Substance Use Disorders

• About

  A substance can be anything that is ingested in order to produce a high, alter one's senses, or otherwise affect mood, perception and consciousness.

  Substance use can be common in young people, and individuals have different patterns of use (bingeing, occasional or continual) and reasons for use (for example as an 'experiment', for 'fun' or to 'escape', to 'join in' with peers, or to get through a certain situation- such as the desire to stay awake). Where use is prolonged, heavy, or creating social or personal problems it may meet a 'diagnosis' for a substance use disorder: substance dependence or substance abuse (1).  

  In substance abuse a person experiences harmful changes in their behaviour as a result of repeatedly using a substance, that negatively affects their work/school responsibilities, social relationships, and can lead to increased risk taking and other personal or social problems. In substance dependence, a person relies on a substance despite the problems caused by continuing its use. In addition to the social and personal problems of substance abuse, dependence leads also to cognitive, behavioural and physical symptoms if a person continues using.

  Burden and onset of substance use disorders in young people

  Substance use is common among young people, and alcohol is the most common substance used by youth. A survey of Australian secondary students aged between 12 and 17 years, found that 80 percent had tried alcohol, 14 percent had used cannabis, and 19 percent had used inhalants at some time in their lives (2). 

  People with substance use disorders often don't recognise or seek help for the problem, and may not be screened for substance abuse when they seek treatment for other health conditions, which means that substance abuse and dependence disorders are often under-recognised and undertreated. Despite this, substance use disorders are among the most common of mental health disorders experienced by young people. In Australia, 12.7 percent of people aged 16-24 are estimated to have a substance use disorder, with higher rates among young men than young women (around 16% of males and 10% of females) (3). Harmful use of alcohol was the most commonly reported substance use disorder (at around 9%) (4).

  Overall, about half of people with substance use disorders first experience substance use issues by the age of 20 (5).  Substance use disorders in younger adolescents are most commonly harmful use or abuse; substance dependence remains less common until later in adolescence/early adulthood (5, 6).

  Substance use disorders can result in significant short and long-term ill effects. These consequences arise from the type of substance and the way it is used (for example, respiratory problems resulting from smoking and spread of infections such as Hepatitis via injecting); from the immediate effects of intoxication (such as overdose, traffic accidents and falls, risky sexual behaviour, violence and aggression); from the longer terms physical effect of the drug (such as brain damage, liver disease, cancer) and the significant mental distress caused associated with drug dependence (7).

  There is a close relationship between substance use disorders and other mental disorders, and use of some substances may increase the risk of developing certain disorders, however it is often unclear whether one issue causes the other. It is common for young people with substance use issue to have one or more co occurring mental health disorders, such as anxiety, depression and schizophrenia(8).

  Risk factors
  A number of factors can increase the likelihood that a person will have a substance use disorder (9-11). They include the following:

  • Related to the individual:  
    • Possible genetic predisposition (eg. a substance use disorder in another family member) 
    • Personality (for example, social isolation, difficulty accepting rules and authority) 
    • Poor coping skills
    • Educational problems 
    • Early age of first use 
    • Strong personal motivations to use
    • Traumatic experiences (for example, abuse as a child) 
    • Low socioeconomic status 
    • Poor peer or community support 
    • Adverse peer influences.
  • Related to the family: 
    • Patterns of negative communication, low family cohesion
    • Parental monitoring, discipline or family management techniques 
    • Poor family relationships 
    • Parental role modelling (for example, seeing parents engaging in drug use)
  • Related to the community and society: 
    • Traumatic environment 
    • Legislation and law enforcement policies 
    • Availability of drugs 
    • Acceptability of substance use

   

  References:
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th. Edition. (DSM-IV). 1994 1994.

  2. White, V, Smith, G. Australian secondary school students' use of tobacco, alcohol, and over-the-counter and illicit substances in 2008 Drug Strategy Branch, Australian Government Department of Health and Ageing 2009.

  3. ABS. Australian Bureau of Statistics. 2007 National Survey of Mental Health and Wellbeing: Summary of Results. (Document 4326.0). 2008.

  4. Reavley, NJ, Cvetkovski, S, et al. Help-seeking for substance use, anxiety and affective disorders among young people: results from the 2007 Australian National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry. 2010 Aug;44(8):729-35.

  5. Kessler, RC, Berglund, P, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):593-602.

  6. Toumbourou, JW, Stockwell, T, et al. Interventions to reduce harm associated with adolescent substance use. Lancet. 2007 Apr 21;369(9570):1391-401.

  7. Canadian Centre on Substance Abuse. Substance Abuse in Canada: Youth in Focus. Canadian Centre on Substance Abuse, Ottawa. 2007.

  8. Armstrong, TD, Costello, EJ. Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. J Consult Clin Psychol. 2002 Dec;70(6):1224-39.

  9. Hawkins, JD, Arthur, MW, et al. Preventing substance abuse.  In D. Farrington & M. Tonry (Eds.), Crime and Justice, Volume 19: Strategic Approaches to Crime Prevention. Chicago: University of Chicago Press 1995.

  10. Spooner, C, Hall, W, et al. ANCD research paper 2-Structural determinants of youth drug use. Australian National Council on Drugs. 2001.

  11. Frisher, M, Crome, I, et al. Predictive factors for illicit drug use among young people: a literature review. Research Development and Statistics Directorate, Home Office, United Kingdom. 2007.

• Assessment

  A diagnosis of Substance Abuse is based on a 12-month pattern of substance use leading to significant impairment in functioning, demonstrated by at least one of the following: 

  • An inability to fulfill responsibilities at home, at work, or when studying 
  • Repeatedly using substances when it is physically dangerous, for example when driving a vehicle 
  • Legal problems of many different types as a result of short-term intoxication or longer-term cognitive effects on behavior, or arising the desire to obtain more of the substance they are dependant on
  • Recurring personal or social problems.

  A diagnosis of dependence may be made when symptoms of substance abuse are present, along with:   

  • Increased tolerance (requiring higher doses to achieve the same effect) 
  • Withdrawal symptoms when use is stopped 
  • Compulsive substance-taking behaviour.

  Assessment Tools
  There is not a common list of symptoms that can be used to tell if someone is misusing drugs, as different drugs have different affects on different people. To decide whether a young person may be experiencing a substance use disorder, a comprehensive assessment in required. Assessing substance use is also important when someone is presenting for other issues (such as mental health issues). Assessment involves asking questions about a range of aspects of a person's life including substance use and their:

  • Home and Environment; 
  • Education and Employment; 
  • Activities; 
  • Relationships and Sexuality; 
  • Conduct Difficulties and Risk-Taking; 
  • Anxiety and Eating; 
  • Depression and Suicide Risk; 
  • Psychosis and Mania

  See the headspace assessment for more details.

  A comprehensive assessment would include questions to find out the types of substances used and method of ingestion (ie inhaled, injected, etc), the frequency and duration of use and the age of first use.   

  There are large number of screening and assessment tools used to establish substance abuse in young people (1).  Commonly used tools in Australia (2) include the Alcohol Use Disorders Identification Test (AUDIT), the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) the CRAFFT Screening Tool

  
  References:

  1. Martin, CS, Winters, KC. Diagnosis and assessment of alcohol use disorders among adolescents. Alcohol Health Res World. 1998;22(2):95-105.

  2. Crofton, G. Screening for and assessment of co-occurring substance use and mental health disorders by Alcohol & Other Drug and Mental Health Services. Victorian Dual Diagnosis Initiative Advisory Group, Victoria 2007. 
   

• Treatment

  The choice of treatment should take account of the young person's: 

  • Developmental stage 
  • Patterns of substance use 
  • Readiness to change 
  • Ethnicity 
  • Gender 
  • Co-existing needs including other physical and/or mental illnesses, legal problems, housing problems and sexuality issues 
  • Family factors and home life
  • Peers 
  • School life.

  Most research about interventions for reducing substance abuse among young people focuses on approaches to prevent substance use. Less is known about the best methods to treat a substance use disorder once it is established. 

  Approaches that have some benefit in preventing young people's use of drugs in general include motivational interviewing and some family interventions (1); for illicit drugs, skills based school programs (2); and for alcohol use specifically- the Strengthening Families Programme and culturally focused skills training appear to offer promise (3).

  Treatment options that have been demonstrated to be effective or promising include cognitive behaviour therapy (4), multidimensional family therapy, functional family therapy, and group CBT (5, 6), contingency management and brief interventions like motivational interviewing (although with only small effects)(7-9). Family behavior therapy and individual cognitive problem-solving therapy are effective approaches for young people with a dual diagnosis (10). In general, psychosocial treatment is more effective than no treatment, although there are some approaches that have been found to have negative effects. Overall, little is known about the effectiveness of using medications to treat substance use disorders in young people (11).

  Even when an individual does not meet full criteria for a substance abuse related diagnosis, they may benefit from support to reduce the amount of their substance use.

  The evidence map provides reference details for studies of prevention and treatment interventions for substance use disorders in young people.

   

  References

  1. Gates, S, McCambridge, J, et al. Interventions for prevention of drug use by young people delivered in non-school settings. Cochrane Database Syst Rev. 2006(1):CD005030.
  
  2. Faggiano, F, Vigna-Taglianti, FD, et al. School-based prevention for illicit drugs' use. Cochrane Database Syst Rev. 2005(2):CD003020.

  3. Foxcroft, DR, Ireland, D, et al. Primary prevention for alcohol misuse in young people. Cochrane Database Syst Rev. 2002(3):CD003024.

  4. Waldron, HB, Kaminer, Y. On the learning curve: the emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse. Addiction. 2004 Nov;99 Suppl 2:93-105.

  5. Waldron, HB, Turner, CW. Evidence-based psychosocial treatments for adolescent substance abuse. J Clin Child Adolesc Psychol. 2008 Jan;37(1):238-61.
  

  6. Vaughn, MG, Perron, BE, et al. Variations in social contexts and their effect on adolescent inhalant use: a latent profile investigation. Drug Alcohol Depend. 2007 Dec 1;91(2-3):129-33.

  7. Grenard, JL, Ames, SL, et al. Motivational interviewing with adolescents and young adults for drug-related problems. Int J Adolesc Med Health. 2006 Jan-Mar;18(1):53-67.

  8. Tait, RJ, Hulse, GK. A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug. Drug Alcohol Rev. 2003 Sep;22(3):337-46.

  9. Toumbourou, JW, Stockwell, T, et al. Interventions to reduce harm associated with adolescent substance use. Lancet. 2007 Apr 21;369(9570):1391-401.

  10. Bender, K, Springer, DW, et al. Treatment Effectiveness With Dually Diagnosed Adolescents: A Systematic Review. Brief Treatment and Crisis Intervention. 2006 Aug 1;6(3):177-205.

  11. Waxmonsky, JG, Wilens, TE. Pharmacotherapy of adolescent substance use disorders: a review of the literature. J Child Adolesc Psychopharmacol. 2005 Oct;15(5):810-25.
   

• Guidelines

  The following guidelines provide evidence-based information about the treatment of substance use disorders in young people and adults:

  Comorbidity of mental disorders and substance use: A brief guide for the primary care clinician (2008) Drug and Alcohol Services South Australia, Australian Government Department of Health and Ageing. (2008) Australian Government Department of Health and Ageing 

  Paul Haber, Nicholas Lintzeris, Elizabeth Proude and Olga Lopatko Guidelines for the Treatment of Alcohol Problems (2009) Australian Government Department of Health and Ageing 

  Alcohol treatment guidelines for Indigenous Australians, (2007) Australian Government Department of Health and Ageing 

  The management of harmful drinking and alcohol dependence in primary care (2004) SIGN Clinical Guideline 94. United Kingdom

  Treatment of Patients With Substance Use Disorders, Second Edition. (2006) American Psychiatric Association

  Brief interventions and referral for smoking cessation in primary care and other settings. (2006) National Institute for Health and Clinical Excellence (NICE) PHG1, United Kingdom

  Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) National Institute for Health and Clinical Excellence (NICE) Clinical guidelines CG115, United Kingdom

  Alcohol-use disorders. Diagnosis and clinical management of alcohol-related physical complications. (2010)  National Institute for Health and Clinical Excellence (NICE) CG 100, United Kingdom

  Drug misuse: opioid detoxification (2007) National Institute for Health and Clinical Excellence (NICE) Clinical guideline 52

  Drug misuse: psychosocial interventions (2007) National Institute for Health and Clinical Excellence (NICE) Clinical guideline 51

  Detoxification and substance abuse treatment (2006). Substance Abuse and Mental Health Services Treatment Improvement Protocol TIP 45, United States   

• More info

  The following selected articles provide more information about anxiety disorders and anxiety intervention research:

  Frye, S, Dawe, S, et al. Supporting the families of young people with problematic drug use: investigating support options Australian National Council on Drugs. 2008.

  Petrie, J., Bunn, F. & Byrne, G. Parenting programmed for preventing tobacco, alcohol or drugs misuse in children <18: A systematic review. Health Education Research, 2007, 22(2), 177-191.

  Lubman, DI, Hides, L, et al. Intervening early to reduce developmentally harmful substance use among youth populations. Med J Aust. 2007 Oct 1;187(7 Suppl):S22-5.

  Martin, CS, Winters, KC. Diagnosis and assessment of alcohol use disorders among adolescents. Alcohol Health Res World. 1998;22(2):95-105.

  Reavley, NJ, Cvetkovski, S, et al. Help-seeking for substance use, anxiety and affective disorders among young people: results from the 2007 Australian National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry. 2010 44(8):729-35.

  Action for Young Australians Report.  Young people and alcohol - reducing the risk. 2009. The Australian Research Alliance for Children and Youth
  
  Waldron, HB, Turner, CW. Evidence-based psychosocial treatments for adolescent substance abuse. J Clin Child Adolesc Psychol. 2008 Jan;37(1):238-61.

  Dawes, MA, Johnson, BA. Pharmacotherapeutic trials in adolescent alcohol use disorders: opportunities and challenges. Alcohol Alcohol. 2004 May-Jun;39(3):166-77.