Firearms and substance use: bringing synergy to counseling and intervention

KEYWORDS:

• Firearms
• substance use
• counseling and intervention

This article is referred to by:

Gun access, ownership, gun-related experiences, and substance use in young adults: a latent class analysis

Firearms pose substantial health risk to the US population in general and are of particular concern to the health and wellbeing of young adults. By understanding links between firearms and risk and protective behaviors, we can identify new opportunities for clinical screening and intervention to mitigate these risks. The article by Lu & Temple in this edition of the American Journal of Drug and Alcohol Abuse makes an important contribution to the literature by jointly evaluating multiple types of firearm access, firearm-related experiences, and substance use among young adults (1). The authors used cross-sectional data collected in 2017 from the Dating it Safe study, including 663 young adults ages 20–25 in the Southern US. Exposure to firearms was common, and varied considerably across survey items. For example, 41% reported having access to a firearm when needed and 14% had carried a firearm in the past year (not for hunting/target shooting). The authors identified latent classes, or unique groups, defined by patterns of firearm access and firearm-related experiences. The majority of young adult participants (65%) comprised a class with minimal firearm access or experience (defined as having a low probability of either owning/having access to a firearm or having had any firearm-related experiences) while 33% were in the firearm access without firearm-related experience class (defined as high probability of firearm access/ownership but low probability of firearm-related experiences). The smallest class (1.6% of participants) represented young adults with both firearm access and firearm-related experiences (carrying a firearm, being threatened with a firearm, or threatening others with a firearm). Compared to young adults in the first two classes, those in the firearm access with experience class reported significantly more frequent alcohol use, more episodic heavy drinking, and more cigarette use.

Understanding how firearms and substance use intersect, and how these intersections affect health and wellbeing, is imperative. Firearms are the leading cause of death among young adults in the US when considering both homicide and suicide mortality (2). Access to firearms is a critical factor in explaining the risk to young adults (3). Estimates suggest that there are 265 million firearms in civilian possession across the U.S (4). According to the 2015 National Firearm Survey, 13% of 18 to 29 year-olds endorse firearm ownership. In the past 5 years, 18–24 year-olds have acquired 726,000 new firearms (5). Substance use, particularly alcohol use, can remove inhibitions, and can lead to risk taking behavior, including the use of firearms. Surveys suggest that 28% of young adults ages 18–22 report binge drinking in the last 30 days (6). Recent studies also document the precipitous rise of e-cigarette and opioid use among young adults. JUUL use (a popular brand of e-cigarettes) is highest among young adults, with 13% of 18–20 year-olds and 8% of 21–24 year-olds endorsing current use in 2018–2019 (7). Misuse of prescription opioids disproportionately affects young adults and contributes to the drug overdose epidemic, with 8% of 18–25 year-olds endorsing past-year opioid misuse in 2016 (8,9). Given the high prevalence of firearms and high rates of substance use among adolescents and young adults (AYA), tailored strategies to recognize and address these intersections are needed.

Leading medical, public health, and legal organizations support synergistic efforts across health-related sectors to address firearm safety (10,11). A recent position statement from the Society for Adolescent Health and Medicine (SAHM) provides specific recommendations for addressing firearm safety among young adult populations (12). These recommendations include screening for firearm ownership, access, and carrying, as well as risk behaviors, including substance use, suicidality, and homicidality, that may increase risk for firearm injury. The SAHM also recommends providing universal counseling to all young adult firearm owners on safe firearm storage, and ideally coupling this messaging with provision of safe storage devices. High rates of firearm access and firearm-related experiences noted by Lu & Temple (1) reinforce the need to incorporate these best practices broadly across AYA-serving primary care and other clinical settings.

As we think about addressing firearm safety, we also need to consider how best to address co-occurring risk behaviors, including substance use. We need to think broadly about strategies that reach young adults in a variety of clinical and community-based settings (13). Young adults – particularly those engaged in high-risk behaviors – don’t always fit well in either pediatric or adult clinical settings, resulting in lower rates of care utilization compared to other age groups (14). Like many areas of medicine and public health, firearm safety and substance use have historically been siloed. With the opioid epidemic bringing renewed focus and resources to address substance use, now is the time to bring synergy to this work. The Substance Abuse and Mental Health Services Administration and the American Academy of Pediatrics support the use of screening, brief intervention, and referral to treatment (SBIRT) as a comprehensive approach to address substance use across pediatric, AYA, and adult populations in diverse clinical settings (15). It behooves us to think about strategies to incorporate firearm screening, counseling, and intervention into these conversations. In doing so, we can tailor prevention and intervention approaches that address multiple risk behaviors, including firearm carrying, firearm use and substance use, and leverage an individuals’ key strengths to help young people build skills to promote safety and wellbeing.

Importantly, Lu and Temple found the rates at which participants endorsed substance use were very similar between the group without firearm access or experience and the group with access but without experience. In keeping with prior literature (16), substance use appears to be most closely linked with firearm-related experiences. Notably, even among participants in the firearm access with experience class, there was considerable variation in the rates of substance use. These findings are intriguing and important to consider from a clinical and sociological perspective. Binge drinking is commonplace among young adults – in fact the US Preventive Services Task Force (USPSTF) recommends screening and brief intervention for alcohol use disorders in the clinical setting (17), but there is a paucity of data that details the appropriate clinical approach to young adults regarding firearm safety. Being aware of the association between binge drinking and firearm-related experiences should prompt the clinician to, at the least, counsel young adults on the risks of firearm access and carrying both in the context of suicide and unintentional injury.

Separate from the main associations reported in Lu and Temple’s paper, it is important to note that 33% of the young adults surveyed reported firearm access. Studies show that the presence of firearms alone leads to a 3-fold increased risk of completed suicide and twice the odds of homicide victimization (3). Knowing this risk of firearm-related mortality should prompt health care providers to screen for firearm access, and offer appropriate safety counseling, regardless of the presence of binge drinking.

There are several limitations with Lu and Temple’s findings, which offer opportunities for future research. Participants were from a single geographic area and findings may not generalize to other contexts and localities. Studies should seek to replicate these findings among larger samples in varied contexts. In regards to firearm ownership and access, the survey questions did not decipher which participants owned firearms (the participant themselves or someone else in the household), or how participants may have been able to access the firearms. This is particularly relevant for young adults who are developing independence and new living circumstances. Living situations are varied and can be transient (e.g., living at home, being at college for part of the year, living with roommates) which may affect the interpretation of responses to access and ownership survey items. This study did not differentiate between access to parents’ firearms compared to their own. In the current analysis, firearm experiences included firearm carrying, threatening someone with a firearm, and being threatened with a firearm. While all three behaviors can be interrelated, they represent distinct patterns and may be differentially associated with substance use, which cannot be assessed when they are considered jointly. Firearms questions were only part of the most recent wave of data collection in the Dating it Safe study, and thus analyses were cross-sectional. This precludes inferring temporality or causality from the described associations.

Future studies should build upon Lu and Temple’s findings by assessing ownership, access, and firearm-related experiences with further granularity. Event-level and activity path data may offer unique insights into individual and situational factors that affect links between substance use and firearm-related behaviors among young adults (18,19). In addition, co-occurrence patterns must be followed over time to understand how dynamic trends in substance use impact these associations.

In summary, Lu and Temple’s findings build on the literature that describes associations between firearms and other risk behaviors that impact young adult health. Further, understanding the prevalence of firearm access in this age group, and the indisputable link to common causes of mortality, highlight the urgency for the health care community to expand efforts to screen young adults for firearm access, offer counseling on the risks firearms pose, and discuss the appropriate approach to safe storage of firearms.

Potential conflicts of interest

The authors have no conflicts of interest to disclose.

Additional information

Funding

No external funding.