Addiction

This review will discuss what we currently know about drug use among young people, highlighting what we don’t know or where there is uncertainty in relation to the evidence. Irrespective of the age group it is just as important to be aware of what we don’t know as what we can be more confident about. This is particularly true of young people and drug use, as most research investigating prevention and interventions has tended to focus on adult populations. This can leave those working with young people unsure about the approach they should take when discussing drugs with them and knowing how to respond when they develop problems with substances including alcohol.

This review will conclude by taking a look into what lies ahead and suggesting some priorities for future research. Although the review draws on data and policy from the United Kingdom, wider sources have been included where possible.

About the author

Associate Professor Ian Hamilton
Associate Professor Ian Hamilton

Ian is an Associate Professor of Addiction at the University of York. He is a lecturer in mental health in the Department of Health Sciences, with an interest in the relationship between substance use and mental health (Dual Diagnosis).

Ian trained and worked as a mental health nurse in South London, working with people who had a severe mental health problem and used drugs or alcohol problematically. He joined the Department in 2004 as a lecturer. His interest in this client group has continued through his work with teams which come into contact with such clients, and also facilitating sessions in this area.

  • Introduction

    Firstly, it is important to try and understand the scale of the issue: how many young people are exposed to drugs, how many of these young people will go on to develop a problem, what are the problems young people encounter, and how do these differ, if at all, from the problems adults face?

    Estimating how many adults use drugs is difficult for many reasons. People can be reluctant to share this information, fearing it may be shared with law enforcement agencies or that it could, in one way or another, create problems for them. This also applies to estimates of young people’s use of drugs. In some ways, the difficulties are amplified as substances which may be permitted for use by adults such as alcohol are prohibited for young people. With these caveats in mind, it is likely that any estimates of young people’s use of drugs including alcohol are likely to be underestimated at a population level.

    The Home Office conducts an annual survey of drug use in a sample of the population including young people aged between 16 and 24. This is probably the best estimate we have of drug use in this group and because it has been conducted for over twenty years it provides some valuable data in relation to overall trends of drug use among young people (Home Office, 2018).

    There appears to have been a slight increase in frequent drug use over the last 2-3 years as seen in Figure 1. It is clearly difficult to know if this is just a temporary change in the longer-term trend showing a gradual decline in drug use or if it marks a change in the trend, time will tell.

    Figure 1, frequent drug use 16-24 year olds England and Wales

    It is interesting to see the well-used term ‘drugs and alcohol’, which implies that alcohol is somehow distinct from drugs. However, alcohol is just as much a drug as tobacco is. Therefore it is important to include these two substances when exploring estimates of drug use among young people, although as if to demonstrate the point the Home Office does not include these two substances in their annual survey. So we need to look beyond England and Wales where the Home Office survey is conducted and turn to a survey that is conducted across Europe. The European School Survey Project on alcohol and other drugs is again not perfect but is probably the best resource we have for estimates of young people’s use of substances at a population level. This survey does not include young people from the United Kingdom. Interestingly, the survey reveals a gradual decline in young people’s use of alcohol and tobacco, see Figure 2. Although we can’t directly compare the Home Office survey and the European one it is interesting that both surveys show a long term decline in respective substance use.

    Figure 2, tobacco and alcohol use 15-16 year olds in Europe

    No one knows why fewer young people are using drugs but there are suggestions that attitudes have changed with more young people being comfortable in saying they don’t use drugs (Daly, 2017). It is also possible that their parents’ problematic relationship with drugs and alcohol has put them off from replicating the behaviours and problems they have witnessed. The rise in social media has left young people potentially more exposed and visible to others, so they may be reluctant to engage in drug use for fear of this being shared and judgements being made about them (Ramstedt, 2013; Pennay et al, 2015). The desire to succeed at school and university may also be a factor. However social media has also been found to increase the risk of problematic alcohol use for some young people (Nichols, 2012). These contrasting findings point to the need for further research. Although, it is possible that there are several factors potentially influencing young people’s use of substances rather than one factor which explains the gradual decline in use over time.

    Although trend data provide an overview of population-level drug use, it does not help us understand what is happening with sub-groups of young people. For example, despite an overall decline in drug use, there has been an increase in the use of cocaine and ecstasy by young people in England and Wales aged between 16 and 24 years old (Home Office, 2018).

    One Dutch study suggests that a small proportion of adults account for the majority of drugs consumed (van Laar et al, 2013). We do not know if this is also the case for young people but it is worth bearing in mind.

    Adolescence is a key period in human physiological and psychological development. It is also a time when some young people will initiate substance use. A mix of genetic and social factors appear to explain why some young people are at risk of developing problems while for others the impact on their lives is minimal. As with adults, availability and acceptance of drug use is influential. Thus, being offered drugs or at least having access to them is an obvious risk factor, as is the social acceptance of drug use in your immediate social circle, for if this group tolerates drug use then it also facilitates drug use (La Scala et al, 2005). Being male and having a sibling who uses drugs also increases the risk (Stone et al, 2012). Studies drawn from across the world, although these are dominated by western sources, consistently show that twice as many young men as young women are exposed to drugs (Degenhardt et al, 2016).

    Affiliation with marginalised, anti-social groups that use drugs remains the most consistent risk factor for drug use even when the previous risk factors mentioned are taken into account (Fergusson et al, 2008). It is still unclear what role socioeconomic status plays in adolescent drug use, and this is also true for adults. Therefore, although it may seem intuitive to link poverty and drug use, this link has still to be evidenced (Hall et al, 2016).

    Alcohol and tobacco are the most commonly used drug at this age (Degenhardt et al, 2016). Some children will be offered alcohol by their parents, whose attitudes to drinking have a significant influence on their children’s consumption of alcohol (Donovan, 2004).

    Beyond regulated drugs like alcohol and tobacco the most commonly used illicit drug is cannabis, which is frequently cited by adults with drug problems as to where they started their career of drug using (Public Health England, 2017). Although tobacco use is declining, some young people will be introduced to tobacco unintentionally via a cannabis joint, as cannabis is often combined with tobacco in a cannabis joint (Hamilton, 2017).

    A class of drugs known as Novel Psychoactive Substances (NPS) continues to present a risk to some young people even though most of these substances were made illegal following the introduction of the Psychoactive Substances Act in 2016. The term NPS is an umbrella term for synthetic drugs which claim to mimic the effects of other drugs, although, some NPS derivates will produce markedly differing effects compared to their more traditional counterparts. This can create confusion among young people and some health and social care staff in discerning exactly what class of substance the young person has used. For example, synthetic cannabinoid receptor agonists (SCRA’s) appear physically similar to organic cannabis but this physical resemblance is often the only similarity as the two drugs have significantly differing chemical constituents and effects on young people (Winstock et al, 2015).

    The most recent survey of school children in England aged between 11 and 15 years of age shows that 4% had tried nitrous oxide (laughing gas) and 2% had tried some other type of NPS (NHS Digital, 2017). This compares to 8% who had tried cannabis, 19% who had smoked a cigarette and 44% who had drunk alcohol.

    What to look out for that might indicate problem drug use

    Although there are some signs of drug use related to specific drugs there are some general points to consider in a clinical presentation. It is important to stress that these are just potential indicators and as you will see from the list, some factors could also be due to issues such as poor mental health rather than substance use, although both issues occurring in a young person are not uncommon. It is also important to stress that not all the factors listed need to be present to suggest a problem. The list is merely some suggested prompts to think about and explore with the young person or their carer.

    School; forgetting homework, truanting, declining grades; suddenly getting into trouble at school

    Personal appearance; loss of interest in personal hygiene, looking tired

    Appetite; sudden increase or decrease in appetite

    Having bloodshot eyes or dilated pupils; using eye drops to try to mask these signs

    Loss of interest in old hobbies; lying about new interests and activities

    Missing medications, prescriptions, money or valuables

    Acting uncharacteristically isolated, withdrawn, angry, or depressed

    Sudden mood changes or repeated health complaints, constant fatigue

    Dropping one group of friends for another; being secretive about the new peer group

    Demanding more privacy; locking doors; avoiding eye contact; sneaking around

    Risk factors to consider in a young persons presentation

    In tandem, it is useful to be aware of factors that increase the chances of a young person using substances. Although some of these were discussed in the earlier part of this introduction Mentor-ADEPIS an organisation that works with schools provides some additional risk factors in young people which can elevate the likelihood of drug use:

    10-16 year olds:

    • serious anti-social behaviour;
    • being in trouble at school (including truanting and exclusion);
    • friends in trouble;
    • being unhelpful;
    • early smoking;
    • not getting free school meals;
    • minor anti-social behaviour.

    And for 17-24 year olds:

    • anti-social behaviour;
    • early smoking;
    • being in trouble at school (including truanting and exclusion);
    • being impulsive;
    • being insensitive;
    • belonging to few or no groups.

    Potential mitigating factors include:

    • Strong family bonds;
    • Experiences of strong parental monitoring with clear family rules;
    • Family involvement in the lives of the children;
    • Successful school experiences;
    • Strong bonds with local community activities;
    • A caring relationship with at least one adult.

    Mentor ADEPSIS also makes the important point that the majority of children and young people will not report using drugs. This can sometimes be forgotten by workers, parents and young people, who might assume that the norm is to try drugs when the evidence suggests the reverse.

  • What we know already

    We know that many young people who experience adversity or trauma are at an increased risk of developing a problematic relationship with drugs (Moustafa et al, 2018). In some ways the use of substances as a method of coping with such trauma makes sense as some substances provide an effective way of numbing psychological pain as well as physical discomfort. Although this might provide a means of survival for some young people it is clearly not a solution to their problems as drug use can exacerbate the problems they face. Thus, while drugs may psychologically soothe, they can also create a range of other problems for young people. There is reasonable evidence pointing to the disruptive effect that drug use has on education, relationships and other areas of development, particularly in adolescence (Degenhardt et al, 2016).

    Given the impact drugs have on young people it would make sense to try and prevent or at least reduce the number of young people who use drugs, particularly for those at risk of developing problems due to drug use. Prevention has been the focus of successive governments in the United Kingdom and beyond. However, there is little evidence to support school-based drug education programmes, in fact some of these programmes have been found to be counter-productive in that they can stimulate interest in drugs (Fletcher et al, 2010). Rather than have a school-based drugs education programme for all age groups, it is better to provide children up to age 14/15 with an intervention which enhances life skills and focuses on building the child’s ability to think independently and assert themselves. Then when they reach sixteen, provide a more focussed programme around the reality of drug use which should include the pleasures as well as problems people experience.

    Overall the limited evidence as to what works in preventing young people from initiating drug use suggests that peer influence provides one way of potentially mitigating the risk. In a trial conducted in England, the ASSIST study used peer influence to good effect among school-aged children who were at risk of using cigarettes (Campbell et al, 2008). The role of peers continues to be explored as a means of minimising drug use in this age group, as evidenced in this recent announcement of a trial that will use popular peers to try and influence children to avoid drugs (White 2019). It is worth checking the results of this trial when they become available.

    Clinical guidance

    Using the available evidence, which it must be stressed is limited, some clinical standards have been produced. Four groups collaborated, The Royal College of Psychiatrists, Alcohol concern, Drugscope and the Royal College of General Practitioners to produce practice standards specifically for young people who are at risk of developing problems (College Centre for Quality Improvement 2012). Crucially, in drawing up these standards they consulted with Child and Adolescent Mental Health Services, although the guide is for a broad group of workers who come into contact with young people. In summary, the guide suggests the following areas are important to consider in responding to young people:

    1. engagement of the young person, and their family where possible;
    2. skilled initial analysis of the young person’s difficulties, including mental disorders and developmental problems such as learning disability, and life circumstances;
    3. engaging local systems so that they work together;
    4. coordinated, well-led interventions that mobilise the resources of local communities as required, including safeguarding, education, training, mental health and accommodation;
    5. active follow-up to detect the need for further episodes of support or intervention;
    6. prioritising and delivering the training and support of staff.

    These points may not look novel but they continue to be challenging to achieve. For example, joint work between mental health and drug treatment makes sense but both types of service often operate exclusion criteria that restricts access for young people who have co-occurring mental health and substance use problems (Hamilton, 2014).

    However, the guide does provide a useful summary of points to consider in assessment as well as what might be effective for specific groups of young people in the way of interventions. Broadly speaking this supports the idea that a whole team approach which uses a shared approach to treatment is recommended.

  • Areas of uncertainty

    Most of what we know about drugs and the problems people develop as a result of using them is based on the experience of adults. Research is, therefore, adult-centric and the evidence base for clinical interventions has been developed with adult-based samples. However, when we explore all interventions for people who develop problems such as dependency, what becomes apparent is that no one intervention is superior to another. So whether an intervention is cognitive in approach or behavioural or a combination of these approaches, the qualities and skills of the therapist are critical (Miller et al, 2015). These include being empathic, warm, genuine, honest, a good listener etc, it is likely that this also stands for working with children and young people who have problems with drugs, they are also more likely to engage and respond to a worker/therapist who demonstrates these qualities. This should reassure CAMHS workers as these are skills that they are likely to have already and will continue to hone throughout a career.

    There are significant gaps in our knowledge regarding what are effective ways of preventing young people from using drugs and then how best to intervene with young people who use drugs and develop a problem. Most of what we know about clinical interventions is based on adults and has not been tested on young people, and this needs to change (Stockings et al, 2016).

  • What’s in the pipeline

    It is encouraging to see a more sophisticated approach to prevention evolving in school-based drugs education. While it is clearly important to try and reduce the number of young people developing problems with drugs it is unlikely that we will prevent all problematic drug use.

    We need to think about high-risk groups of young people, which broadly fall into two groups. The first is the naïve user who might try a drug including alcohol for the first time and due to their inexperience or lack of knowledge become unwell or overdose. It is important not to assume that young people have all the facts and knowledge about the drugs they intend on using. This could provide an opportunity for those in contact with this group to explore the young person’s knowledge and perception of risk. Although abstaining from use might not be possible there is an opportunity to discuss harm minimisation with the young person. For example, ask them to consider starting with a small dose of a drug and waiting for that to take effect before re-dosing. Also, to ensure they are in a safe place and with people they trust to help them if they do develop a problem. Mobile applications are showing some promise in their ability to deliver such messages to young people about substances including alcohol (Hides et al, 2018).

    One of the difficulties everyone faces when using drugs is not knowing what is in the drug or how potent it might be. Over recent years drug testing facilities have emerged at music festivals, city centres and universities providing important information to young people about the potency of a drug they might use or if it contains toxic contaminants (Measham, 2018).

    The second group are those who will start their drug using career early in life. Thus far, the service response to this group has been to compartmentalise their problems. For example, mental health services will only support the young person’s mental health, even if this is influenced by use of drugs. Drug services mirror this by referring a young person onto mental health services when a mental health problem is identified. This needs to change and move towards an integrated service response that recognises underlying factors such as trauma which instigates problems with drugs and mental health. Although this issue is not new, unfortunately providing a more joined-up approach to this group of young people remains an ambition rather than a reality. Reflecting this ambition, Young Minds and Addaction produced an expert briefing which provides recommendations on how commissioners and providers of services can respond to young people who have these dual needs (Young Minds/Addaction, 2017).

    We have seen reduced funding for young people’s services in the United Kingdom over recent years. Therefore, in this environment there is a need to accelerate more imaginative ways of reaching out to young people and providing support in a timely and appropriate way. Social media applications are one such way that should be considered either as a stand-alone method or to augment more structured treatment approaches. These types of interventions have the potential to be individually tailored, to provide privacy, to be low cost and to be delivered at any time and at a pace that suits the young person (Ward et al, 2017).

  • Summary

    Reducing the potential for harm that young people might be exposed to in relation to drugs should be the focus of prevention strategies and clinical intervention. However, since 2010 the British government has promoted abstinence from drugs at a population level and in directives to treatment commissioners. This has been driven by political ideology rather than evidence. Some young people will not be served well by abstinence-orientated approaches to treatment and abstinence may not be a realistic aim in treatment. Harm reduction approaches such as drug testing, outreach and informal education are good ways of engaging young people who are at risk.

    It is encouraging to see an increased research focus on young people and their use of drugs. It is of paramount importance that we consider young people as a distinct group worthy of time and attention and not simply apply adult-tested interventions on them. Although there is much more to understand on this issue there have been promising developments which are worth following, particularly those that augment traditional treatment approaches such as the use of social media.

    As with fashion, new drugs will emerge and the old staples like cannabis will continue to be used. It should be reassuring for those working with young people that the ability to form a therapeutic relationship is critical in treatment irrespective of the type of drug used. Although skills in communication and attributes such as warmth, honesty and empathy take a career to hone, we all have the ability to employ them.

    Young people who develop problems with drugs will have issues that go beyond just the type of drugs used, whether that is coping with mental health, trauma or social problems. No worker can successfully deal with this range of issues on their own, and therefore collaboration with others will be key. Though it is not a fashionable nor novel idea, relationships need to be forged and maintained.

  • Useful organisations and resources

    Drugscope provide a daily round up of news, research & opinion related to drugs to your email inbox. This is a useful way of keeping up to date, subscribe via this link.

    My Crew is an organisation funded by the Scottish government which aims to provide impartial advice about drugs, This includes a risk checker where a young person can enter the name of a drug or up to three drugs at once and read information about the risks of using.

    Volteface provide a useful summary of drug education programmes 

    Introduction

    British Medical Journal, 2017. Novel psychoactive substances; types, mechanisms of action, and effects

    Daly, M. 2017. This is why gen Z isn’t into drink or drugs

    Degenhardt, L., Stockings, E., Patton, G., Hall, W.D. and Lynskey, M., 2016. The increasing global health priority of substance use in young people. The Lancet Psychiatry3(3), pp.251-264.

    Donovan, J.E., 2004. Adolescent alcohol initiation: A review of psychosocial risk factors. Journal of adolescent health35(6), pp.529-e7.

    Fergusson, D.M., Boden, J.M. and Horwood, L.J., 2008. The developmental antecedents of illicit drug use: evidence from a 25-year longitudinal study. Drug and alcohol dependence96(1-2), pp.165-177.

    Hall, W.D., Patton, G., Stockings, E., Weier, M., Lynskey, M., Morley, K.I. and Degenhardt, L., 2016. Why young people’s substance use matters for global health. The Lancet Psychiatry3(3), pp.265-279.

    Hamilton, I. 2017. Healthcare professionals need more guidance to reduce the risk of cannabis related health problems. British Medical Journal

    Home Office 2018 Drug misuse: findings from the 2017 to 2018 CSEW

    LaScala, E., Freisthler, B. and Gruenewald, P.J., 2005. 2.5 Population Ecologies of Drug Use, Drinking and Related Problems. Preventing harmful substance use: The evidence base for policy and practice, p.67.

    Mentor-ADEPIS

    Nicholls, J., 2012. Everyday, everywhere: alcohol marketing and social media—current trends. Alcohol and alcoholism47(4), pp.486-493.

    NHS Digital, 2017. Smoking, drinking and drug use among young people in England – 2016

    Pennay, A., Livingston, M. and MacLean, S., 2015. Young people are drinking less: It is time to find out why. Drug and alcohol review34(2), pp.115-118.

    Public Health England, 2017. What we know about young people in alcohol and drug treatment

    Ramstedt M. Determinants of non-drinking among Euro-pean adolescents: a cross cultural comparison. Kettil BruunSociety Alcohol Epidemiology Symposium; Kampala, Uganda, 2013.

    Stone, A.L., Becker, L.G., Huber, A.M. and Catalano, R.F., 2012. Review of risk and protective factors of substance use and problem use in emerging adulthood. Addictive behaviors37(7), pp.747-775.

    The European School Survey Project on alcohol and other drugs, 2016. Results from the European School Survey Project on Alcohol and Other Drugs

    van Laar, M., Frijns, T., Trautmann, F. and Lombi, L., 2013. Cannabis market: User types, availability and consumption estimates.

    Winstock, A., Lynskey, M., Borschmann, R. and Waldron, J., 2015. Risk of emergency medical treatment following consumption of cannabis or synthetic cannabinoids in a large global sample. Journal of Psychopharmacology29(6), pp.698-703.

    What we know already

    Campbell, R., Starkey, F., Holliday, J., Audrey, S., Bloor, M., Parry-Langdon, N., Hughes, R. and Moore, L., 2008. An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial. The Lancet371(9624), pp.1595-1602.

    College Centre for Quality Improvement, 2012. Practice standards for young people with substance misuse problems

    Fletcher, A., Bonell, C. and Sorhaindo, A., 2010. “We don’t have no drugs education”: The myth of universal drugs education in English secondary schools? International journal of drug policy21(6), pp.452-458.

    Hamilton, I., 2014. The 10 most important debates surrounding dual diagnosis. Advances in Dual Diagnosis7(3), pp.118-128.

    Moustafa, A.A., Parkes, D., Fitzgerald, L., Underhill, D., Garami, J., Levy-Gigi, E., Stramecki, F., Valikhani, A., Frydecka, D. and Misiak, B., 2018. The relationship between childhood trauma, early-life stress, and alcohol and drug use, abuse, and addiction: An integrative review. Current Psychology, pp.1-6.

    White, J. 2019. Frank friends

    Areas of uncertainty

    Miller, W.R. and Moyers, T.B., 2015. The forest and the trees: relational and specific factors in addiction treatment. Addiction110(3), pp.401-413.

    Stockings, E., Hall, W.D., Lynskey, M., Morley, K.I., Reavley, N., Strang, J., Patton, G. and Degenhardt, L., 2016. Prevention, early intervention, harm reduction, and treatment of substance use in young people. The Lancet Psychiatry3(3), pp.280-296.

    What’s in the pipeline

    Hides, L., Quinn, C., Cockshaw, W., Stoyanov, S., Zelenko, O., Johnson, D., Tjondronegoro, D., Quek, L.H. and Kavanagh, D.J., 2018. Efficacy and outcomes of a mobile app targeting alcohol use in young people. Addictive behaviors77, pp.89-95.

    Measham, F.C., 2018. Drug safety testing, disposals and dealing in an English field: Exploring the operational and behavioural outcomes of the UK’s first onsite ‘drug checking’ service. International Journal of Drug Policy.

    Ward, J., Davies, G., Dugdale, S., Elison, S. and Bijral, P., 2017. Achieving digital health sustainability: Breaking free and CGL. International Journal of Health Governance22(2), pp.72-82.

    Young Minds / Addaction 2017. Childhood adversity, substance misuse and young people’s mental health