Substance Use and Psychological Distress Among U.S. Young Adults: Patterns and Sex Differences In the 2023 National Survey on Drug Use and Health

Background and Purpose

Young adults in the United States remain at high risk for substance use. National data show elevated use of alcohol, cannabis, nicotine products, and other drugs among those aged 18-25. Past research documents sex differences in substance use and a strong link between psychological distress and substance-related outcomes. However, many studies focus on single substances, broad age groups, or small samples. Few studies examine multiple substances within a nationally representative young adult sample. This study addresses these gaps using a recent national dataset. We examine three aims. First, we identify the most commonly used substances among U.S. young adults ages 18-25. We estimate prevalence overall and by sex. Second, we assess key correlates of substance use. Third, we test whether sex moderates the relationship between psychological distress and substance use outcomes.

Methods

Data were drawn from the 2023 National Survey on Drug Use and Health (NSDUH). The analytic sample includes 13,587 young adults, representing a weighted population of 34,033,146. We estimated survey-weighted prevalence of past-year use for alcohol, marijuana, nicotine vaping, tobacco, hallucinogens, cocaine, opioids, and methamphetamine. We then fit survey-weighted logistic regression models for five substance use outcomes: alcohol, marijuana, cocaine, nicotine vaping, and opioids. Models adjusted for sex, education, income, employment, and psychological distress (measured using the Kessler Psychological Distress Scale). Interaction terms were then estimated to test whether sex moderates associations between psychological distress and each substance use outcome.

Results

Alcohol was the most commonly used substance. It was slightly more prevalent among females than males (69.3% vs. 66.5%). Marijuana use was similar across sexes (37.1% males vs. 35.8% females). Male participants reported a higher use of tobacco (32.6% vs. 19.0%), hallucinogens (7.4% vs. 5.9%), and cocaine (3.6% vs. 2.7%). Opioid use was comparable across males (2.7%) and females (2.8%). Methamphetamine use was rare in both groups (less than 0.5%). Psychological distress was associated with higher odds of all substance use outcomes (adjusted odds ratios: 1.02 for alcohol, 1.04 for marijuana, 1.10 for cocaine, 1.04 for nicotine vaping, and 1.11 for opioids). Higher income was associated with lower odds of using marijuana, nicotine, and opioids. Employment was associated with lower odds of marijuana, alcohol, and nicotine use. Education was associated with higher odds of alcohol and cocaine use but lower odds of nicotine vaping. Interaction results showed that sex moderated associations between psychological distress and opioids and marijuana use. No significant moderation was found for other substances.

Conclusions and implications

Findings highlight the need for integrated mental health and substance use care for young adults. Psychological distress is consistently associated with increased risk across substances, supporting routine screening and early intervention. Sex differences vary by substance, suggesting targeted, substance-specific prevention rather than one-size-fits-all approaches. Structural factors such as poverty and employment also matter, underscoring the need for policy actions to address social determinants. Addressing these needs can improve young adults’ well-being, strengthen equitable access to care, and support full participation in society, ultimately advancing the common good and democratic engagement.