["Addiction, Volume 121, Issue 5, Page 1207-1216, May 2026. ", "\nAbstract\n\nBackground and aims\nOpioid use disorder (OUD), cannabis use disorder (CUD) and cocaine use disorder have been associated with a range of adverse health outcomes, including certain ocular manifestations; however, their impact on diabetic retinopathy (DR) remains insufficiently explored. This study aimed to measure the association between OUD, CUD and cocaine use disorder and the risk of DR among patients with type 2 diabetes mellitus (T2DM).\n\n\nDesign\nPropensity‐score‐matched retrospective cohort study.\n\n\nSetting\nThis study used the TriNetX US Collaborative Network to access electronic health records (EHRs), including data on demographics, diagnoses, medication use and laboratory results.\n\n\nParticipants/cases\nA total of 131 088 adult patients with T2DM and comorbid OUD, CUD or cocaine use disorder, and 131 088 adult patients with T2DM without these conditions, were identified following propensity score matching.\n\n\nMeasurements\nThe primary outcome was the risk of DR evaluated over a 5‐year follow‐up period. The risks of various DR subtypes and diabetic macular edema (DME) were also assessed. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated.\n\n\nFindings\nOver a 5‐year follow‐up period, patients with T2DM comorbid with OUD, CUD or cocaine use disorder had a statistically significantly higher risk of developing DR [HR (95% CI) = 2.90 (2.55–3.30), P < 0.00] compared with those without any drug use disorder. Drug use disorders were also associated with elevated risks of vision‐threatening diabetic retinopathy (VTDR) [HR (95% CI) = 2.78 (2.24–3.46), P < 0.00], non‐proliferative diabetic retinopathy (NPDR) [HR (95% CI) = 3.10 (2.61–3.68), P < 0.00], proliferative diabetic retinopathy (PDR) [HR (95% CI) = 3.17 (2.26–4.45), P < 0.00] and DME [HR (95% CI) = 2.64 (2.04–3.42), P < 0.00] among patients with T2DM.\n\n\nConclusions\nOpioid use disorder, cannabis use disorder and cocaine use disorder appear to be associated with an elevated risk of diabetic retinopathy among patients with type 2 diabetes mellitus.\n\n"]