Brain Structure and Substance Use: Disentangling Risk, Exposure, and Drug-Specific Effects

ImportancePolysubstance use is common, but substance use associations with neuroimaging measures have largely been investigated within individual drug types. Whether effects are substance-specific or -general, and how predispositional risk and exposure contribute, remains unclear. ObjectiveIdentify shared and unique associations between substance use and brain structure, and characterize the contributions of predispositional risk and environmental exposure, in a large sample of young adults in the US. DesignThis cross-sectional family-based study used data from the Human Connectome Project (2017 release, collected from 2012-2015). SettingData were collected at Washington University in St. Louis, MO, USA. ParticipantsTwins, non-twin siblings, and singletons with magnetic resonance imaging (MRI) and substance use self-report were included in the analysis. Data were analyzed in 2025. ExposureHistory of substance use was assessed using the Semi-Structured Assessment for the Genetics of Alcoholism. Variables included lifetime use, heavy or past-year hazardous use, and age of use onset for alcohol, marijuana, tobacco, and illicit drugs. Additionally, alcohol and marijuana dependence were assessed. Main Outcomes and MeasuresLinear mixed-effect models examined associations between substance use and brain structure, with an initial focus on past-year hazardous alcohol use, as 95% of the sample endorsed lifetime alcohol use. Analyses then tested associations with other substance use variables, and whether effects were shared or substance-specific. Between-family, within-family, and genetic variance component analyses tested risk and exposure effects. Results1,113 participants (N = 445 families; ages 22 - 37; M=28.8, SD=3.7) had no missing data for the primary analyses. Hazardous alcohol use was negatively associated with global brain thickness ({beta} = -0.12, p < 0.001), which explained all other regional and global associations. Of the drugs with a shared-effect on global brain thickness, only lifetime marijuana use explained unique variance over alcohol ({beta} = -0.08, p = 0.013). Within-family analyses found evidence for unique putative exposure effects of both alcohol ({beta} = -0.11, p < 0.001) and marijuana use ({beta} = -0.07, p = 0.002) on global thickness. Marijuana use further showed a predispositional effect, both in between-family comparisons ({beta} = -0.11, p = 0.007) and genetic variance component analyses ({rho}G = -0.2, p = 0.004), which were not explained by alcohol use. Conclusions and RelevanceBrain structural associations with substance use reflect substance-general and -specific effects, as well as a combination of predispositional and exposure effects. Findings suggest that the negative consequences of polysubstance use may reflect the additive effects of multiple unique exposures.