Learn more about the Addiction Recovery Management Service

Learn more about the Department of Psychiatry

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