Substance Use
Jump to: Youth Substance Use | Adult Substance Use
Use of alcohol, tobacco, and cannabis is closely linked to increased risk of opioid misuse, dependence, and overdose—both as early precursors and as co-occurring substances. Individuals who use these substances are more likely to initiate opioid use, and those who use them concurrently with opioids face significantly worse health outcomes. Early use of alcohol or cannabis, especially during adolescence, has been associated with a higher likelihood of progressing to prescription opioid misuse or illicit opioid use in adulthood, suggesting a potential "gateway" pattern for some individuals. Tobacco use, which remains highly prevalent among people with opioid use disorder (OUD), is not only associated with increased vulnerability to opioid misuse, but also with lower treatment success rates and higher relapse risk during recovery.¹ In one study, 73.5-94% of adults receiving substance use treatment for opioids that included methadone maintenance also reported regular cigarette use, which has been linked to increased cravings and worsened mental health symptoms.² Co-use of alcohol and opioids significantly increases the risk of respiratory depression and overdose due to their combined effects on the central nervous system.³ While some individuals report using cannabis as a substitute for opioids, especially for pain management, research remains mixed—frequent cannabis use has also been associated with higher rates of opioid misuse and poorer recovery outcomes in certain populations.
Youth
Youth substance use involving alcohol and cannabis is associated with an increased risk of later opioid misuse and dependence. Early initiation of these substances can prime the developing brain for heightened sensitivity to other drugs, including opioids, by altering neurobiological pathways related to reward, impulse control, and stress regulation. Research suggests that adolescents who engage in substance use are more likely to engage in prescription opioid misuse or illicit opioid use in young adulthood. These patterns underscore the importance of preventing early substance use as a strategy to mitigate future opioid-related harms, particularly given the compounded risks of polysubstance use and its contribution to overdose likelihood. Addressing early use of these substances through comprehensive prevention efforts may reduce both immediate and long-term risks associated with opioid misuse.
Adults
Among adults, the use of alcohol, cannabis, and tobacco is similarly associated with opioid misuse, dependence, and other adverse health outcomes. These substances are frequently co-used with opioids, which can compound health risks and complicate treatment efforts. Alcohol, when consumed alongside opioids, raises the risk of respiratory depression and overdose due to their synergistic effects on the central nervous system. Tobacco use is disproportionately high among individuals with opioid use disorder (OUD) and is associated with poorer treatment retention, lower success rates in medication-assisted treatment (MAT), and greater all-cause mortality. Meanwhile, cannabis use among adults with OUD presents a complex picture: while some evidence suggests it may serve as a harm reduction tool for pain management or reducing opioid dose, other studies indicate that cannabis use—particularly frequent or early use—is associated with increased opioid misuse and poorer recovery outcomes. These intersecting substance use patterns highlight the need for integrated, multi-substance approaches in both prevention and treatment strategies for opioid use disorder.
