Onset Of Alcoholism Research Articles

Substance use risk profiles and associations with early substance use in adolescence.

We examined whether anxiety sensitivity, hopelessness, sensation seeking, and impulsivity (i.e., revised version of the Substance Use Risk Profile Scale) would be related to the lifetime prevalence and age of onset of alcohol, tobacco, and cannabis use, and to polydrug use in early adolescence. Baseline data of a broader effectiveness study were used from 3,783 early adolescents aged 11–15 years. Structural equation models showed that hopelessness and sensation seeking were indicative of ever-used alcohol, tobacco or cannabis and for the use of more than one substance. Furthermore, individuals with higher levels of hopelessness had a higher chance of starting to use alcohol or cannabis at an earlier age, but highly anxiety sensitive individuals were less likely to start using alcohol use at a younger age. Conclusively, early adolescents who report higher levels of hopelessness and sensation seeking seem to be at higher risk for an early onset of substance use and poly substance use.

Panic Disorder Respiratory Subtype: Psychopathology, Laboratory Challenge Tests, and Response to Treatment

Our objective is to summarize the new findings concerning the respiratory subtype (RS) of panic disorder (PD) since its first description. Two searches were made in the Institute for Scientific Information Web of Science: with the keywords "panic disorder" and "respiratory symptoms," and all articles that cited Briggs and colleagues' 1993 article "Subtyping of Panic Disorder by Symptom Profile" (Br J Psychiatry 1993;163:201-9). Altogether, 133 articles were reviewed. We describe and discuss RS epidemiology, genetics, psychopathology, demographic features, clinical features, correlations with the respiratory system, traumatic suffocation history, provocative tests, and nocturnal panic. Compared to patients with the nonrespiratory subtype (non-RS), the RS patients had higher familial history of PD, lower comorbidity with depression, longer duration of illness, lower neuroticism scores, and higher scores in severity scales, such as the Panic and Agoraphobia Scale, Panic-Agoraphobia Spectrum scale and the Clinical Global Impression scale. Tests to induce panic attacks, such as those with CO(2), hyperventilation, and caffeine, produce panic attacks in a higher proportion of RS patients than non-RS patients. Differences in the subtypes' improvement with the pharmacologic treatment were found. There are also some controversial findings regarding the RS, including the age of onset of PD, and alcohol and tobacco use in RS patients. Some characteristics, such as the increased sensitivity to CO(2) and the higher familial history of PD, clearly distinguish the RS from the non-RS. Nevertheless, there are also controversial findings. More studies are needed to determine the validity of the RS subtype.

Medications Acting on the Serotonergic System for the Treatment of Alcohol Dependent Patients

Research suggests that alcoholics show comparatively lower levels of serotonin (5-HT) than non-alcoholics. Medications aimed at increasing synaptic 5-HT have long been studied as potential treatments for alcoholism. Studies with selective serotonin reuptake inhibitors (SSRI) in a heterogeneous population of non-depressed alcoholics have produced inconsistent results. Further exploration involved whether or not treatment of co-morbid alcoholism and depression was a more practical approach. However, even in the presence of co-occurring depression, antidepressants in general lack the power to demonstrate a significant reduction of alcohol use among alcohol dependent patients with carefully diagnosed major depression. Further statistical analysis has also determined that perhaps genotypic and phenotypic variations differ for persons with alcohol dependence including those with or without comorbid alcohol dependence and depression suggesting important subgroups might respond differently to treatments. Clinical trials have also used the anxiolytic buspirone, a 5-HT(1A) partial agonist, as many alcoholics suffer from anxiety. When controlling for baseline anxiety, buspirone was no more effective than placebo for alcoholic patients. Another serotonergic drug, ritanserin, did not demonstrate effectiveness in relapse prevention in alcohol dependence. However, research on the use of the 5-HT(3) antagonist ondansetron for alcohol dependence continues to provide promising results, particularly for patients with early onset alcoholism. As demonstrated by the studies with serotonergics, responses based on individual variables suggest that alcoholics may respond differentially based on various serotonin 5-HT subtypes. Of course, future studies need to further delineate and confirm the differences between these alcoholic subtypes.

Mental disorders as risk factors for substance use, abuse and dependence: results from the 10‐year follow‐up of the National Comorbidity Survey

The comorbidity of mental disorders and substance dependence is well documented, but prospective investigations in community samples are rare. This investigation examines the role of primary mental disorders as risk factors for the later onset of nicotine, alcohol and illicit drug use, abuse and dependence with abuse. The National Comorbidity Survey (NCS) was a nationally representative survey of mental and substance disorders in the United States carried out in 1990-92. The NCS-2 re-interviewed a probability subsample of NCS respondents in 2001-03, a decade after the baseline survey. A total of 5001 NCS respondents were re-interviewed in the NCS-2 (87.6% of baseline sample). Aggregate analyses demonstrated significant prospective risks posed by baseline mental disorders for the onset of nicotine, alcohol and illicit drug dependence with abuse over the follow-up period. Particularly strong and consistent associations were observed for behavioral disorders and previous substance use conditions, as well as for certain mood and anxiety disorders. Conditional analyses demonstrated that many observed associations were limited to specific categories of use, abuse or dependence, including several mental disorders that were non-significant predictors in the aggregate analyses. Many mental disorders are associated with an increased risk of later substance use conditions, but important differences in these associations are observed across the categories of use, abuse and dependence with abuse. These prospective findings have implications for the precision of prevention and treatment strategies targeting substance use disorders.

A prospective study of personality features predictive of early adolescent alcohol misuse

Personality factors implicated in alcohol misuse have been extensively investigated in adult populations. Fewer studies have clarified the robustness of personality dimensions in predicting early onset alcohol misuse in adolescence. The aim of this study was to examine the predictive utility of two prominent models of personality (Cloninger, 1987; Eysenck & Eysenck, 1975) in emergent alcohol misuse in adolescence. One hundred and 92 secondary school students (mean age = 13.8 years, SD = 0.5) were administered measures of personality (Revised Junior Eysenck Personality Questionnaire – abbreviated; Temperament scale of Junior Temperament and Character Inventory) and drinking behavior (quantity and frequency of consumption, Alcohol Use Disorders Identification Test) at Time 1. At 12-month follow-up, 170 students (88.5%) were retained. Hierarchical multiple regressions revealed the dimensions of psychoticism, extraversion, and Novelty-Seeking to be the most powerful predictors of future alcohol misuse in adolescents. Results provide support for the etiological relevance of these dimensions in the development of early onset alcohol misuse. Findings can be used to develop early intervention programs that target personality risk factors for alcohol misuse in high-risk youth.

Trajectories of Substance Use Disorders in Youth: Identifying and Predicting Group Memberships

This study used latent class regression to identify latent trajectory classes based on individuals' diagnostic course of substance use disorders (SUDs) from late adolescence to early adulthood as well as to examine whether several psychosocial risk factors predicted the trajectory class membership. The study sample consisted of 310 individuals originally recruited as children in a long-term prospective study. Diagnoses of alcohol or cannabis use disorders (abuse or dependence) were assessed when individuals were 18 (T1), 20 (T2), and 22 (T3) years old. The results showed that two trajectory classes were identified for both alcohol and cannabis use disorder cases and that the trajectory class membership was predicted by being male, dropping out of high school, receiving a diagnosis of CD or ODD in childhood, having an early age of onset of alcohol or cannabis use, previously using illicit drugs other than cannabis, and the number of risk factors an individual is exposed to. Prevention work should focus on the individuals exposed to these risk factors previously to decrease their likelihood of transition from drug use or single diagnosis to repeated diagnosis during the early years of emerging adulthood.

Early onset alcohol dependence with high density of family history is not “male limited”

Objective Based on classical adoption studies, early onset type II alcoholism was originally described as “male limited.” We examined the possible expression of this subtype in present day alcohol-dependent women. Detailed systematic assessment was obtained from 200 treatment-seeking alcohol-dependent women and 189 healthy population controls. Women fulfilling type II alcoholism criteria had higher alcoholism severity as measured by The Alcohol Use Disorders Identification Test and markedly higher use of illicit drugs. Both alcoholism subtypes scored higher than normal on anxiety and impulsivity traits, but type II women scored markedly higher on aggression subscales than either of the other groups. Importantly, density of family history was markedly higher in type II women, suggesting a higher heritability. Despite its original description as male limited, early onset alcoholism with high density of family history is likely to be a valid construct in women. Its recognition has important implications for diagnosis, treatment, and research.

Social integration in young adulthood and the subsequent onset of substance use and disorders among a community population of urban African Americans

This paper examines the association between social integration in young adulthood and the later onset of substance use and disorders through mid-adulthood. Design Data come from a community cohort of African Americans followed longitudinally from age 6-42 years with four assessment periods. The cohort all lived in the Woodlawn neighborhood of Chicago in 1966, an urban disadvantaged setting. All Woodlawn first graders in 1966 were asked to participate; 13 families declined (n = 1242). Substance use was measured via interview at age 42 and includes the onset of alcohol and drug use disorders and the onset of cocaine/heroin use between ages 32 and 42 years. Social integration measures were assessed via interview at age 32 and include social roles (employee, spouse, parent), participation in religious and social organizations and a measure of overall social integration. Control variables were measured in childhood and later in the life course. Multivariate regression analyses suggest that unemployment, being unmarried, infrequent religious service attendance and lower overall social integration in young adulthood predict later adult-onset drug use disorders, but not alcohol use disorders once confounders are taken into consideration. Unemployment and lower overall social integration predict onset of cocaine/heroin use later in adulthood. Results show meaningful onset of drug use and substance use disorders during mid-adulthood and that social integration in young adulthood seems to play a role in later onset of drug use and drug disorders, but not alcohol disorders.

Severity of alcoholism in Indian males: Correlation with age of onset and family history of alcoholism

Background:Family History of Alcoholism and earlier Age of Onset are found to predict Severity of alcoholism. Previous Indian studies in this regard have methodological issues related to the definition of alcoholism and reliability of information obtained.Aims:To study the relationship between the Age of onset/Family History and Severity of alcoholism.Settings and Design:Consecutively admitted, 20 to 50 year old men, with alcohol-related problems at an urban teaching hospital, were recruited.Materials and Methods:After detoxification, alcohol use detection inventory test, severity of alcohol dependence questionnaire, schedule for clinical assessment in neuropsychiatry, and family interview for genetic studies were administered. Family history density was computed.Statistics:Pearson’s correlations, linear regression, and ANOVA tests were used.Results:Family history density and severity of alcoholism were positively correlated. Age of onset of initiation had a significant negative correlation with severity. The effect of family history on the rapidity of development of Problem-drinking did not reach statistical significance among those with early age of onset. The variance explained by the ‘family history status’ and ‘age of onset’ for the severity of alcoholism was similar to that reported in earlier western studies.Conclusion:This study, with enhanced methodology, using a general hospital sample of problem drinkers concludes that the age of onset of initiation is a better predictor of severity of alcoholism, than family history of alcoholism alone. Postponing the use of alcohol till the age of 25 years could be explored as a primary prevention strategy in genetically vulnerable adolescents.

Clinical course of development of alcohol and opioid dependence: What are the implications in prevention?

In India, it is estimated that 75 million people are alcohol users and nearly 3 million are opioid users.(1) Of these, there has been a noted prevalence of 19.78-21.4%(2) of alcohol use and 5% of alcohol dependence in Indian population.(3) The prevalence of opium use in India has also been increasing and it is now considered to be a ’party drug’ or ’relaxation drug’. Several studies have described the prevalence of opium abuse to be 1.51-2%(3,4) although a recent study notes it to be around 0.4%.(2) Yet, there is a concerning increase in the social acceptance of alcohol even for frequent self-induced intoxication and easier access to ’hard drugs’ like opioids is now responsible for driving adolescents toward substance use and a trend is being noted toward lower ages of onset of both alcohol and opioid use. Even though opium use is generally frowned upon, alcohol use is widely accepted. There is, therefore, an urgent need for reduction in the demand of drugs of addiction, both legal and illegal, which may otherwise lead to numerous health, family and societal consequences. One of the ways this can be made possible is by identifying and preventing the development of dependence in both alcohol and opioid users. This study is therefore aimed at: Studying the clinical course of development, in terms of ages, order of onset and duration of criteria of ICD-10 dependence, of both alcohol and opioid dependence. Comparing and contrasting the two substances to evaluate differences if any, to formulate a strategy for primary prevention. Materials and Methods Consecutively admitted patients of ≥18 years of age for treatment of dependence in the period of August 2005 to May 2006 in Centre for Addiction Psychiatry, Central Institute of Psychiatry, Ranchi, India with ICD-10 DCR(5) diagnosis of alcohol dependence syndrome or opioid dependence syndrome (made by a senior resident/senior consultant) and giving written informed consent were recruited for the study. Subjects with other co-morbid psychiatric disorders/substance dependence/general medical condition and with MMSE score <24 and were excluded from the study. All the subjects participated in the personal face to face interview after medically supervised withdrawal using alcohol or other drug (opioid) section of SSAGA-II(6) (revised in 1997) according to individual diagnosis of patient. The details of this instrument and the methods have been given in an earlier paper.(7) Since it was a retrospective recall study, questions were framed individually to trigger the recall with reasonable accuracy using anchor questions to memorable events, tagging the questions with specific examples and defining the technical terms.(8) All ratings were done by an investigator blind to the diagnosis and current status of the subjects. The data were statistically analyzed by means of T-test for descriptive variables and the Chi-squared test for categorical variables.

Why do we need to control alcohol use through legislative measures? A south east asia perspective?

Background:Even though prevalence of alcohol use in the world is very high, it has not been brought under legal control in several countries, contrary to other controlled substances like opium, cocaine, cannabis, and so on.Aim:To demonstrate the similarities in both alcohol and opioid dependence by comparing and contrasting the course of clinical dependence for both substances.Patients and Methods:Consecutively admitted patients during the period August 2005 to May 2006, in the Center for Addiction Psychiatry, Central Institute of Psychiatry, Ranchi, India, with ICD-10 (DCR) diagnosis of alcohol dependence syndrome or opioid dependence syndrome were recruited for the study and administered the alcohol or other drug (opioid) section of SSAGA-II, respectively, and the data was entered in the corresponding tally sheet.Results:The total sample size was 150, of which 112 consented to participate. Eighty-one (72%) were alcohol-dependent and 31 (28%) were opioid-dependent. Mean ages of the patients of alcohol dependence for opioid dependence was 35.16 ± 10.2 compared to 26.09 ± 5.65. Mean age of onset of alcohol and opioid use were similar (18.72 ± 6.84 and 20.73 ± 3.93 years, respectively). Patterns of dependence were also similar for both substances, from the first criteria to dependence (0.49 years for alcohol versus 0.64 years for opioids), and from the appearance of the second criteria to dependence (0.24 years versus 0.28 years).Conclusion:This study recommends alcohol to be treated on par with opioids and calls for legislations for the control of alcohol, uniformly, across the world, as a public health policy, on the lines of the Framework Convention for Tobacco Control.

PW01-217 - Gender differences in patients with alcohol dependence cortisol levels and stress-coping styles before and after alcohol withdrawal

Female and male alcohol dependent patients present an inhomogeneous group regarding to the drinking outcome. Stress, as well as stress-coping-styles are relevant predictive factors for the progress of alcohol dependence.MethodsSocial data, data of drinking behaviour, stress-styles and cortisol concentrations in plasma and cerebrospinal fluid (CSF) were measured in 130 patients with alcohol dependence (35F and 95M) before and after inpatient treatment.The age of onset alcohol dependence, the amount of alcohol consumption since last 3 months, the responsibility for education from children, living situation, and the practice of positive ore negative stress coping styles were investigated.ResultsFemale alcohol dependent patients show a significant higher age of onset for alcohol dependence (p=0.02) and have a significant lower consumption of alcohol in relation to male alcohol dependent patients (p=0.004).Moreover, female alcohol dependent patients are significant more frequent involved in education of children (p=0.04), and are living significant less alone (p=0.023).The cortisol levels in plasma and CSF between female and male alcohol dependent patients does not differ. However, female alcoholics show a significant higher score of negative stress-coping styles than male alcoholics (p= 0.023).ConclusionThere are significant psychosocial differences between female and male alcohol dependent patients. These gender specific differences relating to social stressors and handling with stress may be clinical relevant for treatment and outcome in alcohol-dependent patients.

Predicting drinking onset with discrete-time survival analysis in offspring from the San Diego prospective study

Previous research has shown that an early onset of drinking is associated with a range of problematic drinking outcomes in adulthood. However, earlier drinking is also linked to additional characteristics that themselves predict alcohol problems including male gender, a family history (FH) of alcoholism, age, race, parental alcoholism, depression symptoms, prior drug use, and conduct problems. This study tested the relationship between the age of first drink (AFD) and a range of risk factors that predict the onset of alcohol use. Participants were offspring from the San Diego Prospective Study (SDPS) who were at least 15 years old at the time of their most recent interview ( n = 147). Discrete-time survival analysis (DTSA) was used to relate multiple characteristics to the hazard function of alcohol onset across a relevant age range. The results demonstrated the predicted relationships to AFD for conduct problems, male gender, prior marijuana use, and a FH of alcoholism, even when these characteristics were estimated together. Furthermore, an interaction occurred such that offspring with both conduct problems and marijuana use were at substantially higher risk for alcohol use onset during this time period than would be predicted from the effect of these two risk factors alone. However, age at interview, ethnicity, parent education, and depressive symptoms did not predict the pattern of onset of drinking. Implications for future research and prevention efforts are discussed.

Socio-demographic risk factors for alcohol and drug dependence: the 10-year follow-up of the national comorbidity survey.

Continued progress in etiological research and prevention science requires more precise information concerning the specific stages at which socio-demographic variables are implicated most strongly in transition from initial substance use to dependence. The present study examines prospective associations between socio-demographic variables and the subsequent onset of alcohol and drug dependence using data from the National Comorbidity Survey (NCS) and the NCS Follow-up survey (NCS-2). The NCS was a nationally representative survey of the prevalence and correlates of DSM-III-R mental and substance disorders in the United States carried out in 1990-2002. The NCS-2 re-interviewed a probability subsample of NCS respondents a decade after the baseline survey. Baseline NCS socio-demographic characteristics and substance use history were examined as predictors of the first onset of DSM-IV alcohol and drug dependence in the NCS-2. A total of 5001 NCS respondents were re-interviewed in the NCS-2 (87.6% of baseline sample). Aggregate analyses demonstrated significant associations between some baseline socio-demographic variables (young age, low education, non-white ethnicity, occupational status) but not others (sex, number of children, residential area) and the subsequent onset of DSM-IV alcohol or drug dependence. However, conditional models showed that these risk factors were limited to specific stages of baseline use. Moreover, many socio-demographic variables that were not significant in the aggregate analyses were significant predictors of dependence when examined by stage of use. The findings underscore the potential for socio-demographic risk factors to have highly specific associations with different stages of the substance use trajectory.

A Finer Examination of the Role That Negative Affect Plays in the Relationship Between Paternal Alcoholism and the Onset of Alcohol and Marijuana Use

This study was designed to separately examine the relations between four fundamental components of negative affect (sadness, fear, guilt, and hostility) and the onset of substance use. An additional goal was to examine the potential mediating roles that these components of negative affect play in the relationship between paternal alcoholism and the initiation of substance use. The sample included 200 adolescents ages 15-19 years (62% girls; 68% white; 56% children of alcoholics [COAs]) and their fathers. The adolescents were followed up 5 years later when they were in early adulthood. Participants completed a clinical psychiatric interview and self-report questionnaires that assessed negative affect and substance use. Results from structural equation modeling indicated that higher levels of hostility and lower levels of guilt were associated with earlier substance-use initiation. In addition, hostility played an indirect role in the relationship between paternal alcoholism and the onset of marijuana use, with COAs reporting higher hostility levels than non-COAs and higher hostility predicting earlier marijuana use. These results underscore the importance of separately examining different components of negative affect when investigating the role that negative affect plays in substance use.

A Within‐Group Design of Nontreatment Seeking 5‐HTTLPR Genotyped Alcohol‐Dependent Subjects Receiving Ondansetron and Sertraline

Serotonergic mechanisms are associated with the development of alcohol dependence (AD), however, studies evaluating serotonergic medications have produced conflicting results. One hypothesis suggests that differential response may be due to a functional polymorphism of the 5-HTTLPR promoter region of the serotonin re-uptake transporter (5-HTT). The L/L genotype is postulated to be associated with early onset alcoholism and the S/S or S/L genotypes associated with late onset alcoholism. The aim of this study was to match and mismatch L/L, S/S, or S/L genotypes with administration of ondansetron and sertraline. Fifteen nontreatment seeking alcohol-dependent individuals were randomized to 1 of 2 counterbalanced arms to receive either 200 mg/d of sertraline or ondansetron 0.5 mg/d for 3 weeks followed by an alcohol self-administration experiment (ASAE), then received placebo for 3 weeks followed by a second ASAE. Participants then received the alternate drug for 2 weeks followed by a third ASAE. At the first ASAE compared to sertraline, ondansetron significantly improved drinking outcomes for the L/L genotype for the ASAE volume consumed (100% reduction based on between-subjects comparison, t = 2.35), and for drinks per drinking day during the 7 days prior to the ASAE (79% reduction and t = 4.34). Compared with ondansetron for S/S or S/L genotypes, outcomes at ASAE 1 for sertraline and S/S or S/L genotypes are opposite than hypothesized. Overall, subjects reduced drinking across their participation in the trial, as there appears to be an order effect. This study suggests that ondansetron may reduce alcohol consumption in alcohol-dependent individuals who have the L/L genotype as measured naturalistically and during the ASAE. By contrast there was no support that sertraline reduces alcohol use in individuals who have S/S or S/L genotypes. Evidence in the literature suggests that AD in some individuals may be influenced by a gene by socio-environmental interaction making pharmacological treatment with serotonergic drugs complex. Research must consider that typologies may predict successful treatment of AD in future trials.

Childhood sleep problems, early onset of substance use and behavioral problems in adolescence

Background Very few prospective studies examine the relationship between childhood sleep problems and subsequent substance use. In this study, we examined how sleep problems at ages 3–8 predicted onset of alcohol, cigarette, and marijuana use in adolescence. We also investigated the relationships between childhood sleep problems and adolescent internalizing and externalizing problems. Methods Study participants were 292 boys and 94 girls from a community sample of high risk families and controls in an ongoing longitudinal study. Results Controlling for parental alcoholism, sleep problems at ages 3-8 predicted onset of alcohol, cigarette, and marijuana use among boys and onset of alcohol use among girls. Childhood sleep problems were related to maternal ratings of internalizing and externalizing problems during adolescence for both boys and girls. Adjusting for these problems did not weaken the effects of sleep problems on onset of substance use. Conclusions This is to our knowledge the first study that prospectively examines gender differences in the relationship between sleep problems and early onset of substance use. Childhood sleep problems predicted early onset of substance use for boys but not girls. If childhood sleep problems indeed increase the probability of substance use onset, greater attention by parents to sleep problems in children and adolescents would potentially have ameliorative long-term effects. Parents are encouraged to explore different ways to help their children sleep better, including obtaining information and suggestions from their primary care physicians.

Percutaneous Ethanol Ablation of Hepatocellular Carcinoma: Periprocedural Onset Alcohol Toxicity and Pancreatitis Following Conventional Percutaneous Ethanol Ablation Treatment

A novel case of acute pancreatitis in a patient treated with percutaneous ethanol injection (PEI) ablation for hepatocellular carcinoma is described. The most commonly reported adverse effects of PEI are hepatic or peritoneal hemorrhage, hepatic insufficiency or infarction. There are no previous reports of fatal acute pancreatitis as a result of conventional PEI.

Violence-Related Behaviors Among Dominican Adolescents: Examining the Influence of Alcohol and Marijuana Use

ABSTRACT This study identified the predictors of youth violence and violent victimization among a sample of Dominican adolescents (N = 155) attending high school in a northeastern urban community. As part of a broader community-based needs assessment, students participated in an evaluation of a substance abuse prevention program funded by the Substance Abuse and Mental Health Services Administration. Correlations, principal components, multiple imputation, and stepwise regression analyses were systematically employed to develop a parsimonious model for predicting violence-related behaviors among Dominican youth. Findings suggest that early onset of alcohol and marijuana use was associated with an increased likelihood of engaging in violence-related behaviors or being the victim of a violent act. In addition, students who reported a lowered sense of safety were more likely to be involved in acts of violence. However, adolescents who reported depressive symptoms were less inclined to become involved in violence-related behaviors. Implications for culturally-tailored violence and substance abuse prevention programming efforts are discussed.

Violations of the usual sequence of drug initiation: prevalence and associations with the development of dependence in the New Zealand Mental Health Survey.

For 3 decades, studies have reported that the usual sequence of drug initiation is licit drugs, then cannabis, and then other illicit drugs. This article describes the prevalence of violations of this sequence, the predictors of violations, and the relationship between violations and the onset of alcohol or drug dependence. The New Zealand Mental Health Survey is a nationally representative sample with 12,992 face-to-face interviews carried out in 2003-2004. The response rate was 73.3%. The World Health Organization Composite International Diagnostic Interview (CIDI 3.0) was used in the survey. Reports of the age at first use were obtained for alcohol and drugs but not for smoking. Violations of the usual sequence of drug initiation were uncommon in the population (2.6%). Use of other illicit drugs before cannabis was the main violation, found in 2.3% of alcohol users, 3.0% of cannabis users, 8.6% of cocaine users, and 16.7% of those who had used other illicit drugs. Use of other illicit drugs before cannabis was more predominant in younger cohorts and those with more early-onset internalizing disorders. Violations had little association with the development of dependence in users when other important predictors such as age at onset of use and the number of illicit drugs used were taken into account. Internalizing disorders and early-onset bipolar disorder also predicted dependence. In New Zealand, violations of the gateway sequence are not common and they are not markers of progression to dependence.