Associations between educational attainment and substance use, disorders, and treatment: cross-sectional findings from the National Survey on Drug Use and Health, 2022–2023

Background: Educational attainment may shape alcohol and drug use and treatment access, yet differences across educational levels and the substance use-to-treatment continuum remain poorly understood. Objectives: Examine differences in past-year substance use (alcohol and/or drug), meeting DSM-5 substance use disorders (SUD), and treatment engagement by educational attainment. Methods: Cross-sectional analysis of pooled 2022–2023 National Survey on Drug Use and Health data among adults aged ≥ 18 years (unweighted N = 92,233; 55.5% female). Multivariable logistic regression assessed associations between educational attainment and any past-year substance use, type and severity of DSM-5 SUDs, screening, and treatment. Exploratory analysis examined perceived barriers to unmet treatment need. Results: Compared with less than high school education, college graduation was associated with higher odds of past-year alcohol or drug use (aOR = 2.8, 95% CI = 2.4–3.2) and alcohol use disorder (aOR = 2.0, 95% CI = 1.5–2.8), but lower odds of DSM-5 SUD (aOR = 0.63, 95% CI = 0.54–0.73), drug use disorder only (aOR = 0.54, 95% CI = 0.40–0.72), severe SUD (aOR = 0.54, 95% CI = 0.40–0.74), alcohol screening (aOR = 0.36, 95% CI = 0.24–0.53), drug screening (aOR = 0.70, 95% CI = 0.51–0.95), and treatment receipt (aOR = 0.42, 95% CI = 0.28–0.61); all adj. p < .001 except drug screening (adj. p = .014). Among those with unmet treatment need, logistical, stigma, privacy, and treatment-ambivalence barriers differed significantly by educational attainment (p < .05). Conclusion: Educational attainment associates with distinct patterns in substance use, disordered use, screening, and treatment engagement. Rather than uniformly reducing risk, higher education may shape unique risk profiles and barriers, underscoring the need for tailored strategies to improve early intervention and treatment uptake.