Substance Use and Exposure to Adverse Childhood Experiences in Undergraduate and Graduate Nursing Students

BACKGROUND: Substance misuse remains a public health crisis and contributor to morbidity and mortality. The nursing workforce is not immune to the impacts of substance misuse as rates are thought to mirror those of the general population. Additionally, as substance misuse often begins in adolescence or early adulthood, prevalence of misuse among practicing nurses highlights the fact that students are also at risk. OBJECTIVES: The purpose of this study was to examine rates and patterns of substance use and adverse childhood experience (ACE) exposure among nursing students while also examining associations between substance use and ACE exposure. METHOD: This study utilizes a cross-sectional and descriptive design through the provision of email surveys to nursing students. Email surveys consisting of the Alcohol Use Disorders Identification Test, the Drug Abuse Screening Tool 10-item survey, the ACE Questionnaire, and a demographic inquiry were distributed via Qualtrics survey software. RESULTS: A total of 662 individuals participated in the survey, the majority of whom self-identified as female, were undergraduate students, and were between 18 and 21 years. Moderate- to high-risk alcohol use was identified in 20% of students, while moderate- to high-risk drug use was identified in 3.6% of students. More than half of students endorsed exposure to at least one ACE. Significant associations were found between the Drug Abuse Screening Tool 10-item survey and the ACE Questionnaire. CONCLUSIONS: The results of this study have significant implications for nursing educators and must inform groundwork for the development of policies and interventions that are evidence based, nonpunitive, and trauma informed.

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Open secret, or imagined problem: Drug and alcohol use in Tanzanian road traffic accident drivers

10.21203/rs.3.rs-28349/v1 ◽

2020 ◽

Author(s):

Adeline Rose Dozois ◽

Paulina Nkondora ◽

Erin E Noste ◽

Juma Mfinanga ◽

Hendry R Sawe ◽

...

Keyword(s):

Substance Use ◽

High Risk ◽

Alcohol Use ◽

Drug Use ◽

Alcohol Use Disorder ◽

Screening Tool ◽

Road Traffic ◽

World Health ◽

Urine Drug Screen ◽

Research Assistants

Abstract Background Road traffic accidents (RTAs) have emerged as an important public health problem in low and middle-income countries, where 90% of RTA deaths occur. The World Health Organization has suggested strategies to address excess mortality from RTAs including efforts to combat driving while intoxicated. The association between substance use and RTAs is well known in high-income countries, but data is more limited in low-resource settings including Tanzania. The objective of this study is to examine the prevalence of drug use, alcohol use, and substance use disorders in Tanzanian RTA drivers. Methods This prospective observational study was conducted in the Emergency Department of Muhimbili National Hospital, a national referral hospital in Dar es Salaam, Tanzania. Research assistants available 24 hours per day enrolled adult drivers who presented within 24 hours of an RTA. In eligible patients, research assistants collected a saliva test of blood alcohol content (BAC) and a urine drug screen (UDS), and administered a validated substance abuse screening tool, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Patients were excluded from individual analyses if they could not produce a saliva or urine test or answer questions. Primary outcomes were rates of positive BAC, UDS and self-reported high-risk alcohol and drug use patterns. Descriptive statistics were calculated using Excel. Results We screened 5264 trauma patients and enrolled 538, in whom 191 had a BAC, 362 had a UDS, and 417 had a complete ASSIST. Fifteen of 191 patients (7.8%) had a positive BAC, and 68/362 (18.7%) patients had a UDS that was positive for at least one drug. Based on the ASSIST, 104/417 (24.5%) of patients were at moderate or high risk for alcohol use disorder. Few were at risk for disordered use of other non-tobacco substances. Conclusion In our population of drivers presenting within 24 hours of an RTA, positive BAC and UDS tests were rare. A substantial portion of the population was at moderate to high risk for an alcohol use disorder. Ideal screening for substance use in trauma populations may involve a verbal screening tool, particularly when the time between injury and hospital arrival is delayed.

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Alcohol and other substance use among medical and law students at a UK university: a cross-sectional questionnaire survey

Postgraduate Medical Journal ◽

10.1136/postgradmedj-2017-135136 ◽

2017 ◽

Vol 94 (1109) ◽

pp. 131-136 ◽

Cited By ~ 5

Author(s):

Paul Bogowicz ◽

Jennifer Ferguson ◽

Eilish Gilvarry ◽

Farhad Kamali ◽

Eileen Kaner ◽

...

Keyword(s):

Substance Use ◽

Medical Students ◽

Alcohol Use ◽

Questionnaire Survey ◽

Substance Misuse ◽

Law Students ◽

First Year ◽

Cross Sectional ◽

Students First ◽

Second Year

Purpose of the studyTo examine the use of alcohol and other substances among medical and law students at a UK university.Study designAnonymous cross-sectional questionnaire survey of first, second and final year medical and law students at a single UK university.Results1242 of 1577 (78.8%) eligible students completed the questionnaire. Over half of first and second year medical students (first year 53.1%, second year 59.7%, final year 35.9%) had an Alcohol Use Disorders Identification Test (AUDIT) score suggestive of an alcohol use disorder (AUDIT≥8), compared with over two-thirds of first and second year law students (first year 67.2%, second year 69.5%, final year 47.3%). Approximately one-quarter of medical students (first year 26.4%, second year 28.4%, final year 23.7%) and over one-third of first and second year law students (first year 39.1%, second year 42.4%, final year 18.9%) reported other substance use within the past year. Over one-third of medical students (first year 34.4%, second year 35.6%, final year 46.3%) and approximately half or more of law students (first year 47.2%, second year 52.7%, final year 59.5%) had a Hospital Anxiety and Depression Scale anxiety score suggestive of a possible anxiety disorder.ConclusionsStudy participants had high levels of substance misuse and anxiety. Some students’ fitness to practice may be impaired as a result of their substance misuse or symptoms of psychological distress. Further efforts are needed to reduce substance misuse and to improve the mental well-being of students.

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Functional-Belief-Based Alcohol Use Questionnaire (FBAQ) as a Pre-Screening Tool for High-Risk Drinking Behaviors among Young Adults: A Northern Thai Cross-Sectional Survey Analysis

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18041536 ◽

2021 ◽

Vol 18 (4) ◽

pp. 1536

Author(s):

Nalinee Yingchankul ◽

Wichuda Jiraporncharoen ◽

Chanapat Pateekhum ◽

Surin Jiraniramai ◽

Kanittha Thaikla ◽

...

Keyword(s):

Young Adults ◽

High Risk ◽

Alcohol Use ◽

Screening Tool ◽

Drinking Behavior ◽

Standard Drink ◽

Cross Sectional Survey ◽

Discriminative Ability ◽

Cross Sectional ◽

High Risk Drinking

Background: an alcohol-use disorders identification test (AUDIT) is a standard screening tool for high-risk drinking behavior. Standard drink calculation is difficult to comprehend and may lead to inaccurate estimates. This study intended to develop a practical pre-screening tool for the identification of high-risk drinkers among young adults. Methods: a cross-sectional survey was conducted in Northern Thailand from July 2016 to December 2016. Data was collected on relevant characteristics and health beliefs about drinking. The 12-month AUDIT was used as the reference standard. Logistic regression was used for the score derivation. The discriminative ability was measured with an area under the receiver operating characteristic curve (AuROC). Result: a total of 1401 young adults were included. Of these, 791 people (56.5%) were current drinkers. Three functional-belief items were identified as independent predictors of high-risk drinking and were used to develop the functional-belief-based alcohol-use questionnaire (FBAQ). The FBAQ demonstrated an acceptable discriminative ability—AuROC 0.74 (95% confidence interval (CI) 0.70, 0.77). Conclusion: The FBAQ contains only three simple belief questions and does not require unintelligible standard drink calculation. Implementing the FBAQ score and the AUDIT in a serial manner might be a more effective method in a mass-screening program for alcohol-use disorder in young adults.

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The Association between Sociocultural Factors and Substance Use among Haramaya University Students

Substance Abuse Research and Treatment ◽

10.1177/11782218211004522 ◽

2021 ◽

Vol 15 ◽

pp. 117822182110045

Author(s):

Zelalem Tadese Feyisa

Keyword(s):

Substance Use ◽

Alcohol Use ◽

University Students ◽

Health Workers ◽

Sociocultural Factors ◽

University Management ◽

Negative Consequences ◽

Cross Sectional ◽

Negatively Associated ◽

Khat Use

All the associated risk factors were not equally responsible for influencing individuals either in alcohol use, khat use, tobacco, or cannabis use. This study attempted to examine sociocultural factors influencing university students in substance use by comparing one with another. A cross-sectional study was carried out. The study used a quantitative approach to collect data from 384 students. Compared with their involvement in khat use, female students were positively influenced in cigarette and hashish use (Adjusted Odds Ratio, AOR = 1.102, 95% CI: 1.056, 1.149) and alcohol use (AOR = 1.066, 95% CI: 1.021, 1.113). The involvement of students in alcohol use (AOR = 0.884, 95% CI: 0.838, 0.932) and cigarettes and hashish use (AOR = 0.909, 95% CI: 0.866, 0.953) were negatively associated with stress related to their academic activities. The involvement of students in alcohol use (AOR = 0.942, 95% CI: 0.906, 0.979) was negatively associated with parental influences; involved in alcohol use (AOR = 0.445, 95% CI: 0.210, 0.941) was negatively associated with the thoughts of considering substances as an energizer. The involvement of students in alcohol use (AOR = 4.980, 95% CI: 1.614, 15.368) was positively associated with peer influences. It was, thus, suggested that the management of Haramaya University should work on creating awareness of the negative consequences of substance use. Concerned professionals, including sociologists, psychologists, and health workers, should work on raising students’ awareness as it was possible to undertake their studies without substance use. Moreover, the university management is strongly recommended to expand recreational centers within the campus. Lastly, Haramaya woreda administration should restrict the availability and accessibility of these substances around the campus.

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Alcohol Use and Sexual Violence among Nursing Students in Catalonia, Spain: A Multicentre Cross-Sectional Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18116036 ◽

2021 ◽

Vol 18 (11) ◽

pp. 6036

Author(s):

Concepció Fuentes-Pumarola ◽

Zaira Reyes-Amargant ◽

Alba Berenguer-Simon ◽

David Ballester-Ferrando ◽

Maria Dolors Burjalés-Martí ◽

...

Keyword(s):

Nursing Students ◽

Alcohol Use ◽

Sexual Violence ◽

Cross Sectional Study ◽

Sectional Study ◽

Future Health ◽

Cross Sectional ◽

Convenience Sample ◽

Sexual Activities ◽

Estimate Prevalence

(1) Background: Sexual violence (SV) has become common in universities for reasons related to unwanted social/peer pressures regarding alcohol/drug use and sexual activities. Objectives: To identify perceptions of SV and alcohol use and estimate prevalence among nursing students in Catalonia, Spain. (2) Methods: Observational descriptive cross-sectional study of a convenience sample of nursing students attending public universities. (3) Results: We recruited 686 students (86.11% women), who reported as follows: 68.7% had consumed alcohol, 65.6% had been drunk at least once in the previous year, 62.65% had experienced blackouts and 25.55% had felt pressured to consume alcohol. Drunkenness and blackouts were related (p < 0.000). Of the 15.6% of respondents who had experienced SV, 47.7% experienced SV while under the influence of alcohol and were insufficiently alert to stop what was happening, while 3.06% reported rape. SV was more likely to be experienced by women (OR: 2.770; CI 95%: 1.229–6.242; p = 0.014), individuals reporting a drunk episode in the previous year (OR: 2.839; 95% CI: 1.551–5.197; p = 0.001) and individuals pressured to consume alcohol (OR: 2.091; 95% CI: 1.332–3.281; p = 0.001). (4) Conclusions: Nursing instructors need to raise student awareness of both the effects of alcohol use and SV, so as to equip these future health professionals with the knowledge and skills necessary to deal with SV among young people.

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Knowledge, attitude, and practice on COVID-19 among undergraduate students of B. P. Koirala Institute of Health Sciences, Dharan, Nepal: An online cross-sectional survey

Journal of Biomedical Sciences ◽

10.3126/jbs.v8i1.38457 ◽

2021 ◽

Vol 8 (1) ◽

pp. 15-22

Author(s):

KR Pandey ◽

DR Panday ◽

P Pyakurel ◽

S Marahatta ◽

SP Rimal ◽

...

Keyword(s):

Nursing Students ◽

Undergraduate Students ◽

Human Life ◽

Statistical Significance ◽

Medical Institute ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Health Crisis ◽

Female Ratio ◽

Validated Questionnaire

Background: COVID-19, a global health crisis of the 21st century, has threatened possibly every aspect of human life. Since the pandemic is not yet over, this study was carried out among undergraduate students of a medical institute in Nepal to assess and boost their KAP status on the disease. Material and methods: It was an online cross-sectional census survey performed among consenting undergraduate healthcare students of BPKIHS. A self-made and validated questionnaire assessing KAP on COVID-19 was prepared in Google form and distributed online among target students. The study population was 745. Both descriptive and inferential analysis of the data was performed. Student’s T-Test and one-way ANOVA were applied for which level of statistical significance was kept at p<0.05. Results: Ninety-six students participated in a pilot-study (Cronbach α= 0.792). The response rate was 76.27%. Most participants (76.76%) were from Nepal. The male/female ratio was 0.76. Most (59.2%) had not participated in such studies before. For 93.54%, the source of information was the internet. Assessed by questionnaire, right Knowledge (n=16) was 85.06% ± 8.81%; right Attitude (n=6) was 65.00% ± 16.16 and right Practice (n=6) was 82.88%± 8.50%. Male were more knowledgeable about the disease (p=0.011). However, females secured higher in practical aspects (p=0.000). Indian students possessed better knowledge (p=0.005) and a better attitude (p=0.033). MBBS students had better knowledge (p=0.000), but Nursing students secured higher in Practice (p=0.012). Attitude is better in the earlier years (p=0.045). Conclusion: We assessed KAP related to COVID-19 via score among healthcare undergraduate students. Different co-factors do impact students’ overall KAP status.

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Medication Adherence among Mentally Ill Patients with comorbid- Substance Use Disorder

KYAMC Journal ◽

10.3329/kyamcj.v6i2.33736 ◽

2017 ◽

Vol 6 (2) ◽

pp. 602-609

Author(s):

Nasim Jahan ◽

Mohammad Muntasir Maruf ◽

Md Faruk Hossain ◽

Md Waziul Alam Chowdhury ◽

Anwara Begum

Keyword(s):

Substance Use ◽

Medication Adherence ◽

Mentally Ill ◽

Substance Misuse ◽

Tertiary Care ◽

Cross Sectional Study ◽

Care Hospital ◽

Psychiatric Medication ◽

Cross Sectional ◽

Care Givers

Substance misuse is usually associated with poorer psychiatric medication adherence among mentally ill patients. Identifying proportion & predictors of medication adherence among patients with dual psychiatric and substance misuse problems is important because poor adherence is associated with relapse and re-hospitalization. This study was a descriptive cross sectional study conducted among the patients dually diagnosed with psychiatric and substance use disorders attending OPD in a tertiary care hospital of Dhaka city, during the period from May 2013 to November 2013. The main objective of the study was to explore the proportion of psychotropic medication adherence among the respondents who were on such medication for at least last 6 months (N=151). Respondents were selected purposefully. An informed consent was taken from the patients or care givers and data were collected using the questionnaire designed by the researcher based on Factors Influencing Neuroleptic Medication Taking Scale (FNIMTS). Diagnoses were done previously according to DSM-IV TR by psychiatrist appointed in inpatient and outpatient department. Questionnaire was filled up by the researcher by interviewing the patients and attending care givers as needed. Over half of the respondents (57.0%) admitted they had missed taking their medications on more than one occasion in the week prior to the interview. Thus this study found the proportion of medication adherence to be 43% among the respondents.KYAMC Journal Vol. 6, No.-2, Jan 2016, Page 602-609

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LO90: Epidemiologic trends in substance and opioid misuse in Alberta: a cross-sectional, time-series analysis

CJEM ◽

10.1017/cem.2018.152 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S39-S39

Author(s):

J. Moe ◽

C. Camargo ◽

S. E. Jelinski ◽

S. Erdelyi ◽

J. Brubacher ◽

...

Keyword(s):

Public Health ◽

Time Series ◽

Time Series Analysis ◽

Substance Misuse ◽

Young Patients ◽

Opioid Misuse ◽

Cross Sectional ◽

Health Crisis ◽

Series Analysis ◽

Ed Visits

Introduction: Substance and opioid misuse are growing public health concerns in Canada. Substance use disorders affect 21.6% of Canadians and accounted for $267 million in healthcare costs in 2011. Opioid misuse is a current public health crisis. The extent of the rise in substance and opioid misuse-related Emergency Department (ED) visits in Canada and the demographic groups in which the rise is concentrated have not been elaborated. Alberta has one of the most complete provincial ED visit records and provides an important understanding of national trends. The objective of this study was to evaluate trends in substance and opioid misuse-related ED visits in Alberta from 2010/11 to 2014/5 within demographic cross-sections of the population using administrative ED visit data from the National Ambulatory Care Reporting System (NACRS). Methods: All visits made by adult patients (18 years old) to any of more than 100 Albertan EDs for a substance misuse-related presentation between 2010/11 and 2014/15 were analyzed. Visits were classified as being related to substance or opioid misuse if the primary and/or secondary visit diagnoses were among an a priori determined group of ICD-10 codes. Annual substance misuse-related visits were compared as visits per 100,000 adult population in Alberta to standardize for population growth. Linear regression was used to assess whether ED visits increased significantly over time. A cross-sectional time-series analysis was employed to examine trends within subgroups defined by sex and age categories (18-29, 30-39, 40-49, 50-59, and 60 years) over a 60-month period. Results: 149,719 substance misuse-related visits were made by 65,089 patients and 8768 opioid misuse-related visits were made by 5763 patients. From 2010/11 to 2014/15, substance misuse-related ED visits in Alberta increased by 38% from 811 to 1119 visits per 100,000 population. Opioid misuse-related ED visits increased significantly (64%) from 44 to 72 per 100,000 population. Conversely, total ED visits per 100,000 population did not increase significantly. Substance and opioid misuse-related visits rose more in non-rural than rural areas. Cross-sectional time-series analysis showed that the greatest increase in substance and opioid misuse-related ED visits occurred in males and in the 18-29 year age category, in which visit increases for opioid misuse appeared exponential. Conclusion: Substance and opioid misuse-related ED visits increased significantly from 2010/11 to 2014/15 in Alberta, with the most dramatic increases occurring in young patients and males. These findings have important implications for targeting urgent preventative public health interventions to stem the rise of this epidemic.

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S238. PATIENT ENGAGEMENT TO EARLY INTERVENTION IN PSYCHOSIS SERVICES: RETROSPECTIVE ANALYSIS OF ENGAGEMENT PATTERNS

Schizophrenia Bulletin ◽

10.1093/schbul/sbaa031.304 ◽

2020 ◽

Vol 46 (Supplement_1) ◽

pp. S129-S130

Author(s):

Candice Crocker ◽

Michael Teehan ◽

Zenovia Ursuliak ◽

Jason Morrison ◽

Nancy Robertson ◽

...

Keyword(s):

Substance Use ◽

Early Intervention ◽

Alcohol Use ◽

Health Services ◽

Well Being ◽

Time Frame ◽

Individual Risk ◽

Cross Sectional ◽

Data Set ◽

Early Intervention In Psychosis

Abstract Background Within outpatient mental health services there exists an important awareness of the difficulties in engaging and maintaining contact with patients, as well as the understanding of the negative effects of disengagement, including worse patient outcomes and increased healthcare burden. Despite the importance of engagement on service delivery and recovery outcomes, few studies have examined rates and predictors of engagement in the early phase psychosis population. Although better than community care, it has been reported that an average of 30% of patients disengage from specialized early intervention services for psychosis (EIS). We examined rates of disengagement to a 5 year EIS for psychosis, including potential individual risk factors for disengagement at entry to service. Methods This cross-sectional cohort study examined engagement to services to a single EIS site from November 2006 to November 2016. Disengagement was determined retrospectively on review of medical records, defined as not attending to clinic services despite repeated attempts by clinicians/clinic for a three month time frame. Gender, age at clinic entry, ethnicity, Positive and Negative Syndrome Scale (PANSS), Drug Attitude Inventory (DAI-30), General Assessment of Function (GAF), Social and Occupational Functioning Assessment Scale (SOFAS), WHO-ASSIST version 3.0, and the Psychological General Well Being (PGWB)scale at entry to service were examined between groups. . Descriptive statistical and survival analyses for time to disengagement were conducted on the patient data set. Results 331 patient records were complete (with above scales) from entry to service to discharge or loss to follow-up. Patients were found to fall into 3 categories with regard to patterns of engagement. The first category we named “engagers” as they remained committed to their care throughout the program and comprised 50% of the sample. The second group were labeled the disengagers (20% of the group) and these were individuals who disengaged at some point in the program and did not return, in contrast to “intermittent engagers“ who comprised 30% of the sample. Intermittent engagers were patients who at some point during their care would meet criteria for disengagement but would re-engage later (still within the 5 years from entry to EIS) and complete the program. Absolute disengagement by the disengager group was predominantly prior to 12 months of treatment (78% of the group) with a survival analysis showing a median time to absolute disengagement of 8 months. The 3 groups though defined based on their engagement status, did not significantly differ in age, gender and ethnicity. Additionally, the clinician reported scores GAF and SOFAS did not differ between the groups. Patterns of substance use differed between the groups. There was a trend toward higher tobacco use in the two groups showing disengagement. Cannabis use did not differ significantly between groups but the pattern of use was highest in the disengagers followed by the engagers and then intermittent engagers. Alcohol use was significantly different between the groups with 81% of the disengagers having problem levels of alcohol use (WHO ASSIST v. 3.0 score above 4), however, there was no correlation between alcohol score and time to disengagement. Discussion Our retrospective study found a surprisingly large portion of the patient population will wax and wane in their commitment to health services but ultimately maintain attendance to complete the program, suggesting that patients should not be discharged early from EIS for psychosis. Substance use patterns and functional measures may identify patients who are at risk of early disengagement from EIS.

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Prevalance of Using Cigarette,Alcohol,Substance Among High School Students and Factors Affected Them

European Journal of Public Health ◽

10.1093/eurpub/ckz186.129 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

Y Levent ◽

A Ozer ◽

A Gokce

Keyword(s):

High School ◽

Substance Use ◽

High School Students ◽

Alcohol Use ◽

Cross Sectional Study ◽

School Students ◽

Chi Square ◽

Cross Sectional ◽

Cigarette Smokers ◽

Alcohol Users

Abstract Background Usage rate of cigarette, alcohol, and substance is increasing day by day.Protectiv efactors have primary importance for prevention of substance use.The aim of this study is to investigate the prevalance of using cigarette, alcohol and substance and research relationship between risk factories and substance using, among high school students. Methods Ä°n Malatya city there are 17866 Anatolian, 14381 Vocational,10362 Religious high school students.Totally all of this 42629 students form the universe of this cross-sectional study. When the prevalance of using cigarette accepted as 25 % in high school students; sample size in Anatolian high school,Occupatioanal high school and Religious high school was found 283, 283 and 280 respectively.This survey was conducted in 9 different high schools which choosed by stratified sampling method, and 975 high school students have been reached in this survey.Ä°n the statistical analysing of data,Chi square test, logistic regression test were used. Results The prevalance of cigarette, alcohol and substance using found 34%, 14.3% and 4.2% respectivey among students participating in the survey.Cigarette using; in male students is 2.2 times higher (Cl 95%,1.661-3.073), in alcohol users is 7.6 times higher(Cl 95%,4.919-11.834)(p < 0.05).Alcohol using is 9.6 times higher(Cl 95%, 5.712-16.250) in cigarette smokers(p < 0.05).And alcohol using in students with alcohol use in their families is 26.8 times higher(Cl 95%,12.489-57.711)(p < 0.05).Substance using; found 12.2 times higher(Cl 95%,4.900-30.566) in alcohol users,2.4 times higher(Cl 95%,5.712-16.250) in cigarette smokers and 5.6 times higher(Cl 95%,1.366-23.068)in students with substance use in their families (p < 0.05). Conclusions Cigarette using is more common in males and alcohol users.Alcohol use increses in smokers and students with alcohol use in their families.Substance use among students increases when student uses cigarette or alcohol and if there are substanceuse in their families. Key messages Alcohol use increses in smokers, smoking increses in alcohol users. Substance use increses in smokers, alcohol users and in the students with substance use in their families.

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