The other case involved tacalcitol ointment as the inciting agent. In addition, we recently encountered a second case of oral vitamin D-induced acute pancreatitis , which we are currently examining. Early use of substances has been associated with more severe addictions and subsequent poor treatment outcomes . Early age at first substance use can lead to different addiction use trajectories, including early-onset and severe SUD symptoms persisting into adulthood, early-onset in adolescence that improves in adulthood, and SUD symptoms emerging later with varying degrees of severity and persistence . Additionally, early age at first substance use not only negatively impacts mental health outcomes, but it also influences the addiction recovery process. Earlier age at inaugural substance use exerts a significant influence on later severe SUDs and constitutes a risk factor for comorbid mental health issues . Early age at first substance use can also extend the addiction recovery process , influence relapse frequency , and suicide attempts . To date, available evidence on associations between age at first substance use and later SUD varied across study populations, and research conducted in regions other than North America and Europe, especially sub-Saharan Africa is scarce . However, the majority of SSA countries is disproportionally affected by fragile security and armed conflicts ; which are among factors for proliferation of psychoactive substances in the region . This dearth of research may obstruct interventions toward the growing substance use issues, such as alcohol use disorders and subsequent deaths among youth in Africa . Globally, substantial evidence links first alcohol use,vertical hydroponic garden before 18 years old, with higher alcohol and other drug disorders . In Canada, individuals consuming alcohol between the ages of 11 and 14 had more risk for developing alcohol disorders compared with those who started drinking alcohol after the age of 19 .
Donoghue et al. in a study conducted in the UK likewise found a strong association between age of the first alcohol consumption, before the age of 15, tobacco use, lower quality of life, and emergency room admissions for alcohol use disorders among adolescents. Similarly, a recent systematic review of prospective studies highlighted the impact of early first alcohol use on future alcohol use disorders . In a birth cohort study, Newton-Howes and Boden demonstrated that early age of first drug use significantly increased the risk for later alcohol use disorders, nicotine dependence, and illicit drug dependence. However, after controlling for covariate factors, such as family living standards, ethnicity, and childhood sexual abuse, earlier first substance use was found to have no significant associations with these SUDs . In an Australian study, young age substance exposure was associated with later poly drug use, such as methamphetamine and heroin . In contrast to the above evidence, other research found no statistically significant associations between early-age substance use and later SUD . A few studies conducted in SSA reported the age at onset of only two types of psychoactive substances, alcohol , and tobacco . In youth tobacco surveys from nine Western Africa countries, Veeranki et al. found that the age of smoking onset was as early as 7 years old. Osaki et al. in a Tanzanian secondary school and college students aged 15–24 found that the age of alcohol consumption was as early as 10 years old. Contextual factors for alcohol use onset included exposure to a stressful environment, social events, and home alcohol consumption under the influence of parents, relatives, peers, and intimate partners . Likewise, a systematic review for cross-country comparison by Townsend et al. demon-strated that tobacco use primarily began in late adolescence and early adulthood in SSA. However, Townsend et al. found no association between tobacco use and socioeconomic status or urban/rural difference.
The strength of the association be-tween first substance use to SUD seems to be moderated by contextual factors. Variations in the strength of associations between first substance use and SUD may be partially explained by environmental factors, such as life adversity and conflict-related psychology strains . In the recent UK Millennium Cohort Study of 10,498 11-year-old participants, having a friend who drank was a strong risk factor for increased alcohol use patterns . Besides, McCann et al. indicated that relationships, including higher levels of parental control and lower levels of child openness to parents, were linked with less frequent alcohol use. Furthermore, child-hood traumatic experiences in the forms of severe and mild physical abuse significantly correlated with an earlier age at first alcohol consumption, as well as illicit and poly drug use . Other factors, such as premorbid cognitive deficit early-age major depression , bipolar disorders , and impulse control influence early-age substance use and addiction trajectory following first substance. Additionally, interactions between premorbid mental health deficits and the effects of substance use on cognitive development may influence the early substance use onset and rapid spirals into substance dependence . Overall, there is little and inconsistent evidence on the association between early age at first substance use and later severe addiction issues worldwide. While the associations between PTSD and SUD are well documented, little is known about how young age substance use coupled to PTSD contributes to later severe addiction. Likewise, PTSD has been studied somewhat in SSA and substantially in Rwanda ; however, there is minimal data on associated substance misuse. The identified studies focused on a few substances and did not examine the transition from first use to addiction and contributors to later addiction severity.Addiction severity was measured using the Addiction Severity Index lite version . The ASI assesses disturbances during the previous 30 days across seven domains, including medical status, employment/occupation status, alcohol use, drug use, legal status, family/social status, and psychiatric status. Calculations of addiction severity weight were guided by the ASI composites score weighting instructions .
The total score on all seven composites is seven, i.e., a maximum score of one at each composite, and a high overall rating indicates severe addiction problems. This ASI weighting procedure for each of addiction severity areas has been validated and showed significant convergent validity and has a high predictive validity . The study that tested the scale found good reliability with an alpha coefficient of at least 0.70 across all composites . The present study had an overall Cronbach’s alpha coefficient of α 0.68.Data analysis was conducted in IBM Statistical Package for Social Sciences, 26th version. Initially, analyses consisted of conducting descriptive statistics for sociodemographic variables and bivariate analyses between addiction severity and potential confounding variables, including the level of education in years , areas of residence, sex, motives,plant bench indoor living with active alcohol, and non-prescribed drugs using one-way analysis of variance . Then, a hierarchical regression model consisted of entering the age at first substance use, followed by the other variables, PTSD as well as the level of education, area of residency, as both of which showed significant bivariate relationships with addiction severity. Regression diagnostics were performed to check whether there were potential violations of the linear regression assumptions.The present study examined the extent to which age, motives for the first substance use, and PTSD influence later addiction severity. The study results demonstrate that first substance use occurs as early as 5 years old. Half of the sample have had their initial psychoactive substance before or at their 18th birthday. The majority of participants were male , which suggests that fewer female participants sought addiction services in Rwandan mental health settings during the study period. This gender difference in addiction service utilization may require further exploration. The study results also suggest that the Rwandan clinical cohort had the first substance use 2 years earlier compared with other SSA populations . Among the study participants, substance use patterns could be as severe as using seven different types of psychoactive substances, and up to nearly three times daily. The identified substance patterns are worrisome because of potential increases in risks for negative neurobiological changes that result from regular substance and polydrug use, especially before the brain fully matures. Such brain changes have the potential to contribute to maladaptive cognition, motivation, and affective states throughout a person’s entire lifetime . In many ways, the study results support previous studies which indicated that early-age exposure to substance use increases risks for severe addiction. The results suggest that delayed first substance use may be associated with a significant reduction of risks for addiction severity. Such risks may vary with the type of substance consumed. Previous research has shown significant associations between poor mental health outcomes, such as psychosis onset, and age at onset of cannabis use but not of alcohol use . Progressing from first cannabis use to cannabis use disorders takes a shorter time than for alcohol and nicotine, whereas poly substance use speeds up transitions to addiction disorders . By establishing the contribution of age at first substance use and addiction severity, these results reinforce previous findings on the progression of addiction trajectories following the first substance use .
The study also supports previous evidence on increased risks for poly substance use among individuals exposed to earlier psychoactive drug use . As such, the present study results call for research testing the effectiveness of health promotion and prevention interventions aimed at delaying the age of exposure to first substance use. The implementation of such interventions may face difficulties since drinking cultural norms, in some SSA countries, permit alcohol drink during childhood, especially at family social events. Moreover, long-term instability predominant in SSA countries may add to the complexity of earlier substance use. Long-term instability may lead to the absence of adults moderating how and when young people can drink and use of a substance to self-medicating for post traumatic disorders. The present study further underscores the influence of PTSD on later complications of addiction problems after early-age first substance use. Besides, coupling PTSD and young age at first substance use indicate a statistically significant increase in addiction severity . The identified increase in variance explained by PTSD emphasizes that PTSD is a significant predictor of later addiction severity among individuals who face early substance use problems. These results are consistent with previous research, which associated early childhood experience of trauma with early substance use onset and transition to poly drug use . Additionally, previous handful evidence has consistently established associations between SUD and PTSD and provided explanatory hypotheses underlying these associations. Given that at SSA populations such Rwandans had experienced horrific events , these results may be interpreted through well-documented risky use of psychoactive substances for coping with post disaster distress . However, it is challenging to delineate which of the two conditions occurs first because SUD and PTSD affect the stress processing system. Chronic SUD, such as alcohol use disorders, increased individual vulnerability to PTSD due to alcohol related defects of endocrinal response to distress events and reduced cortisol release . On the other hand, PTSD influences neurotransmitters changes, such as serotonin, in the hypothalamic-pituitary-adrenaline axis, which have been linked to risks for worsened SUD . The identified positive association between level of education and addiction severity may be partially explained by the Rwandan cultural and conception of mental illness.Thus, educated people may find it challenging to seek early help for their SUD due to fear of being subject to attached stigma and use psychoactive substances as self-medication.The present study, to our knowledge, is the first to investigate the contributions of age, motives for first substance use, and post traumatic distress to later addiction problems using a clinical sample in sub-Saharan Africa. The study used a compelling alternative to the random sampling strategy, recruiting every participant presenting for inpatient addiction care in two existing settings over 8 months. This study has a few limitations, including relying on self-reported data that may be prone to recall and social desirability biases. However, we attempted to minimize these biases by collecting data through face-to-face semi-structured interviews conducted by trained and qualified mental health professionals who were not part of a healthcare circle .The state of California has the second-lowest smoking prevalence in the United States . For more than 30 years, the state has devoted tobacco tax revenues to building community capacity, changing social norms about tobacco, and providing support for local tobacco control programs.