Substance Use Assessment & Treatment

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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. There are nine separate classes of drugs identified in the DSM-5 (1) that can involved in a substance use disorder: alcohol; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants (amphetamine-type substances, cocaine, and other stimulants); tobacco; and other (or unknown) substances.

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. See Assessment section for diagnostic criteria.

Onset, prevalence, and burden 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 74% had tried alcohol, 15% had used cannabis, and 17% had used inhalants at some time in their lives (2).

Substance use disorders are among the most common of mental health disorders experienced by young people. In Australia, 12.7% 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%).

Studies have consistently demonstrated that the prevalence of substance use and abuse increases with age during adolescence and peaks in early adulthood. Overall, about half of people with substance use disorders first experience substance use issues by the age of 20 years (4).

Despite the high prevalence, people with substance use disorders often don't recognise or seek help for the problem. They also may not be screened for substance use when they seek treatment for other health conditions, which means that substance use disorders are often under-recognised and undertreated. An Australia survey found that despite disproportionately high rates of substance use disorders in young people, there was a very low rate of help-seeking associated with these, particularly in young men (5).

In those aged 10-24 years, alcohol use is the fourth leading contributor to the burden of disease in males (6). The burden from substance abuse is more than three times as high in males as in females (7).

A number of adverse outcomes have been associated with excessive substance use (8-11). They include the following:

  • In the short-term, excessive alcohol consumption increases the risk of physical injury from falls, violence and road accidents
  • Long-term harms include liver and cardiovascular disease, cancers, obesity, as well as increased risk of mental illness
  • Young drinkers have also been found to be particularly at risk of memory loss, violence, and unwanted sexual activity, as a result of alcohol use
  • Substance use (cannabis use in particular has been researched in a number of studies) poses a risk for delayed social and academic development, and may also impact on brain development among adolescents

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 (12). However it is often unclear whether one issue causes the other.  An Australian survey found high rates of comorbidity in those with substance use disorders (13). 1 in 5 Australians with a substance use disorder also met criteria for an affective disorder and 1 in 3 met criteria for an anxiety disorder.

Risk factors

A number of factors can increase the likelihood that a young person will develop a substance use disorder (14-16). They include the following:

Related to the individual:

  • Being male
  • Tendency for disinhibited behaviour (e.g. engaged in risk-taking behaviours in childhood)
  • Early age of first use (e.g. risk of alcohol dependence is 4x higher for people who first tried alcohol before the age of 15 years, compared to before the age of 20 years)
  • Personal beliefs (e.g. beliefs that substance use does not have a negative impact on health, or lack of belief in conformity or moral order)
  • Low self-esteem
  • Underachievement at school or low commitment to school
  • Traumatic experiences (e.g. abuse as a child, or being bullied)
  • Childhood ADHD or conduct disorder
  • Other mental disorders (e.g. depression, anxiety)
  • Poor coping skills (e.g. responding to interpersonal conflicts in an aggressive manner)

Related to the family:

  • Parents or family members have a substance use disorder (heritability of substance dependence is estimated at 30-60%)
  • Parental attitude towards drugs and alcohol and parental role-modelling (e.g. seeing parents engaging in drug use)
  • Low parental monitoring or discipline
  • Poor family cohesion
  • Patterns of negative communication in the family

Related to the community and society:

  • Peers use drugs or alcohol
  • Drugs or alcohol are readily available
  • Acceptability of substance use

 

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

2 White, V. B., & Bariola, E. (2013). Australian secondary school students' use of tobacco, alcohol, and over-the counter and illicit substances in 2011. Report prepared for: Drug Strategy Branch Australian Government Department of Health and Ageing. December 2012.

3. Australian Institute of Health and Welfare 2011. Young Australians: their health and wellbeing 2011. Cat. no. PHE 140 Canberra: AIHW

4. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey ReplicationArchives of General Psychiatry62(6), 593-602.

5. Reavley, N. J., Cvetkovski, S., Jorm, A. F., & Lubman, D. I. (2010). Help-seeking for substance use, anxiety and affective disorders among young people: results from the 2007 Australian National Survey of Mental Health and WellbeingAustralian and New Zealand Journal of Psychiatry44(8), 729-735.

6. Gore, F. M., Bloem, P. J., Patton, G. C., Ferguson, J., Joseph, V., Coffey, C., ... & Mathers, C. D. (2011). Global burden of disease in young people aged 10-24 years: a systematic analysis. The Lancet, 377(9783), 2093-2102.

7. Begg S, Vos T, Barker B, Stevenson C, Stanley L, Lopez AD, 2007. The burden of disease and injury in Australia 2003. PHE 82. Canberra: AIHW.

8. National Health and Medical Research Council (Australia). (2009). Australian guidelines to reduce health risks from drinking alcohol. Canberra: National Health and Medical Research Council.

9. Bonomo, Y., Coffey, C., Wolfe, R., Lynskey, M., Bowes, G., & Patton, G. (2001). Adverse outcomes of alcohol use in adolescentsAddiction96(10), 1485-1496.

10. Masten, A. S., Faden, V. B., Zucker, R. A., & Spear, L. P. (2008). Underage drinking: A developmental frameworkPediatrics121(Supplement 4), S235-S251.

11. Macleod, J., Oakes, R., Copello, A., Crome, I., Egger, M., Hickman, M., ... & Smith, G. D. (2004). Psychological and social sequelae of cannabis and other illicit drug use by young people: a systematic review of longitudinal, general population studiesThe Lancet363(9421), 1579-1588.

12. Riggs, P., Levin, F., Green, A. I., & Vocci, F. (2008). Comorbid psychiatric and substance abuse disorders: recent treatment researchSubstance Abuse29(3), 51-63.

13. Teesson, M., Slade, T., & Mills, K. (2009). Comorbidity in Australia: findings of the 2007 national survey of mental health and wellbeingAustralian and New Zealand Journal of Psychiatry43(7), 606-614.

14. Meyers, J. L., & Dick, D. M. (2010). Genetic and environmental risk factors for adolescent-onset substance use disordersChild and Adolescent Psychiatric Clinics of North America19(3), 465-477.

15. Stone, A. L., Becker, L. G., Huber, A. M., & Catalano, R. F. (2012). Review of risk and protective factors of substance use and problem use in emerging adulthoodAddictive Behaviors37(7), 747-775.

16. Crome, I., Macleod, J., Bloor, R., & Hickman, M. (2007). Predictive factors for illicit drug use among young people: a literature review. UK: Research Development and Statistics Directorate, Home Office

Assessment

In the DSM-5, a substance use disorder is diagnosed based on evidence of at least 2 of the following features (1):

Impaired control:

(1) Substance often taken in larger amounts or over a longer period than was intended

(2) Persistent desire or unsuccessful efforts to cut down or control substance use

(3) Significant time spent trying to obtain substance, or recovering from its effects

(4) Craving, or a strong desire or urge to use substance

Social impairment:

(5) Recurrent substance use resulting in a failure to fulfil major role obligations (e.g. at work, school, or home)

(6) Continued substance use despite recurrent social or interpersonal problems related to substance use

(7) Important social, occupational, or recreational activities are given up or reduced because of substance use

Risky use:

(8) Recurrent substance use in situations in which it is physically hazardous

(9) Continuing substance use despite knowing that it is likely to have caused or exacerbated a physical or psychological problem

Pharmacological criteria:

(10) Developing tolerance to the substance

(11) Experiencing withdrawal symptoms

 

Severity of the disorder is determined by the number of diagnostic criteria met:

Mild: 2-3 symptoms

  • Moderate: 4-5 symptoms
  • Severe: ≤ 6 symptoms

 

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 effects 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

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 is a large number of screening and assessment tools used to establish substance abuse in young people (2,3).  Commonly used tools in Australia (4) include the Alcohol Use Disorders Identification Test (AUDIT), the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), and the CRAFFTScreening Tool.

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

2. Martin, C. S., & Winters, K. C. (1998). Diagnosis and assessment of alcohol use disorders among adolescentsAlcohol Health and Research World22(2).

3. Winters, K. C., & Kaminer, Y. (2008). Screening and Assessing Adolescent Substance Use Disorders in Clinical PopulationsJournal of The American Academy of Child & Adolescent Psychiatry47(7), 740.

4. Croton, G. (2007). 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.

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 on social competence and social influence (2); and for alcohol use specifically, family-based programs (3) (in particular, the Strengthening Families Program) and culturally-focused skills training appear to offer promise (4).

Treatment options for young people that have been demonstrated to be effective or promising include motivational interviewing (5), group counseling (6), family therapy (multidimensional and fuctional) and group cognitive behavior therapy (6-8). Family behavior therapy and individual cognitive problem-solving therapy are effective approaches for young people with a dual diagnosis (9).

When medications are used in this group, it is often to counteract the adverse effects of withdrawal or to treat co-occurring mental disorders, rather than to treat the substance use. Overall, little is known about the effectiveness and safety of using medications to treat substance use disorders in young people (8,10).

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

References

1. Gates S, McCambridge J, Smith LA, Foxcroft D. Interventions for prevention of drug use by young people delivered in non-school settings. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005030. DOI: 10.1002/14651858.CD005030.pub2.

2. Faggiano F, Minozzi S, Versino E, Buscemi D. Universal school-based prevention for illicit drug use. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD003020. DOI: 10.1002/14651858.CD003020.pub3.

3. Foxcroft DR, Tsertsvadze A. Universal family-based prevention programs for alcohol misuse in young people. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD009308. DOI: 10.1002/14651858.CD009308.

4. Foxcroft D, Ireland D, Lowe G, Breen R. Primary prevention for alcohol misuse in young people. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. No.: CD003024. DOI: 10.1002/14651858.CD003024.pub2.

5. Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele, R. G. (2011). Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic reviewJournal of Consulting and Clinical Psychology79(4), 433.

6. Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). The comparative effectiveness of outpatient treatment for adolescent substance abuse: A meta-analysisJournal of Substance Abuse Treatment44(2), 145-158.

7. Waldron, H. B., & Turner, C. W. (2008). Evidence-based psychosocial treatments for adolescent substance abuseJournal of Clinical Child & Adolescent Psychology37(1), 238-261.

8. Deas, D. (2008). Evidence-based treatments for alcohol use disorders in adolescentsPediatrics121(Supplement 4), S348-S354.

9. Bender, K., Springer, D. W., & Kim, J. S. (2006). Treatment effectiveness with dually diagnosed adolescents: A systematic reviewBrief Treatment and Crisis Intervention6(3), 177.

10. Simkin, D. R., & Grenoble, S. (2010). Pharmacotherapies for adolescent substance use disorders. Child and Adolescent Psychiatric Clinics of North America19(3), 591-608.

Guidelines

The following guidelines provide evidence-based information about the treatment of substance use disorders in young people (marked with an *) and adults:

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.

Haber, P., Lintzeris, N., Proude, E., and Lopatko, O. (2009). Guidelines for the Treatment of Alcohol Problems. Australian Government Department of Health and Ageing.

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

School based interventions on alcohol (2007). National Institute for Health and Clinical Excellence (NICE) public health guidelines PH7, United Kingdom.

Interventions to reduce substance misuse among vulnerable young people (2007). National Institute for Health and Clinical Excellence (NICE) public health guidelines PH4, United Kingdom.

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

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

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

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

More Information

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

Centre of Excellence in Youth Mental Health. Evidence summary: the effectiveness of Motivational Interviewing for young people engaging in problematic substance use. (2012). Melbourne: Orygen Youth Health Research Centre.

Winters, K. C., Botzet, A. M., & Fahnhorst, T. (2011). Advances in adolescent substance abuse treatmentCurrent Psychiatry Reports13(5), 416-421.

Parenting Strategies Program (2010). Parenting Guidelines for Adolescent Alcohol Use. Melbourne: Orygen Youth Health Research Centre, University of Melbourne.

National Health and Medical Research Council. (2009). Australian guidelines to reduce health risks from drinking alcohol.

Mental Health First Aid Australia. Helping someone with problem drinking: mental health first aid guidelines. Melbourne: Mental Health First Aid Australia. 2009.

Mental Health First Aid Australia. Helping someone with drug use problems: mental health first aid guidelines. Melbourne: Mental Health First Aid Australia; 2009.

Mental Health First Aid Australia. Helping someone with problem cannabis use: mental health first aid guidelines. Melbourne: Mental Health First Aid Australia; 2009.

Centre of Excellence in Youth Mental Health. Evidence summary: the effectiveness of motivational interviewing for young people with substance use and mental health disorders. (2009). Melbourne: Orygen Youth Health Research Centre.

Dawe, S., Harnett, P., Kowalenko, S., & Harlen, M. (2008). Supporting the families of young people with problematic drug use: Investigating support options. Canberra: Australian National Council on Drugs