Divergent Pathways to Care: Predictors of Substance Use Disorder Treatment, Unmet Treatment Need, and Mental Health Treatment Among Emerging Adults with Alcohol Use Disorder

Background and Purpose: Alcohol use disorder (AUD) prevalence peaks during emerging adulthood, yet fewer than 11% receive treatment annually, highlighting a profound gap between clinical need and accessed care. A critical gap also exists in how service utilization and unmet need diverge across behavioral health sectors for emerging adults with AUD. Guided by Andersen’s Behavioral Model of Health Service Use, this study examines how predisposing, enabling, and need factors predict three pathways: (1) substance use disorder (SUD) treatment, (2) unmet SUD treatment need, and (3) mental health (MH) treatment.

Methods: We analyzed pooled 2022–2023 National Survey on Drug Use and Health data among emerging adults ages 18–29 with past-year DSM-5 AUD (N=5,302). Predictors included predisposing (demographics, religiosity, risk perceptions), enabling (income, insurance), and need (AUD severity, psychological distress, major depressive episode [MDE]) factors. Outcomes were SUD treatment receipt, perceived unmet SUD treatment need, and MH treatment receipt (all past-year). Multivariable logistic regressions were estimated for each outcome with significance set at p<.05.

Results: 10.8% (n=575) of the sample received SUD treatment, 5.6% (n=296) reported unmet need, and 27.2% (n=1,444) received MH treatment. Need factors were the strongest predictors: compared to mild AUD, severe AUD increased odds of SUD treatment (OR=4.75), unmet need (OR=4.90), and MH treatment (OR=1.52); past-month distress and past-year MDE were associated with higher odds across outcomes, with MDE tripling the odds of receiving MH treatment (OR=3.17). Predisposing factors were associated with divergent pathways: college attendance decreased SUD treatment (OR=0.74) but increased MH treatment (OR=1.38). Racial inequities were stark: Native American/Alaska Native participants had twice the odds of unmet need (OR=2.05) vs. White peers. Black (OR=0.55), Hispanic (OR=0.63), Native Hawaiian/Pacific Islander (OR=0.13), and multiracial (OR=0.73) participants were less likely than White peers to receive MH treatment. Women (OR=2.00 vs. men) and those valuing religion (OR=1.24) had higher MH and SUD treatment odds, respectively; those aged 26–29 (OR=2.01 vs. 18–20) reported greater unmet need. Alcohol risk perceptions indicated a service-fit mismatch: perceiving episodic heavy drinking (5+ drinks weekly) as harmful predicted greater SUD treatment (OR=1.60), whereas perceiving chronic drinking (around 4–5 drinks daily) as harmful predicted lower SUD treatment (OR=0.69) but higher unmet need (OR=1.58). Enabling factors were associated with SUD treatment: full-year insurance increased it (OR=1.42), while higher income decreased it (OR=0.94).

Conclusions and Implications: Findings indicate that service pathways for emerging adults with AUD do not reliably translate clinical need into appropriate care. Consistent with Andersen’s model, predisposing, enabling, and need factors shape distinct trajectories, with need factors most influential. Service use reflects a recognition–access gap, whereby greater AUD burden increases both SUD treatment use and unmet need. Similarly, recognizing harms of chronic drinking is linked to unmet need rather than treatment. Our results also suggest that MH services may be a more accessible entryway. However, sociodemographic patterns reveal inequities in access to both SUD and MH care. These findings highlight the need for low-threshold, integrated behavioral health approaches that better align with emerging adults’ help-seeking patterns and prioritize racial equity.