Characterizing substance users and risk profiles across treatment centers: insights from Iran

Abstract

Background

Substance use remains a pressing global public health concern and has shown a marked increase in recent years. This study investigates the characteristics and risk behaviors of individuals who use substances across various treatment centers in the city of Kerman, Iran.

Methods

This descriptive cross-sectional study was conducted in May 2023 across multiple treatment centers in Kerman. A total of 470 participants were recruited from Methadone Maintenance Treatment (MMT) centers, Therapeutic Community (TC) centers, Article 16 compulsory treatment centers, and Drop-in Centers (DICs). Data were collected using the Maudsley Addiction Profile (MAP) questionnaire and laboratory tests, and analyzed using STATA software.

Results

Ninety percent of participants were male, with the most common age range being 26 to 45 years. More than 70% reported initiating substance use after the age of 18. Approximately 64.89% had attempted to stop using substances fewer than two times, while 13.62% had made more than six unsuccessful attempts. Patterns of alcohol, opium, and methamphetamine use varied across treatment settings. The highest rates of syringe sharing, unprotected sexual activity, and criminal activity were reported in the Article 16 center, whereas MMT centers reported the highest levels of spousal conflict. TC centers had the lowest levels of methamphetamine and morphine use.

Conclusion

The majority of participants were male and began using substances after the age of 18. Patients in the Article 16 center exhibited the highest levels of high-risk behaviors, including injection-based substance use, unprotected sexual activity, and criminal involvement. In contrast, MMT centers showed the highest levels of familial conflict, and TC centers had the lowest prevalence of methamphetamine and morphine use. These findings highlight the need for context-specific harm reduction and treatment strategies tailored to the distinct substance use patterns and risk profiles within each treatment setting. Given the structural and demographic differences—such as voluntary enrollment in MMT versus mandated treatment in Article 16—comparative interpretations should remain descriptive and cautious.

Background

Substance use remains a significant global public health issue. In 2021, one in every 17 individuals aged 15–64 had used an illicit substance in the past year. The estimated number of people who use substances increased from 240 million in 2011 to 296 million in 2021, accounting for 5.8% of the global population in this age group—a 23% rise, partly attributed to population growth [1, 2].

According to the 2019 United Nations Office on Drugs and Crime (UNODC) report, approximately 35 million individuals worldwide experience substance use disorders. Among the estimated 11 million people who inject substances globally, the prevalence of HIV is 12.7%, hepatitis C is 50.9%, and HIV/HCV co-infection is 10.9%. Substance injection has been reported in 148 countries, and 120 of these have reported HIV transmission in this population [3].

In the Middle East and North Africa (MENA), the 2016 UNAIDS report indicated that, as of 2015, approximately 230,000 individuals were living with HIV, with 28% of new cases attributed to substance injection [4]. Given the harmful physical, psychological, cognitive, and social consequences of opioid use, addressing substance use is a pressing priority [5].

Globally, two dominant approaches have emerged in response to substance use: the"war on drugs"and harm reduction. The former, which gained traction in the 1970 s, promoted a punitive strategy aimed at eradicating production, trafficking, and consumption of illicit substances [6, 7]. Many countries adopted strict drug control policies that consumed vast financial and legal resources. Despite these efforts, global trends showed continued increases in substance use. In response, harm reduction approaches were developed to reduce the adverse health, social, and economic consequences of substance use without necessarily eliminating use itself. This pragmatic, health-centered approach has since gained momentum in many countries, including Iran [7,8,9,10,11].

Substance use poses a major public health concern in Iran, where the prevalence of several substances is notably high. Per 100,000 population, estimated use rates are approximately 150 for opium, 660 for opium paste, 590 for crystal methamphetamine, 470 for hashish, and 350 for heroin [12, 13]. Iran’s geographic location—sharing 1,800 km of borders with Afghanistan and Pakistan, the world’s primary producers of opium and heroin—places it directly along the East–West drug trafficking route [14], thereby increasing its exposure to the harms associated with trafficking and substance availability [15].

National data indicate a growing burden of substance use disorders in Iran. The estimated prevalence rose from 1.61% in 1990 to 1.97% in 2017. Over the same period, mortality due to substance use increased from 2.25 to 3.68 per 100,000 population, and disability-adjusted life years (DALYs) climbed from 668.48 to 871.73 per 100,000 population [3].

Like many other countries, Iran initially implemented punitive drug control strategies. However, in 2004, the country began shifting toward harm reduction. Under Iran's anti-narcotics law, substance use is legally classified as a crime. Nevertheless, individuals with substance use disorders may seek treatment and rehabilitation at licensed facilities—affiliated with the Ministry of Health and the Welfare Organization—without facing legal prosecution during the treatment period. Most individuals attend these centers voluntarily, except for those referred to Article 16 centers. The treatment network includes Methadone Maintenance Treatment (MMT) centers, Drop-in Centers (DICs), Therapeutic Communities (TCs), and Article 16 compulsory residential facilities [10, 16].

These treatment modalities differ in structure, target populations, and admission procedures. MMT centers primarily serve individuals with opioid dependence through long-term outpatient methadone therapy. DICs provide low-threshold harm reduction services—such as sterile syringes, basic medical care, and psychosocial support—to high-risk and marginalized populations, including people who inject drugs (PWID) and individuals experiencing homelessness. TCs are peer-led residential programs designed for individuals with chronic or severe substance use disorders. In contrast, Article 16 centers are compulsory residential facilities mandated by the judiciary for individuals arrested for substance-related offenses. This form of legally enforced treatment is relatively rare internationally and reflects Iran’s integrated approach to managing substance use. These centers typically implement either detoxification or maintenance therapy protocols [17].

In recent years, the number of individuals receiving substance use treatment in Iran has risen significantly. From 2017 to 2022, the number of clients at licensed treatment centers increased from 486,460 to 659,031. During the same period, admissions to voluntary programs grew from 1,254,704 to 1,570,256, while admissions to Article 16 centers increased from 82,665 to 132,937 [18].

Ongoing monitoring of substance use trends is essential for policymakers aiming to implement evidence-based interventions and enhance outcomes such as social functioning—a key indicator of treatment effectiveness. Although prior studies in Iran have examined outcomes within individual treatment modalities, such as methadone programs or harm reduction services [1,2,3,4,5], comparative research across the spectrum of treatment settings—including both voluntary and compulsory programs—remains limited. Internationally, data on compulsory residential treatment centers like Iran’s Article 16 facilities are also scarce, particularly in low- and middle-income countries.

This study aims to address these gaps by providing a comprehensive profile of individuals receiving care at MMT centers, TCs, DICs, and Article 16 centers in Kerman, Iran. Specifically, it examines substance use patterns, health-related risk behaviors, social functioning, and criminal activity, disaggregated by treatment modality. These findings may support the development of tailored harm reduction and treatment strategies that reflect the unique risk profiles and structural contexts of each setting—including factors such as history of incarceration, primary substance of use, and the nature of admission (voluntary vs. compulsory).

Methods

Study design and setting

This descriptive cross-sectional study was conducted in May 2023 across four types of treatment centers in Kerman Province, Iran: Methadone Maintenance Therapy (MMT) centers, Therapeutic Communities (TCs), Drop-in Centers (DICs), and Article 16 compulsory residential centers. Kerman, the largest province in Iran, includes both Kerman and Bam counties—selected because they are the only locations with operational TC centers. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.

Study population and sampling

The study population comprised individuals newly admitted to selected treatment centers in Kerman. Sampling followed the World Health Organization (WHO) guidelines for evaluating substance use treatment programs [15], which recommend a minimum of 100 participants per treatment modality to ensure statistical reliability and data consistency. Centers with fewer than 30 clients were excluded.

Using Cochran’s formula for an unknown population size, with a 95% confidence level (Z = 1.96), a 5% margin of error, and an assumed prevalence of 0.5, the minimum sample size was estimated at 384. To allow for subgroup analysis and potential non-response, the target sample size was increased to 470 participants.

A stratified convenience sampling approach was used across the four treatment modalities. The final sample included 220 participants from MMT centers, 101 from DICs, 101 from Article 16 centers, and 48 from TCs. Only newly admitted individuals were included to minimize recall bias. Among the eligible population approached, 23 individuals refused to participate, resulting in a participation rate of approximately 95%.

Although WHO guidelines recommend at least 100 participants per treatment type, the number of eligible individuals in TC centers was limited. All 48 eligible individuals from TC centers were included, exceeding the minimum acceptable threshold of 30 participants for subgroup validity.

Sampling strategy

In addition, for each treatment modality, the target proportion of male and female participants was aligned with the sex distribution of clients served in the previous year. This was considered in center selection and sampling to reflect real-world beneficiary profile. In Kerman's five urban regions, two MMT centers were randomly selected per region; in one region with only one eligible MMT center, nine MMT centers were ultimately included. All DIC, TC, and Article 16 centers in Kerman were included. Due to limited enrollment in Kerman’s TC center, the TC center in Bam was also included. It is important to note that, during the study period, Therapeutic Community (TC) and Article 16 centers in Kerman were authorized to admit only male clients. No female-only TC or Article 16 centers were operational in the region at the time of data collection.

Included Centers.

A total of 15 centers were included: nine MMT centers, three DICs, one Article 16 center, and two TC centers (one in Kerman and one in Bam).

Eligibility Criteria.

Participants met the following criteria:

Aged 18 years or older.

Newly admitted to one of the selected centers.¹

Provided informed consent.

Individuals who had already begun treatment or declined consent were excluded.

Data collection tools

Data were collected using the Maudsley Addiction Profile (MAP) questionnaire [16, 17] and urine toxicology tests using Abon kits, capable of detecting substances such as morphine and cocaine. The MAP was selected due to its validated structure and multidimensional assessment of functioning among individuals with substance use disorders. It has been widely implemented in both clinical and research settings internationally and is considered suitable for capturing behavioral and psychosocial information relevant to this population.

The MAP is a structured, interviewer-administered questionnaire composed of four key domains: (1) substance use patterns, (2) health-risk behaviors, (3) physical and psychological health, and (4) social functioning. It uses a combination of frequency-based and categorical items, with a primary focus on behaviors and symptoms experienced during the past 30 days.

The psychometric properties of the MAP have been rigorously evaluated in various populations and contexts. Studies have reported high internal consistency (Cronbach’s alpha up to 0.96), strong test–retest reliability, and acceptable levels of content, construct, and criterion validity [19,20,21]. Urine tests were administered by licensed psychologists or authorized personnel at each center to verify self-reported substance use data. All MAP interviews were conducted face-to-face with patients by trained in-house psychologists either on the day of admission or immediately afterward. Data were collected directly from the patients, not extracted from medical records. This ensured real-time self-reporting and minimized recall bias.

Definitions of key variables

Unprotected sex: Engaging in sexual activity without condom use within the past 30 days.

Syringe sharing: Use of injection equipment (e.g., syringes or needles) that had previously been used by another person, assessed over the past 30 days.

Criminal activity and interpersonal conflict: Operationalized according to the Maudsley Addiction Profile (MAP) guidelines.

Data analysis

All analyses were performed using STATA version 15. Descriptive statistics and chi-square tests were used, with significance set at p < 0.05. It is important to note that the treatment centers serve distinct populations: individuals in MMT centers generally seek treatment voluntarily, while those in Article 16 centers are mandated by judicial order. These structural differences were carefully considered in interpreting results (Fig. 1).

Fig. 1

Final sample size and number of included centers by treatment modality

Findings

Based on Table 1, 90% of the study participants were male. The majority of individuals receiving treatment services were between 26 and 45 years of age. Approximately 70% of the sample reported initiating substance use after the age of 18. Friends were the most commonly cited source of substance exposure, with nearly 41% indicating that their friends had a history of substance use.

Table 1 Frequency distribution of demographic variables by treatment modality

About 64.89% of participants had attempted to stop using substances fewer than two times prior to seeking treatment, while 13.62% had made more than six unsuccessful attempts. Notably, 25% of individuals in the TC group had attempted to quit more than six times.

Only 3% of participants reported a history of injection-based substance use. Among the treatment modalities, the transitional model—referring to the Article 16 centers—had the highest proportion of participants with such a history (approximately 10%).

Nearly 29% of participants reported a history of incarceration. This was most prevalent among those in the Article 16 centers (53.47%), whereas the lowest rate was observed among individuals receiving treatment at MMT centers.

Previous treatment experience varied significantly across treatment settings (p < 0.000). More than half of the participants in TC centers (56.25%) reported prior treatment episodes, compared to 40.9% in MMT centers, 36.63% in Article 16 centers, and only 19.8% in DICs. These differences likely reflect the unique patient pathways and structural characteristics of each treatment setting. TC centers may serve individuals with persistent or recurrent substance use challenges who require structured and repeated interventions. MMT clients, who often voluntarily seek opioid substitution therapy, may already be engaged with the treatment system. DICs function as low-threshold, harm reduction facilities and are often accessed by first-time or socially marginalized individuals. The compulsory nature of Article 16 centers may result in a more heterogeneous population, including both first-time and repeat treatment seekers.

Table 2 presents the primary substances reported by participants across treatment centers. Opium or opium paste was the most frequently reported substance overall, particularly among individuals receiving care at MMT centers (68.2%). Heroin use was most prevalent among participants in DICs, accounting for 30.7% of cases. Methamphetamine was notably common among individuals in Article 16 centers, with a prevalence of 22.8%. Other substances—including cannabis, crack, marijuana, and illicit methadone—were reported at lower frequencies across all treatment modalities.

Table 2 Primary substance used by participants across treatment modalities

According to Table 3, only 6.8% of study participants reported alcohol consumption in the past 30 days. The highest prevalence of alcohol use was observed among individuals in Therapeutic Community (TC) centers (14.5%), while the lowest was among participants attending Methadone Maintenance Therapy (MMT) centers. More than half of the sample reported opium or opium paste use in the past 30 days, with the highest prevalence among individuals in MMT centers (65%). The lowest prevalence was observed in Article 16 centers (27.72%). For heroin use, the highest reported rates were found in Article 16 centers, while the lowest were among participants in MMT centers (18.18%).

Table 3 Frequency of substance use in the past 30 days by treatment modality

Approximately 12% of participants reported using prescribed methadone in the past 30 days. Prior to entering treatment, individuals in community-based programs (e.g., DICs) reported higher use of prescribed methadone, with 25% indicating use, while the lowest rate was observed in MMT centers (8.18%). About 21% of participants reported using unprescribed methadone in the past 30 days. This was most common among those in TC centers (33.66%) and least common among individuals in Article 16 centers.

Among the substances assessed, marijuana showed relatively higher prevalence, with 10.6% of participants reporting use. Article 16 centers had the highest rate of marijuana use, while the lowest was again observed in MMT centers. Approximately 75% of participants did not report using crystal methamphetamine in the past 30 days. However, among treatment modalities, the highest rate of crystal methamphetamine use was observed in TC centers (42.57%), and the lowest in MMT centers (11.82%).

According to Table 4, only 0.43% of participants—equivalent to two individuals—reported injecting substances using a shared syringe within the past 30 days. Both cases occurred in the Article 16 center, and no injection-related substance use was reported in any other treatment settings.

Table 4 Frequency of health risk behaviors, social functioning, and criminal activity by treatment modality (past 30 days)

Approximately 13% of participants reported engaging in unprotected sexual activity, with the highest incidence among those at the Article 16 center. The lowest rate was reported among individuals attending Therapeutic Community (TC) centers.

Around 29.15% of participants reported experiencing conflict with their spouse or partner during the past 30 days. This was most prevalent among individuals receiving methadone therapy (35.91%) and least common among those in TC centers.

About 12.7% of participants reported involvement in drug dealing within the past 30 days. The highest rate was reported among individuals in Article 16 centers (27.72%), while the lowest rate (1.8%) was observed in MMT centers.

With regard to other high-risk or criminal behaviors, the following proportions were reported: theft from shops (3.4%), rights violations (4.26%), car theft (1.49%), car burglary (2.34%), physical altercations or disputes (10.64%), and extortion (2.98%). Patients in Article 16 centers had the highest rates of shoplifting, interpersonal conflict, and extortion, while those in TC centers showed higher rates of rights violations and car theft. Notably, the highest incidence of car theft was observed among participants in Detox centers.

According to Table 5, no positive urine tests for cocaine were observed among participants across treatment centers, indicating no detectable use of this substance in the sample. Amphetamine was detected in 30.2% of participants, with the highest positivity rate observed among individuals in Article 16 centers (54.46%).

Table 5 Urinalysis results by treatment modality

Methamphetamine was detected in 31.9% of urine samples, while cannabis was found in 14.2%. The highest methamphetamine positivity was observed in Article 16 centers (62.3%), whereas MMT centers had the lowest rate (18.64%).

Methadone was detected in 39.3% of samples overall, with the highest detection rate in Article 16 centers (83.17%) and the lowest in TC centers (14.58%).

Morphine was present in 81.06% of participants'samples. The highest morphine positivity was recorded in Article 16 centers (93.07%), while the lowest was reported among individuals attending TC centers (39.58%).

Discussion

This study provides a comprehensive overview of substance use characteristics and risk behaviors across multiple treatment centers in Kerman, Iran. Notably, 90% of participants were male, in contrast to findings by Luty et al., where 63% of participants were male This discrepancy may be explained by the male-only admission policies at TC and Article 16 centers in Kerman at the time of data collection, although Article 16 centers in other regions may admit female patients [23,24,25].

In addition to structural admission policies, factors such as stigma, social judgment, and cultural norms surrounding substance use among women may have contributed to their underrepresentation in this study. These factors can discourage women from seeking treatment or accessing available services, particularly in formal or residential settings. A key finding was that 41% of participants cited peer influence, particularly from friends, as a major factor in initiating substance use, emphasizing the importance of social networks—a pattern also noted by Jatau et al. [26] and Daneshmandan et al. [27].

Regarding treatment history, 64.89% of participants had attempted to quit fewer than two times before seeking treatment, while 13.62% had made more than six unsuccessful attempts. Among those in TC centers, 25% had attempted to quit more than six times, suggesting that these programs may attract—or be better suited for—individuals with chronic substance use patterns and multiple prior relapses. These results align with the notion that persistent substance use may require more structured or intensive interventions.

The variation in quit attempts compared to findings such as those of You et al. [28], who reported a 38% relapse rate, may reflect differences in population characteristics or treatment modalities. Notably, 25% of individuals in TC centers had attempted to quit more than six times, suggesting that this modality may be more appropriate for individuals with multiple prior relapses who require additional support. Future research should further investigate the impact of different treatment modalities on individuals with repeated quit attempts, focusing on factors that influence treatment success or failure.

Importantly, the study revealed substantial variation across treatment settings, with each center serving a distinct population. For example, injection substance use was most frequently reported in Article 16 centers (10%), while DICs, as noted by Moradi et al. [29], have historically catered to high-risk populations, including people who inject drugs (PWID), individuals experiencing homelessness, and sex workers. Such variations highlight how structural factors—such as referral mechanisms, admission criteria, and the voluntary or compulsory nature of care—shape the characteristics and risk profiles of treatment clients.

Nearly 29% of participants had a history of incarceration, with the highest proportion (53.47%) observed in Article 16 centers. These facilities also reported the highest levels of high-risk behaviors, including injection with shared syringes (0.43% overall, both cases in Article 16), unprotected sexual activity, and involvement in drug dealing (27.72%). These findings likely reflect the involuntary nature of treatment in Article 16 centers, where clients are referred through the judicial system and may represent more marginalized or criminalized populations with advanced substance use issues.

The higher prevalence of injection substance use in Article 16 centers may also relate to greater social vulnerability and severity of dependence. Many individuals in these settings are apprehended in high-risk environments—such as public spaces or during drug-related arrests—where injection may be more common due to the type of substance used and availability. This underscores the importance of integrating harm reduction strategies into compulsory treatment, including safe injection education and access to sterile syringes [17], as similarly observed in high-risk populations studied by DesLauriers et al.[30].

The elevated rates of high-risk behaviors—such as drug dealing, syringe sharing, and unprotected sex—observed in Article 16 and DIC settings can be attributed to the vulnerable populations these centers serve [31, 32]. Article 16 centers typically admit individuals through legal mandates, often following criminal offenses, which may explain higher rates of shop theft, extortion, and interpersonal conflict. DICs, as low-threshold harm reduction services, frequently serve individuals who use drugs, those experiencing homelessness, and sex workers [33, 34]. These contextual factors likely contribute to the increased prevalence of conflict, high-risk sexual behaviors, and minor criminal offenses in these settings. Addressing these issues requires integrated interventions that combine substance use treatment with legal support, psychosocial care, and housing assistance [34, 35].

Spousal conflict was reported by nearly one-third of participants, with the highest incidence among those receiving methadone therapy. This may reflect the psychosocial challenges patients face in balancing family dynamics with the demands of long-term medication-assisted treatment. These findings suggest a need to integrate family counseling into MMT programs to reduce interpersonal tensions. [36]. In line with this, Liu et al. [37] reported that family relationships improved in only 23.1% of MMT patients.

Participation in drug dealing was reported by 12.7% of participants overall, with a disproportionately high rate among clients in Article 16 centers (27.72%). This may reflect socioeconomic vulnerability and the continuation of illegal activity due to limited employment opportunities [17]. Similarly, Werb et al. [38] found that compulsory treatment was associated with poor outcomes and a higher likelihood of recidivism.

Other criminal behaviors—including theft from shops, rights violations, theft from cars, vehicle theft, interpersonal conflict, and extortion—were less prevalent overall but were concentrated in certain centers. For example, patients in Article 16 centers reported higher rates of shop theft, extortion, and interpersonal violence, while those in TC centers showed higher rates of rights violations and vehicle theft. These findings highlight the need for center-specific intervention strategies tailored to the criminogenic and behavioral profiles of each patient population.

Overall, these findings highlight the heterogeneity of risk behaviors across treatment centers and underscore the critical need for comprehensive, individualized psychosocial interventions—particularly in settings such as Article 16 centers, where multiple high-risk behaviors frequently co-occur.

Moreover, drug screening results varied significantly across treatment modalities. While no positive tests for cocaine were recorded—possibly due to its high cost and limited availability in Iran [1, 39, 40]—positive results for amphetamines and methamphetamines were most prevalent among clients in Article 16 centers (54.46% and 62.3%, respectively), and least common among those in MMT centers (18.64%), reflecting patterns previously observed in Tehran [41].

These differences emphasize the importance of interpreting findings within the structural and operational context of each treatment setting. MMT centers typically serve individuals who voluntarily seek treatment, whereas Article 16 centers provide compulsory care to individuals referred through legal or judicial systems. Given the distinct nature of these populations, cross-center comparisons should be interpreted descriptively and with caution. Differences in legal status, social conditions, and patterns of substance use all contribute to divergent treatment needs and outcomes.

Accordingly, the findings of this study point to the need for tailored, setting-specific interventions and caution against overly broad generalizations across treatment modalities. These results must also be understood within the broader framework of Iran’s substance use treatment system, which integrates harm reduction, voluntary outpatient care, and compulsory residential programs. The diversity of modalities—ranging from MMT and DICs to TC and Article 16 centers—reflects a national strategy aimed at balancing public health objectives with legal mandates. This approach may differ substantially from those in other countries where compulsory treatment is less common. Understanding these structural distinctions is essential for international readers, as they directly impact service accessibility, client profiles, and treatment outcomes. This context-sensitive lens enhances the interpretability of the study’s findings and reinforces the importance of localized health policy planning.

Conclusion

The findings of this study highlight the diverse patterns of substance use and associated risk behaviors among individuals attending different treatment centers in Kerman, Iran. A significant majority of participants were male, and most reported initiating substance use after the age of 18. The highest rates of syringe sharing and unprotected sexual activity were observed among individuals in Article 16 centers—likely reflecting both the severity of substance use and the compulsory nature of treatment in these facilities.

These results underscore the heterogeneity of patient populations across treatment modalities, each operating within distinct structural and clinical frameworks. For instance, MMT centers—which primarily serve voluntarily admitted individuals—reported the lowest prevalence of high-risk behaviors and substance use. However, since the study focused exclusively on newly admitted participants, these differences are more likely to reflect baseline characteristics than treatment outcomes.

Accordingly, cross-center comparisons should be interpreted descriptively and with caution. The observed differences suggest a need for tailored harm reduction and treatment strategies that reflect the specific risk profiles and contextual characteristics of each setting—particularly in centers such as Article 16 and TC, which often manage individuals with more complex behavioral health needs. Future research should further examine the effectiveness of various treatment modalities while accounting for structural and demographic differences across patient populations. Advancing evidence-based, population-specific interventions is essential to reducing substance-related harms and improving public health outcomes in this context.

Limitations

One key limitation of this study is the absence of certain critical public health indicators, such as overdose events and driving under the influence of substances. While the study provides detailed data on a wide range of health risk behaviors and criminal activities within the past 30 days, it does not include these specific outcomes, which are essential for fully capturing the clinical and public safety implications of substance use. Future research should incorporate these variables to enable a more comprehensive evaluation of the health and societal burdens associated with substance use.