(164) Educational Attainment Levels Shape Substance Use, Disorder Risk, and Care Access

Background & Introduction: Educational attainment is a critical social determinant of health but remains underexplored in substance use disorders. Lower attainment is often linked to socioeconomic disadvantages, such as inadequate insurance and residence in under-resourced areas, which restrict timely access to treatment (Lin et al., 2024). Lower health literacy, strongly dependent on education, is associated with delayed care-seeking, higher treatment attrition, and increased risk for complications, overdose, and death (Coughlin et al., 2020; Rolova et al., 2021). Individuals with lower educational attainment also exhibit higher medical mistrust (Carletto et al., 2025).

These disparities are starkly evident in the opioid crisis. A cross-sectional study of 912,057 overdose deaths found that from 2018–2021, mortality rose by 35.4 per 100,000 among those without a high school diploma compared with 1.5 per 100,000 for those with a bachelor’s degree, a pattern consistent across demographic groups (Powell, 2023). Education also influences alcohol outcomes: higher attainment is linked to more frequent use but less binge drinking and ~50% lower dependence risk (Rosoff et al., 2021).

Prior research has emphasized mortality, leaving gaps regarding substance-specific patterns, treatment engagement, and perceived barriers. This study analyzes how educational attainment influences substance use prevalence, disorder severity, treatment, and perceived barriers to care.

Methods: We conducted a cross-sectional analysis using pooled 2022–2023 data from the National Survey on Drug Use and Health (NSDUH), a nationally representative survey administered annually by the Substance Abuse and Mental Health Services Administration. The analytic sample was restricted to respondents aged 18 or older (N=92,233 unweighted; weighted N=256,912,007), of whom 48.7% were male and 61.4% identified as Non-Hispanic White. Individuals experiencing homelessness, serving in the active-duty military, or living in institutional group settings were excluded, consistent with NSDUH methodology.

Primary outcomes included past-year alcohol and drug use, substance use disorder (SUD) diagnosis and severity, receipt of screening or treatment, and perceived barriers to treatment engagement. SUDs were classified according to DSM-5 criteria, with severity categorized as mild (2–3 criteria), moderate (4–5), or severe (≥6). Specific SUD prevalence estimates included alcohol, cannabis, opioids (heroin or prescription pain relievers), and stimulants (cocaine, methamphetamine, or prescription stimulants).

Key explanatory variables included highest educational attainment, categorized as less than high school, high school graduate, some college/associate’s degree, or college graduate. Multivariable logistic regression models (utilizing R), adjusted for age, sex, race/ethnicity, marital status, income, insurance, and urbanicity, were used to assess associations between education and substance use, disorder risk, and treatment outcomes.

Results: The weighted analytic sample represented 256,912,007 U.S. adults (48.7% male; 61.4% Non-Hispanic White). Differences across education levels were significant (p < 0.001) for all sociodemographic characteristics. Overall, 71.1% reported past-year alcohol or drug use, and 24.4% met DSM-5 criteria for a substance use disorder (SUD). Among those with SUD, 16.8% met criteria for both alcohol and drug use disorders (AUD+DUD), 47.0% for AUD only, and 36.2% for DUD only; 22.7% met criteria for severe SUD. Only 14.3% of respondents with SUD received treatment, while 23.7% were screened for alcohol and 35.3% for drug use by a healthcare provider.

Adjusted models showed that compared to less than high school, higher education was associated with greater odds of any substance use (college graduate adj.OR=2.8, 95% CI: 2.4–3.2) but lower odds of SUD (adj.OR=0.63, 95% CI: 0.54–0.73). Severe SUD,and treatment receipt were less common among college graduates. Screening was lowest among the most educated. Barriers varied: less-educated respondents more often cited logistical challenges, while college graduates reported stigma, privacy concerns, and ambivalence. These findings demonstrate distinct education-related disparities in substance use patterns, disorder severity, screening, and treatment engagement.

Screening patterns also differed by education: college graduates were significantly less likely to report past-year alcohol or drug screening compared to those with less than high school education. Perceived treatment barriers varied across education levels. Logistical challenges, including transportation, childcare, and appointment timing, were more frequently reported by less-educated individuals. In contrast, stigma, privacy concerns, and ambivalence about treatment were more prominent among college graduates. These findings suggest that while higher education is protective against meeting SUD criteria and severe disorders, it may also be linked to underutilization of available treatment services. Addressing these distinct barriers will require tailored strategies to improve treatment engagement across educational strata.

Conclusion & Discussion: This study underscores the complex role of educational attainment in shaping substance use patterns, disorder severity, and treatment engagement. Lower education was associated with higher rates of drug use disorders and severe SUDs, while higher education conferred some protection but did not eliminate barriers to care. Across all education levels, many individuals reported forgoing treatment because they believed they could manage the problem independently, reflecting attitudinal barriers such as self-reliance and denial of need. Stigma also emerged as a deterrent, with concerns about privacy, judgment, and discrimination discouraging treatment initiation. These findings align with prior research emphasizing the impact of both public and provider stigma on healthcare engagement.

Barriers differed by education: logistical obstacles such as transportation and scheduling were more common among less-educated individuals, whereas stigma, ambivalence, and privacy concerns were more frequently endorsed among college graduates. Misconceptions about treatment—such as the belief that it requires abstinence or residential rehabilitation—further limited engagement across groups.

These results highlight the need for equity-oriented, education-sensitive interventions. Strategies should include patient-centered care models, stigma-reduction training for providers, and public health messaging tailored to distinct belief systems. Limitations include the cross-sectional design, reliance on self-report, and exclusion of high-risk groups, which may underestimate disparities.

References: Center for Behavioral Health Statistics and Quality. 2023 National Survey on Drug Use and Health (NSDUH): Methodological Summary and Definitions. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2023.

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Lin C, Cousins SJ, Zhu Y, Clingan SE, Mooney LJ, Kan E, Hser YI. A scoping review of social determinants of health’s impact on substance use disorders over the life course. J Subst Use Addict Treat. 2024;166:209484. doi:10.1016/j.josat.2024.209484

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