Psychoactive substance use and adolescence (part I ...

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Jul 12, 2009 - To cite this article: J. Howard (1997) Psychoactive substance use and ... School of Behavioud. Sciences. Mwquuic. University. Sydney. NSW.
Journal of Substance Misuse

ISSN: 1357-5007 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ijsu19

Psychoactive substance use and adolescence (part I): prevention J. Howard To cite this article: J. Howard (1997) Psychoactive substance use and adolescence (part I): prevention, Journal of Substance Misuse, 2:1, 17-23, DOI: 10.3109/14659899709084611 To link to this article: https://doi.org/10.3109/14659899709084611

Published online: 12 Jul 2009.

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Psychoactive substance use and adolescence (part I): preventiron J. Howard It is generally accepted that the best predictor of experimentation with both illicit and licit substances by young people is being young.

The context of the initiation and maintenance of adolescent substance use in developed and developing countries i s described, as are the functional nature of much substance use by young people and possible consequences of such use. The view is put that school-based prevention efforts to date have yielded few positive results. Suggestions are made to increase the effectiveness of interventions; particularly by increased involvement of the target population(s) and attention to non-school variables such as the family and the community.

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INTRODUCTION

John Howard Mq MClinPsych, PhD. DipCrlm. Director. Clinical Drug Dependence Studies, School of Behavioud Sciences. Mwquuic University. Sydney. NSW. Aurmlia 2 I09

(Rquerufor oflprinu to JH) Mlnurcript accepted December I995

Adolescent psychoactive substance use and dependence are complex and dynaniic public health issues which require comprehensive and integrated approaches. Characterized by rapid changes in the pattern and context of use, types of substances used, and related problems in countries worldwide, they are products of a constellation of factors in the personal and social lives of individual young people and communities. The popular view that illicit substances are the major problem contradicts the scientific evidence that the harm to public health induced by those which are licit (alcohol and tobacco) is far greater (WHO 1995). . In developing countries, the problenis related to the use of tobacco, alcohol and other psychoactive substances are purallel to and associated with other enornious hcalth, econoniic and social problem, making it ditljcult to prioritize actions ( W H O 1994). In addition die

Journal ofbbrtonce Mirurr ( 1997) 1. 17-13

0 I997 P a w n Pmfasiod Ltd

‘drug industry’ can be a source of income to the poor ( W H O 1995). The arrival of HIV/AIDS has exacerbated thc situation and added a sense of urgency, especially where injectinb7 IS ’ common and sexual safety compromised by intoxication and other substance use-related everits, such as impaired judgement (Howard 1993, UNECA 1994). Despite many commonalities, developed and developing countries differ in their experience of substance use and related harm. Most developed countries have seen a stabilization, and even a decline, in alcohol and tobacco use among school-aged youth, although tobacco and alcohol continue to be the most important in terms of public health consequences (Bailey 1989, Newcomb & Bentler 1989). However, some of the gains have begun to erode, with increases in cannabis use, and, in some cases, more young women than men smoking (DHHCS 1995, USDHHS 1993a, 1994). I n contrast, alcohol, and tobacco use and related harm have been rapidly increasing in dcvcloping countries ( W H O 1993). In many countries, particularly in the devcloped world, other changes are occurring (Howard 1994. USDHHS 1 W h ) : Multiple substancc LISC Use of new substances such as Ecstasy (MDM A) 0 Combining stibmiiccs 0 Chaiigcs in modes of adniinistration, (particularly to injecting). 0 0

In sonic developed and dcvclopirig countries, volatile substance abuse is a n increasing problem, especially in marginalized groups, including street children and indigenous young people ( W H O 1993, 1995).

THE IMPACT It is generally accepted that the best predictor of experimentation with both illicit and licit substances by young people is being young. Adolescence is a time of experimentation, esploration, curiosity and identity search, and part of such a quest involves sonie risk taking. By the time of adolescence young people have also been exposed to many substances, especially those which are easily available and relatively cheap such as:

glue tobacco 0 petrol 0 alcohol 0 cannabis. 0 0

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Within a niilieu of social and peer influence and expectations, together with easy availability and variety, substance use can become one aspect of the developmental process, and even a part of life. Adolescence is also the time where many behaviour patterns become more entrenched; including personality disorders, substance use and associated problem behaviours (Howard 1994, Newcomb & Bentler 1989, Perry 1987). Most young people who try substances do not continue their use or develop significant problems (Howard 1994, Rutter & Smith 1995). Some US studies indicate that only between 6% and 10% of adolescents meet criteria for substance dependence (Bailey 1989). Experimentation, and a variable pattern of use and cessation are common. Much use of substances is not mindless or pathological, but flnctional. When surveyed, young people in developed and developing countries cite boredom, curiosity and wanting to feel good (or better) as the main reasons for use (Howard 1994, W H O 1395). Other functions scrvcd by substance use are: 0 0 0 0

0 0

To rclicvc hunger To adopt a rebellious st;iiicc For pccr/social acccytaiicc To rclicvc pain To keep awake or get to slccp To drcaiii.

Therefore, substance use is often seen by young pcoplc as a solution rather than a problcni. Thc pathways for young pcoplc who develop patterns of regular and problciiiatic or liartiifill iisc appear to differ froin those who mcrcly cxpcrinicnt or maintain irregular use. I’cnonality characteristics, individual differences in vulnenbility, family difficulties, association with substance-using peers, differential exposure to substances, shared and non-shared environments, and accumulations of social disadvantage all play a role (Bailey 1989, Howard 1994, Moncher et a1 1991, Rutter & Smith 1995). The interplay of these variables in particular cultures and situations, or more broadly varying contexts, is crucial. Sonie groups of young people have been identified as being at risk of substance use and associated problems, usually due to a greater number of stressors in their lives and/or weakened resilience. Of special concern are young people froni war-tom societies, refugees, indigenous young people, street children and other marginalized young people, for example gay/lesbian young people and those involved in juvenile justice systems (Hamnielman 1993, W H O 1995). These young people may have ditTcrent pattenis of initiation and niaiiitenance ofusc, and may need specific approaches.

Young w o m e n have particular issues in relation to substance use that require attention. There are, in addition to physiological differences, social and economic ones which impinge on fiinctioning and their health. Often, young women are introduced to substance use by male partners, and use may be maintained, for some involved in commercial sex work, by their ‘pimps’. Sexual assault may be more common for young women than young men, and young women ‘on the street’ tend to exhibit greater levels of psychosocial distress and negative life events than do the young men (Howard 1992). Young women substance users are often viewed more negatively than young males. In addition, in many parts of the world, young females have fewer economic opportunities and receive less nutritious and smaller quantities of food than their brothers (WHO 1995). Just as there are diverse patterns of substance use aniong young people there is a wide range of consequences related to such use. These include harniful health consequcnces (physical and mental) related to the direct effects of the substances themselves, the ways in which substaiiccs are used and the situations in which use occiirs. The toxic effects of specific substances cause short-tcmi and long-tcmi hcalth damage, such as aciitc psychotic rcactions mid cardix arrhythmias froni psychostiiiiulant iisc, brain damage froni excessive and prolonged alcohol consumption and, possibly froni inhalation of volatile solvents, and respiratory and cardiovascular disease froin chronic siiioking (Kirsch 1995, lliittcr & Smith 1995, W H O 1995) The co~iscqiiciiccsof LISC arc dctcriiiiiied to a large extent by the cultural, legal, social and econoniic context of use. Furthemiore, harniful effects of substance use by young people are often felt by families, communities and society at large. Harm results directly from personal use as well as from the use of those around them, i.e. other young people, family members and other adults. Harm also results from the criminalization of users, and in particular their incarceration, which can increase their niarginalization and decrease their access to and participation in interventions to address any substance use-related harm. Substance use is associated with many risky behaviours, and broad rather than narrow interventions are required to deal with the range. Risky sexual behaviour while intoxicated increases the risk of unplanned pregnancies and sexually transmissible diseases. Road traffic and other accidents, often associated with substance use, are a niajor cause ofmortality and injury among children and young people. T o survive, inany young people put themselves a t risk of violence by working in the

Psychoactive substance use and adolescence (part I ) illicit substance and comniercial sex industries ( W H O 1995). Finally, the increase in suicides and homicides among young people (in developed countries in particular) is seen to be associated with substance use (Newcomb & Bentler 1989). As substance use spreads through communities, family and social problems become more frequent. Young substance users become alienated within their communities, making them more difficult to reach and more vulnerable to health problems. They find themselves discriminated against and used as scapegoats. Failure at school, early ‘drop out’ and underachievement are further consequences. These problems translate into reduced opportunities for productive employment and independence. Substance use by both parents and children often increases family tension, which may result in farmly breakdown and child abuse. Health consequences may be immediate, or the development of chronic, often fatal, conditions may begin: for example, with tobacco (WHO 1995). However, the use of substances brings many rewards, such as escape and status. T h e age at which initiation and, in particular escalation and maintenance of use occur is crucial. Intensive and/or prolonged usc can truncate, interfere with or circumvent essential maturational processes and dcvelopnient, producing ‘developmental lags’. The initial routc of administration of the substance, dose, whcrc and with whom substances are used, and any changes over time are also significant variables. Risks can be greater for experimenters with limited access to accurate infomiation, equipment and supports, and for chronic dependent users. Thus, how to delay onset of use, or escalation, and route of adnlinistration are important considerations (Howard 1994, Newcomb & Bentler 1989, Trad 1994).

PREVENTION T h e purpose of prevention can be to: 0 0 0

Prevent use (even experimental) Reduce use Encourage safer use Provide for harm/risk minimization.

I t may be seen as an active, assertive process of creating conditions and/or personal attributes that promote the well-being ofpeople. Prevention interventions have typically focused on: 0 0

Mass media campaigns School-located interventions, where students may receive specific input on

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substances and thcir effects. on-going substance USK education as part of a life skills/persoiial developmcnt curriculum, or short programmes delivered by persons external to the school education system, such as nurses, mental health professionals or police officers 0 Community-wide interventions 0 Projects directed toward ‘high risk‘ out-ofschool youth 0 Various activities such as rock concerts and sporting events sponsored by the health promotion sector. These efforts have typically targeted tobacco and alcohol, in part due to the belief that earlier and regular use of these substances is associated with other problem behaviour; other substance use and anti-social activities in particular (Jessor & Jessor 1977). This paper focuses on schoolbased interventions. While the involvement of the health sector may not be obvious in the predominantly school-located interventions, health professionals such as nurses have usually been involved in most developments; providing input to intervention planning, sponsorship and/or funding, assisting in delivery of the intcrventions, o r in the actual delivery. Most available o u t c o m e research on these interventions is froni English speaking and devcloped countrics, and any gencralizing froni this research to non-anglophone and/or devcloping countries should be cautious. That said. the outcomes of prevention efforts to date have not generally been wen as cause for enthusiasni. There have been clainis of s~iccessand counter clainis of negative outcomes but, on balance, the view o f w h e e l e r (1990) appears cogent: T h e history of drug education has not been one of spectacular success.. . This history of failure can be traced to the inability of earlier drug educators to comprehend why people take drugs. Perceiving drug taking to be a totally negative experience, they were forced to conclude that there must be Something wrong with drug takers. (p.140). In addition, school-located programmes can be limited in only being able to address a small range of the complex factors which are associated with the onset, escalation and maintenance of substance use. Schools d o not exist within a social vacuum, and issues of poverty, criminal gangs, the need for income generation for individuals and families (often to support continued involvement in education), and various elenients of family dysfunction and breakdown, are often beyond the reach of schools. Their focus is often, then, niore 011 the individual and negative peer influence resistance.

20 journal ofsubstance Misuse

... many young people who most need an effective interventionare not at school when it is delivered; they are truanting, have been suspended, or are needed by their parents to generate income or provide chiId/houseminding tasks. I

An additional concern is that many young people who most need an effective intervention are not at school when it is delivered; they are truanting. have been suspended, or arc needed by their parents to generate income or provide child/house-minding tasks. The latter is particularly the case in some developing countries where only a small percentage of young people enter and remain in secondary education. The &st generation of drug education (the ‘information deficit model’) assumed that if people knew the dangers they would not take drugs. This generation of programmes yielded results which generally indicated no change to an increase in use (Bangert-Drowns 1988, Perry 1987, USDHHS 1994, Wheeler 1990). The second generation of drug education (the ‘affective and psycho-social models’) assumed that young people had inadequate personal and social dcvclopment, and that if people had better self-esteem, comniunication and decision-making skills they would not take drug. This was a blend of social inoculation. social learning a n d problcni bchaviour theory. The ;ippro;icIi tended to scc pccr pressure atid advertising iis the iiicdiatiiig variables, and low self-cstccni a i i d pcrsoii:iI co~iipcte~icc ;is sigiific;iiit driviiig forces. However, the rclntiotisliip with pccrs has bccii qucstioiicd; is it pccr prcssure or self-sclcctioii ofpccrs with similar interests? Tlic iiiost prcvalciit school-b;iscd prcvcntioii progr;tiiitw in thc USA, Project DARE (I>rug Abuse Iepartmciit of Hcdklr. Housing and Conini unity Services (DHHCS) IWS Statistics on dnig abuw in Australia lYJ4. Austr.lli;iii C;ovcmiiiciit I’rinting Service. Caiibcrra I h i i N. M u j i K I‘YJ2 I)nigprcvciitii~ii: ;I review ofthe Eiiglish I;iiigii:igc Iitcr;~ttirc.Iiirtitiitc b r the Study of I )nig I)cpciiilciicc. Londoi~.I