Adolescence 32 Substance Misuse in Young People K.A.H. Mirza1 , Roshin M. Sudesh2 , and Sudeshni Mirza3 1 Department of Child and Adolescent Psychiatry, Institute of Psychiatry at the Maudsley, King’s College, London, UK 2 King’s College Hospital, London, UK 3 Dr. Somerwell Memorial CSI Medical College Hospital, Kerala, India INTRODUCTION Substance misuse is a major public health problem, with substantial levels of morbidity and mortality. Most children in their middle childhood are exposed to various substances including alcohol and tobacco, and a substantial minority, as high as 10%, continue to use drugs into adolescence and adulthood [1,2]. Many youngsters who misuse drugs have multiple antecedent and coexisting mental health problems, unrecognized learning difficulties, family difficulties, involvement with the justice system and deeply entrenched social problems. Substance misuse takes a high toll in terms of health-care costs, violent crimes, accidents, suicides, social and interpersonal difficulties, and educational impairment [3]. EPIDEMIOLOGY Estimates from the 2009/10 British Crime Survey suggest that 40% of those aged 16–24 have used one or more illicit drugs at some point in their life, with up to 12% having used illicit drugs in the last month [4]. Tobacco, alcohol and cannabis are the most commonly abused substances, with cocaine and heroin accounting for less than 10% [4,5]. Volatile substance use peaks in early adolescence: about 4–7% of 11–15-year-olds sniffed volatile substances in the last year, and roughly 1% inhale solvents regularly, with the prevalence being substantially higher for youngsters from deprived backgrounds [3] (Table 32.1). Most of the campaigns against substance misuse are directed at illegal drugs such as cannabis, heroin, cocaine and ecstasy. However, many more people die or develop problems, either directly or indirectly, as a result of using tobacco and alcohol than all illegal drugs combined, and some of the leading experts in the field of addictions have proposed alternatives to the contentious British system of classification of drugs [6]. DEFINING SUBSTANCE MISUSE IN THE YOUNG: A DEVELOPMENTAL PERSPECTIVE The effects of a drug are not just dependent on the drug itself. The mindset of the individual who takes it and the setting in which it is used are crucial variables. Young people report that they take drugs for a variety of reasons: for pleasure; to conform to attitudes and values of their peer group; to block out traumatic and painful memories; and to relieve sadness and worries associated with their everyday lives. For some young people, the use of drugs and alcohol may become a problem in itself, and a very small minority develop substance dependence. Early onset of substance use and a rapid progression through the stages of substance use are among the risk factors for the development of substance misuse [3]. Longitudinal studies have shown that the highest peak of drug and alcohol use is between the ages of 14 and 18 years, and that most youngsters reduce or stop use by the age of 24 years [7]. The Christchurch Health Child Psychology and Psychiatry: Frameworks for Practice, Second Edition. Edited by David Skuse, Helen Bruce, Linda Dowdney and David Mrazek. © 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd. ISBN: 978-0-470-97382-0 201 Substance misuse in young people Table 32.1 Use of drugs and alcohol in young people in the UK, 2007/2010. Substance Use last year: Use last month: Lifetime use/use Regular use in 16—24-year-olds 16—24-year-olds last year: 11—15-year-olds and 11—15-year-olds 15—16-year-olds Tobacco NA NA 29% (lifetime) 6% (more than one cigarette per day in 11—15-year-olds): 7% in boys and 4% in girls Alcohol NA NA 51% (lifetime) 52% of boys and 55% of girls aged 15—16 engaged in episodic heavy drinking in the last month 16.1% 16% 8.9% (last year) 9% of 15—16-year-olds used in the last month [6] Cannabis 2% of 15—16-year-olds reported harmful use of cannabis Cocaine (cocaine powder and crack) 5.6% 2.6% 1.8% (last year) NA Ecstasy 4.3% 1.9% 1.2% (last year) NA Alkyl nitrites (‘poppers’) 3.2% 0.8% 1.8% (last year) NA Amphetamines 2.4% 0.7% 0.8% (last year) NA Opiates 0.3% 0.2% 0.7% (last year) NA Hallucinogens 1.5% 0.4% 2.2% (last year) NA 3% 0.1% 5.5% (last year) NA 1.7% 0.9% 0.6% (last year) NA Volatile substances (glue) Ketamine Sources: Reproduced with permission from Flatley et al. [4], Fuller, Sanchez [5], and Hibell et al. [6]. and Development study estimated that 10% of cannabis users would become dependent, and at the age of 18 years, about 6% were dependent on drugs or alcohol [2]. Given the natural history of substance use in young people and the heterogeneity of the patterns of use, most researchers and clinicians struggle to define what constitutes substance misuse in young people. 202 Definitions International classificatory systems – the International Classification of Diseases, 10th revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSMIV) – suggest that adult categories like ‘harmful use’ and ‘dependence’ (ICD-10) and ‘substance abuse’ and ‘dependence’ (DSM-IV) could be reliably used to diagnose substance misuse in Adolescence young people. Unfortunately, both systems lack a developmental perspective in psychopathology, and the categories such as ‘harmful use’, ‘dependence’ and ‘substance abuse’ do not seem to capture all stages of substance use in young people [8,9]. For example, tolerance and withdrawal, which typically develop in response to long periods of chronic substance use, are rarely seen in young people. Alternative classifications in young people Clinicians and researchers have proposed alternative criteria to classify substance misuse in young people [8,9]. Based on the seminal work by Joseph Novinsky and colleagues, Mirza and Mirza proposed a developmentally sensitive and dimensional model to classify the stage of substance use in young people [10], starting with non-use at one end, moving through an experimental stage, social stage, at-risk (prodromal) stage, and stage of harmful use to substance dependence at the other end. The above model has the potential to ascertain stages of substance use across the dynamic continuum and choose the most appropriate intervention to suit the stage of substance misuse (Table 32.2). AETIOLOGY: RISK AND PROTECTIVE FACTORS Substance use does not occur in a vacuum. In vulnerable individuals, substance misuse is produced by the interaction of a drug with genetic, environmental, behavioural, psychosocial and cultural factors (Table 32.3; Boxes 32.1 and 32.2). The complex mechanisms by which risk and protective factors mediate and modulate development of substance misuse are beyond the scope of this chapter, and interested readers may refer to excellent reviews or textbooks [11,12]. Antecedent and comorbid mental health problems Community-based longitudinal studies show that depression may predict alcohol dependence and cannabis use [13]. In addition, conduct problems in childhood predict substance abuse and dependence in early adulthood, after controlling for a range of social and other covariates [2]. Similarly, untreated attention-deficit hyperactivity disorder (ADHD) has been shown to be a significant risk factor for development of substance misuse in adolescence and adulthood [14]. The combination of conduct disorder and hyperactivity carries a particularly high risk. The risk of development of substance misuse is high in children exposed to neglect and maltreatment [15,16]. Significant rates of comorbid psychiatric disorders were reported in the community and in clinical samples of young people with substance misuse [17,18], the most common being conduct disorder, major depression, ADHD (with or without comorbid conduct disorder), anxiety disorders [post-traumatic stress disorder (PTSD) and phobias] and bulimia nervosa. Coexisting substance misuse has implications for the onset, clinical course, treatment compliance and prognosis for young people with psychiatric disorders [17,18]. Comorbid substance misuse is the single most important factor that increases the risk of suicide in young people with psychosis or major depression [19]. CONSEQUENCES AND ASSOCIATED FEATURES OF SUBSTANCE MISUSE A hallmark of substance misuse in adolescents is impairment in psychosocial and academic functioning. Impairment can include family conflict or dysfunction, interpersonal conflict, and academic failure. Associated characteristics such as offending behaviour, other high-risk behaviours and comorbid psychiatric disorders contribute further to risks and impairments. Injecting drug use is rare and only a small minority of young people develop physical dependence. Mortality is high due to accidents, suicides and physical complications of substance misuse. In the UK, volatile substance misuse accounts for 65 deaths per year, which is about 2% of all deaths below the age of 18 years [5]. ASSESSMENT Information should be obtained from a variety of sources including the young person, parents/other caregivers, general practitioner, school, 203 Substance misuse in young people Table 32.2 A pragmatic classification of adolescent substance use and the range of interventions. Reproduced from Mirza and Mirza [11]. Stage Purported motive Setting Experimental stage Curiosity and risk taking Alone or with Occasional peer group at best Mind-altering No active drug-seeking effects of drugs are less behaviour relevant Social stage Social acceptance Occasional Usually facilitated by but variable, peer group depending on peer group Mind-altering effects of drugs are clearly recognized and appreciated At risk or prodromal stage Cope with negative emotions or enhance pleasure Alone or with Frequent use peer group: mostly on their own Stage of harmful use (similar to ICD-10) Alone or with Drug use is an altered the primary peer group means of recreation, coping with stress or both Stage of dependence (similar to ICD-10) To deal with withdrawal symptoms, and stop craving Alone Frequency Emotional impact Behaviour Impact on functioning Suggested interventions [3] Relatively little, but rarely results in dangerous outcome Universal prevention (drug education) by Tier 1 services No active drug-seeking behaviour Usually a normative experience. May be associated with significant dangers in rare instances Universal prevention (drug education) by Tier 1 services Active Uses drugs drug-seeking purportedly to alter mood behaviour or behaviour Impairment in functioning in some areas, but able to hide them by and large Targeted intervention/ treatment by Tier 2—3 agencies Regular use, Very important despite negative consequences Active drug-seeking behaviour Impairment in Treatment by Tier 3 almost all agencies areas of life and or distress in near and dear Compulsive use, tolerance and loss of control of use Compulsive drug-seeking behaviour; may engage in acquisitive crimes Physical and psychological complications; impairment in all spheres of life Very important especially dealing with dysphoria and other withdrawal symptoms Treatment and habilitation by Tier 3 and Tier 4 agencies ICD-10, ICD-10 International Classification of Mental and Behavioural Disorders in Children and Adolescents. social services, youth justice system or any other social agencies involved. Clinical and research experience shows that young people are generally more reliable informants than might be assumed. The attitude of the clinician should be flexible, empathic and non-judgemental to engage the young person in the assessment process and to obtain a valid estimate of substance use. Explore the young person’s leisure activities and gently guide them to talk about the nature and extent 204 of substance use, its context, and its impact on various domains of their psychosocial functioning. This will enable the clinician to determine whether the current pattern of substance use constitutes normative stages of substance use, or meets diagnostic criteria for harmful use or dependence. Detailed exploration of comorbid psychiatric disorders and their relationship to substance misuse would help to formulate a differential diagnosis and treatment plan. Substance misuse is almost Adolescence Table 32.3 Risk factors for the development of adolescent substance misuse. Domain Risk factor Neurobiological Genetic susceptibility to substance misuse Psychophysiological vulnerability (EEG, ERPs) Neurochemical abnormalities (DA, 5-HT, opioids etc.) Psychological Depressive disorder Anxiety disorder Early/persistent conduct symptoms, ADHD Physical and sexual abuse Traumatic/stressful life events Early onset of drug use Sensation-seeking traits in personality Family Drug use by parents/other family members Family conflict and disruption Inconsistent or harsh discipline Lack of parental expectations about the child’s future Peer group/school Peer rejection/alienation from peer group Association with drug-using peer group Poor commitment to school Academic failure/underachievement Social/cultural Easy availability of drugs Social norms or laws favourable to drug use Extreme economic deprivation Disorganized, anomic neighbourhood ADHD, attention deficit hyperactivity disorder; DA, dopamine; EEG, electroencephalogram; ERP, Event Related Potential; 5-HT, 5-hydroxtryptamine (serotonin). Box 32.1 Protective factors • Close, affectionate parent— child relationship • Parental monitoring of young person • Authoritative parenting style • High educational aspiration/commitment • Having a non-drug-using peer group • Good social and interpersonal skills • Sense of bonding to school or other social institutions (sports club, church, mosque) • Acceptance of socially approved values and norms of behaviour always not the only problem and a comprehensive developmental, social and medical history should be undertaken to determine the multiple complex needs across different domains. Particular attention should be paid to the young person’s vulnerability, resilience, hopes and aspirations. Evaluating the adolescent’s readiness for treatment or stage of change may help determine the initial treatment goals or level of care. Mental state examination and physical examination Young people may present with features of intoxication or withdrawal. Recent injecting sites, bloodshot eyes, nicotine stains on fingers, unsteady gait and tremulousness give indications of the extent of substance use. Perceptual abnormalities may suggest a primary psychotic illness or the use of drugs such as cannabis, alcohol, amphetamine or cocaine. Inhaling solvents from the bag may lead 205 Substance misuse in young people Box 32.2 High-risk groups (based on longitudinal studies) • Young offenders • Children of drug-misusing parents • Children excluded from school/truants • Young people looked after by local authority • Young people leaving care • Young homeless people • Teenage mothers • Young people attending mental health services • Regular attendees of accident-and-emergency services to a rash around the mouth and nose. Risk of harm to self and others should be systematically assessed, especially in young people with a history of offending behaviour and those with comorbid psychopathology. Psychiatrists should not hesitate to use their hard-won medical skills, and a detailed physical examination including basic neurological examination should always be undertaken. Specific attention should be paid to signs of liver disease, tachycardia and high blood pressure, which may indicate excessive substance use or withdrawal states. Investigations Haematological and biochemical investigations like liver function tests are helpful to establish drug- and alcohol-related harm. Testing bodily fluids (urine, saliva, blood) for specific substances should be part of the initial evaluation, especially in inpatient settings and for court-mandated assessments. Most substances – except benzodiazepine, methadone and cannabis – are detectable in urine for a few days only. Considering the above and the potential for adulteration of samples, a negative urine result does not necessarily mean that the young person is not using drugs. A hair test is more reliable as it gives a longer historical profile of drug use (up to 1 month). However, some professionals argue that testing adds little to the verbal reports of substance use in young 206 people, especially when clinicians have managed to nurture a trusting therapeutic relationship with them. There is little evidence at present to recommend repeated testing of bodily fluids to monitor routine clinical treatment. TREATMENT The primary goal of treatment is to achieve and maintain abstinence from substance use. While abstinence should remain the explicit, long-term goal of treatment, harm reduction may be an interim, implicit goal, in view of both the chronicity of substance misuse in some young people and the self-limited nature of substance misuse in others. Treatment modalities used are largely psychosocial. Medication is used as an adjunct only, though it may offer a window of opportunity for young people to engage in psychosocial treatment [19,20]. Evidence base for treatment Reviews of the literature on adolescent treatment outcomes have concluded that treatment is better than no treatment [21]. Naturalistic follow-up of young people in a number of treatment settings in the USA showed decreased substance misuse and criminal involvement, as well as improved psychological adjustment and school performance, one year after treatment [21,22]. Family therapy approaches such as multisystemic therapy [23] and multidimensional family therapy [24] have the best evidence base for efficacy across a number of domains [25], although individual approaches such as cognitive–behavioural therapy (CBT) – both alone and in combination with motivational enhancement – have been shown to be efficacious [26,27]. There is an emerging evidence base for brief motivational interviewing as well [28–30]. Most of the research on psychological treatment comes from the USA, and is not necessarily directly applicable to the UK context, both in terms of the resources required and cultural differences. However, there are significant overlaps between different forms of psychotherapies in both theoretical conceptualizations and therapeutic techniques, and building on existing skills of practitioners working across voluntary and statutory agencies in the UK could prove to be an effective and cost-effective way of delivering evidence-based interventions. Essential elements of a successful treatment programme may include the following: Adolescence • An empathic and non-judgemental therapist, who takes painstaking efforts to engage even the ‘hard-to-reach’ youngster in the treatment process and rekindles the ability to hope and dream. • A therapeutic process that involves structured and personalized feedback on risk and harm to young people; emphasis on personal responsibility for change; and strategies to increase selfesteem, self-efficacy, practical problem-solving skills and social skills. • Involvement of family and other ‘systems of care’ – such as school, judicial system and social services – to address the multiple complex needs of young people. • A lengthy period of retention in service to ensure good aftercare. Treatment should be tailored to meet the needs of the individual young person. Integrated mental health and substance misuse treatment should be offered to young people with comorbid psychiatric disorders [29,31,32]. Inpatient treatment is required for a very small minority: those with severe and chaotic substance misuse; repeated failed community detoxification; intravenous drug use with complications; and severe mental illness and risk of self-harm. Variables consistently related to successful outcome are treatment completion, low pre-treatment substance use, and peer and parent social support [21]. Other factors predictive of outcome are involvement of family, use of practical problem-solving, and provision of comprehensive services such as housing, academic assistance and recreation [26]. Role of child and adolescent mental health services (CAMHS) Despite the significant expansion of specialist substance misuse services over the past decade, many youngsters still do not receive adequate treatment, and there are ongoing debates regarding the role of CAMHS in adolescent substance misuse Professionals working in CAMHS have an unrivalled opportunity to play a significant role in the early identification and treatment of substance misuse, including children of substance-misusing parents and other high-risk groups. Specific treatment of ‘core’ mental health problems such as depression, eating disorders, ADHD and PTSD is a primary role of the specialist CAMHS [33]. CAMHS professionals could help develop multi-agency treatment services and train other professionals in evidence-based interventions. CONCLUSIONS The notion of a drug-free society is almost certainly a chimera. 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