PUBLIC HEALTH

Youth Substance Use And Abuse: Challenges And Strategies For
Identification And Intervention

Jeremy is 17 and has lived on the street for 3 years. He visits the
emergency department for the fifth time in the past month reporting
chest pain: "My heart's jumping out of my chest. Think I'm having a
heart attack or something." He further reports symptoms of anxiety
and panic attacks. He admits to using cannabis daily, and cocaine and
ecstasy several times a week. The emergency physician takes a few
minutes to ask Jeremy about his health concerns. Jeremy says he wants
"to know that I'm not crazy." The physician wonders why Jeremy has
not visited the substance abuse treatment agency he has been referred
to and subsequently allays his fear that he will be "locked up" if he
goes for treatment. With Jeremy's permission, the physician leaves a
message for a worker at the street youth centre where Jeremy often
hangs out. The following week, the worker accompanies Jeremy for an
assessment at the treatment agency and to an appointment to see a
psychiatrist. With support from the youth centre, Jeremy applies to
stay at a group home to stabilize his living situation while he seeks
treatment.

The above case illustrates the complexities involved in the
assessment of and intervention for young people with substance abuse
disorders, as well as the importance of understanding their
perspectives on their difficulties and motivations for changing their
substance use behaviour.

Drug and alcohol use is common among young people. Health Canada's
Youth Smoking Survey 2004-20051 of Canadian youth in grades 5-9
indicated that the mean age for first use of alcohol was just over 11
years. The survey indicated that, among grade 7-9 students (ages
12-14), 12.6 years was the mean age for first use of cannabis, and
that 12.5% of these students reported ever using a substance other
than alcohol, tobacco or cannabis. Substance use and abuse are
associated with short-and long-term health and psychosocial risks.
Therefore, it is imperative for workers in health care and other
professions involved with youth (e.g., education, child protection,
legal) to understand the prevalence of youth substance use and abuse,
the associated morbidities and, most importantly, effective
strategies for identification and intervention.

Prevalence of substance use and abuse

Table 1 lists common street drugs and their effects. A number of
surveys collect information about the prevalence and trends of
alcohol and drug use. The Centre for Addiction and Mental Health has
conducted the Ontario Student Drug Use Survey2 biannually for 3
decades, using an anonymous self-reporting method. The 2007 survey
data indicated that 64.7% of youth in grades 7-12 reported lifetime
use of alcohol, 29.9% cannabis, 4.3% cocaine and less than 4% other
drugs, including heroin, ketamine and crystal methamphetamine.2 Other
provinces have carried out surveys that revealed similar prevalence
and trends, with few regional variations. The Ontario Student Drug
Use Survey reported that rates of drug use (with the exception of
inhalant use) increased with age during adolescence and were similar
among boys and girls. Recent trends for most drugs have shown
declining or steady rates of use.

The survey also revealed that 26.3% of students in grades 7-12
reported binge drinking (5 or more drinks at one time) in the 4 weeks
before the survey.2 In addition, 19% of the students surveyed
reported hazardous drinking based on the AUDIT (Alcohol Use Disorders
Identification Test)3 (Box 1) and 15% of the students responded
positively to 2 or more items on the 6-item CRAFFT scale4 (Box 2),
which is commonly used to identify the need for further assessment or
intervention. Only 1.5% of the students reported obtaining treatment
services in the year before the survey.

A relatively small proportion (1%-2%) of youth reported the
nonmedical use (also referred to as misuse) of stimulant medication,
including methylphenidate (Ritalin). However, recent data suggested
that the misuse of prescription opiate medication in the year before
the survey was as high as 24% among grade 9 students.2

Such surveys do not capture substance use and abuse by street youth,
youth not attending school, those in correctional facilities or
Native Canadian youth residing on reserves, all of whom have higher
reported rates of substance use than youth in the general
population.5 In particular, street youth have significantly higher
rates of use of methamphetamine, ecstasy
(methylenedioxymethamphetamine), cocaine and ketamine than youth in
the general population. They are also more likely to be involved with
injection drug use, which magnifies the potential for adverse health outcomes.6

Comparative international data are difficult to find, as there is
much variation in survey methods. In general, tobacco and alcohol are
the most frequently used substances by young people, with cannabis
use accounting for 90% or more of the illicit drug use in North
America, Australia and Europe.7 The United Nations Office on Drugs
and Crime Global Youth Network reports that the prevalence of
lifetime use of cannabis among 15- and 16-year-old students in 1999
was 4.5%-5% in Asia, 1%-35% in various regions of Europe, 40.9% in
the United States, 42.8% in Australia and 42.7% in Ontario, Canada.7

Risk factors

A number of risk factors have been associated with substance abuse
among young people (Box 3). According to a 2007 report on youth
substance use in Canada, up to 50% of youth who seek substance abuse
treatment have been found to have a concurrent mental health
disorder, such as depression or anxiety.5 Many risk factors occur
simultaneously, thus there are subsets of youth for whom the
likelihood of substance abuse is very high.

Research in the area of adolescent neurodevelopment suggests that
adolescents' brains may be more vulnerable to the effects of
substances. This research also shows that adolescents may be at risk
of developing patterns of behaviour that result in substance abuse
(continued use regardless of physical or psychosocial problems, or
dependence) and substance dependence (physiologic dependence
demonstrated by withdrawal symptoms or the development of tolerance
to alcohol or drugs).8

Harms associated with substance use and abuse

There is an array of health-related harms associated with substance
use and abuse. Many high-risk behaviours result from drug and alcohol
use. These include having unplanned, unwanted and unprotected sexual
activity; driving while intoxicated; being a passenger in a car while
the driver is intoxicated; failing to wear a seat belt; and
self-injurous behaviour such as cutting and suicide attempts. For
example, 8%-10% of teens who participated in a 2003 Council of
Ministers of Education study reported that using drugs or alcohol was
the reason they had sexual intercourse for the first time.9
Unprotected sexual activity is associated with a higher incidence of
sexually transmitted infections and can lead to unintended pregnancy.

Substance use can cause acute medical complications (Table 1).
Polysubstance use frequently complicates the presentation and
management of these patients in emergency departments. The reported
frequency of medical complications from substance use is likely
underestimated, since some young people are reluctant to seek medical
help because of concern about parental notification or legal involvement.

Youth with substance abuse problems are at increased risk of being
involved with the legal system. They are also at risk of their
education being interrupted or negatively affected.10,11 The complex
interaction of physical, mental, legal, educational and social issues
among youth with substance abuse problems creates the potential for
poor short-and long-term outcomes.

Identification and treatment

Many health care practitioners do not routinely screen adolescents
for substance use and associated risk factors. A number of screening
tools are available, from the general assessment tools such as the
HEADSS assessment (a mneumonic that forms the basis for a
psychosocial assessment)12 and GAPS (Guidelines for Adolescent
Prevention Services),13 to more specific tools for alcohol and
substance abuse such as AUDIT3 (Box 1) and CRAFFT4 (Box 2), both of
which have been validated for use with adolescents. A score of 2 or
higher on the CRAFFT scale identifies a problem with substance use
(sensitivity 76%, specificity 94% as compared with a structured
psychiatric diagnostic interview).4

Urine drug testing is used in many adult substance abuse treatment
programs. In the United States, random urine screening has been
recommended for adolescents, particularly those involved in high
school extracurricular activities. However, there is no evidence in
the literature that random drug testing of adolescents has any
therapeutic benefit.14 Further research is needed to determine
whether there is any role for drug testing as a component of
developmentally focused interventions for adolescents.

The evidence for effective treatment approaches for adolescents with
substance abuse problems is limited and rigorous research in this
area is lacking. Historically, treatments have used an
abstinence-based approach (i.e., the expected outcome of treatment is
no use of alcohol or drugs). Evidence from the literature
demonstrates that programs for adolescents using a pure
abstinence-based approach (the "just say no" approach) are
ineffective in reducing substance use and abuse.15

There is growing recognition that harm-reduction strategies may be
effective.16,17 Such strategies accept that adolescents may choose to
use alcohol or drugs, and acknowledge that alcohol and drug abuse
have potential health and psychosocial risks. Unlike abstinence-based
approaches, which focus on eliminating the behaviour, harm-reduction
strategies aim to reduce related risks by modifying the behaviour
(which may include eliminating use). Interventions incorporating
harm-reduction strategies have been successfully implemented and
evaluated.17-19 Motivational interviewing techniques incorporate the
need to address issues, such as ambivalence or resistance to
treatment and change. Some studies have suggested this type of
intervention leads to a reduction in harm associated with drug use
and is a promising area for further study.15,18,19

To date, there are no compelling data to support a role for
pharmacologic agents in the treatment of substance abuse problems in
adolescents, although this is an emerging area of research focus. The
exception is the treatment of concurrent mood disorders (e.g.,
depression), for which treatment has been found to reduce substance use.20

Despite our understanding about the prevalence and associated risks
of adolescent substance use and abuse, there remain numerous
challenges. There is still much to be discovered about effective
prevention and youth-specific intervention strategies. It is
important that the chosen approach be aligned with the developmental
needs of the adolescent and, when appropriate, able to provide family
support and treatment.21 In addition to reduction of substance use
and abuse, health outcomes need to be examined in a broad context,
including social functioning, legal involvement (or lack thereof),
educational achievement, and physical and mental health.

Health care practitioners can play a key role in the identification
of at-risk youth and of those who already have substance abuse
problems. Practitioners should advocate on behalf of individuals to
ensure that they have access to treatment services and at the
community level to ensure that appropriate resources are directed
toward effective interventions.

Footnotes

This article has been peer reviewed.

Competing interests: None declared.

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