National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Chapter 4. The health of young people
Illicit drug use
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☰ Table of contents

Recommendations: Preventing child maltreatment – Supporting families to optimise child safety and wellbeing

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

Immunisation

 All young people (aged 12–24 years) Review hepatitis B immunisation and immune status and offer vaccination where indicated (refer to Chapter 14: Sexual health and blood-borne viruses) As per Australian standard vaccination schedule GPP 70

Screening

 All young people Assess for presence of risk factors for illicit drug use (Box 1) As part of annual health check GPP 1, 8, 92, 93
Young people with risk factors for drug use (Box 1) Administer one of the following questionnaires to ascertain drug use:
  • CRAFFT screening tool (age ≤21 years)
  • Indigenous Risk Impact Screen (IRIS) tool (age ≥18 years)
  • Substances and Choices Scale (age 13–18 years)
(Refer to ‘Resources’)		 Opportunistic and as followup of annual health check IIB 1, 8, 71, 72, 73, 92
Test for blood-borne viruses and sexually transmitted infection (STI) (refer to Chapter 14: Sexual health and blood-borne viruses) GPP 94

Behavioural

 Young people with multiple risk factors for drug use (Box 1) Refer for preventive case management where services are available* Opportunistic IB 60
Young people who are using illicit drugs Provide brief interventions (eg in conjunction with administration of one of the above screening questionnaires) (refer also to Chapter 1: Lifestyle, ‘Introduction’, 5As framework) Opportunistic IIIB 72, 95
Refer to drug education programs based on social learning theories (eg Life Skills Training program, peer education, youth sport and recreation programs) Opportunistic IIB 60, 78, 79
Families of young people who are using illicit drugs Consider referral where appropriate to parent education programs and family intervention therapy to encourage healthy family development and reduction of parent–adolescent conflict Opportunistic IIB 83,84,85
Young people who are using injecting drugs Refer to needle and syringe exchange programs where appropriate Opportunistic IB 87

Environmental

 

 Promote school completion   GPP 80, 81, 96
  Promote access to community and school-based drug education programs (based on social learning theories) IB 60,97
  Promote youth-friendly primary healthcare services GPP 1, 60, 77, 98
  Support increased access to youth workers
Support community-driven illicit drug use prevention programs (especially valuable for inhalant abuse)		 IIB 78
  Support and promote community engagement strategies such as mentorship IB 60
  Support supervised injecting centres IIB 88,89,90,91
*Preventive case management involves the coordinated delivery of intensive services tailored to meet a range of developmental needs. It requires intensive case management through coordinating family intervention, after-school activity, mentoring, tutoring, individual psychiatric assessment and counselling. The approach therefore requires complex coordination across a range of service types such as health, juvenile justice, education and substance abuse. Key aspects are to assess needs, identify relevant services, coordinate service delivery and monitor outcomes. The young person (and if possible, the family) should be involved in developing the service delivery objectives.60 This can be similar to developing a care plan for people with chronic conditions.

Box 1. Risk factors for illicit drug use 56,60,61

Individual influences

  • Not completing secondary school
  • Unemployment
  • Delinquency
  • Residing in remote and very remote areas
  • Favourable attitudes to drug use
  • Sensation seeking and adventurous personality
  • Relationships with peers involved in drug use
  • Low involvement in activities with adults

Family influences

  • Parental conflict
  • Parent–adolescent conflict
  • Parental attitudes to drug use and rules around drug use
  • Alcohol and drug problems in the family

Environmental influences

  • Perceived and actual level of community drug use
  • Community disadvantage and disorganisation
  • Availability of illicit substances within the community
  • Positive media portrayal of drug use
  • Decreased presence of law enforcement


Background

Illicit drug use includes either use of illegal drugs, or inappropriate use of other substances.56 Prescription drug abuse is out of scope for this chapter. Alcohol use is covered in Chapter 1. In 2014–15, 28% of Aboriginal and Torres Strait Islander people aged 15–24 years reported that they had used an illicit substance in the previous 12 months. When compared with non-Indigenous youth, Aboriginal and Torres Strait Islander youth are almost twice as likely to be recent users of illicit drugs (28% compared with 16.3%), more likely to engage in risky drug use and poly-drug use, experience greater drug-related harm and are more likely to begin use at a younger age.30,56 Aboriginal and Torres Strait Islander people living in non-remote areas were more likely than those in remote areas to have used an illicit substance in the previous year (23% compared with 19%) or earlier in their life (24% compared with 17%).
Cannabis is the most common substance used among Aboriginal and Torres Strait Islander and nonIndigenous people who use illicit drugs. Although the rate of cannabis use has remained stable between 2010 and 2013, the overall rate of cannabis use among Aboriginal and Torres Strait Islander peoples is twice that of the non-Indigenous population (19% compared to 10%).57,58 Additionally, cannabis use in non-urban Aboriginal and Torres Strait Islander peoples has been ‘found to be endemic, with over 70% of males and 20% of females being current users’.59

There are no accurate data on the prevalence of volatile substance use (VSU) in Aboriginal and Torres Strait Islander communities. Young people aged 14–19 years are more likely than those in other age groups to have used inhalants or volatile substances and are more likely to use it frequently (once or more per month).60 Seventy-five per cent of inhalant use occurs in a person’s own home or at a friend’s home.56 The risk of inhalant use is increased in the presence of social disadvantage and family dysfunction. The use of inhalants by marginalised youth tends to be motivated by the need to relieve boredom and cope with emotional distress.56,60

Within remote Aboriginal and Torres Strait Islander communities in Western Australia, Northern Territory, South Australia and Far North Queensland, there has been an overall decline in VSU over the last ten years.61

However, youth aged 10–24 years form the majority of current users.61 In some Aboriginal and Torres Strait Islander communities, one study found that young people engaged in VSU as an expression of power (eg through its ability to provoke outrage and to control body weight through suppressing appetite).62 Aside from the acute hallucinogenic and behavioural derangement problems, the most serious long-term effect of VSU is irreversible neurological damage leading to cognitive impairment. Prenatal exposure is associated with low birthweight, prematurity, developmental delays, neurobehavioural problems and physical malformations.62 There is also emerging evidence that VSU is associated with periodontal disease and failure to thrive, and increases the risk for subsequent and earlier drug use.63,64

The 2013 National Drug Strategy Household Survey data indicate that in the general population, the average age of injecting drug users has risen from 26 to 36 years.56 A study commissioned by the Aboriginal Drug and Alcohol Council of South Australia, involving an urban Aboriginal population, found no significant differences between those aged >25 years and those aged <25 years in terms of drug use patterns. However, this was not a peer-reviewed study and there is still the problem of injecting drug use and the related harm. The report states that ‘the implication of this finding is that those under 25 years may have comparatively poorer outcomes in future years compared to their older counterparts’.65 Among the general population, sources of needles and syringes for injecting drug users are chemists (64.5%), needle and syringe programs (37.2%), friends (25%) and hospital or doctor (14.9%).56 Crystal methamphetamine (ice) use is an emerging issue for some remote and regional Aboriginal communities.66

Young people most commonly acquire illicit drugs through a friend, acquaintance or relative. Curiosity, peer pressure – including having a sense of identity and belonging – and wanting to do something exciting are the most common reasons for initiating illicit drug use. Reasons for continuing drug use are to enhance experiences, or for the excitement. Reasons for not initiating drug use are not being interested, and concerns about health, addiction and the law.56,62

There are social, legal and health-related harms associated with illicit drug use. Poly-drug use is not common among youth in general, but when it occurs is a major risk factor for subsequent drug-related harm.60,67 Harm is experienced by the individual and others. For example, in 2013, 8.3% of the population had been a victim of an illicit drug-related incident. Verbal abuse was the most frequently reported incident overall, and the proportion experiencing physical abuse by someone under the influence of illicit drugs rose from 2.2% in 2010 to 3.1% in 2013. The 2010 and 2013 National Drug Strategy Household Surveys found that illicit drug users were more likely to be diagnosed or treated for a mental illness and report high or very high levels of psychological distress compared with those who had not used an illicit drug in the previous 12 months.56 Specifically, there was a further increase in the proportion of recent users with a mental illness between 2010 and 2013.56 The biggest cause of drug-related hospitalisations was due to mental and behavioural disorders associated with amphetamine use. This hospitalisation rate was more than three times higher for Aboriginal and Torres Strait Islander peoples than non-Indigenous people.56 In 2010–14, the rate of druginduced deaths was 1.9 times higher for Aboriginal and Torres Strait Islander peoples living in New South Wales, Queensland, Western Australia, South Australia and the Northern Territory than for non-Indigenous people.30,56,68 For Aboriginal and Torres Strait Islander young people, there are additional harms since substance dependence further compounds social deprivation, poverty, decreased cultural learning, alienation and the cycle of chronic ill health.62

Cannabis use is associated with lower educational attainment, use of other illicit drugs and criminal offending.59 Regular intoxication may interrupt crucial psychosocial development such as identity formation, interpersonal and occupational skill development. Long-term use in adolescents has been associated with decreased neurocognitive function, such as decreased intelligence quotient scores. Early exposure (before 16 years of age), has been associated with impaired attention, smaller overall brain volume, and reduction in frontal cortex volume leading to increased impulsivity.59 There have been conflicting views on whether cannabis use leads to mental health disorders. Authoritative experts concur that ‘adolescents are more likely to show serious adverse effects, that the age of onset is inversely correlated with those effects and that continuous, heavy usage of cannabis is associated with these effects’.59,60 Risk factors for cannabis dependency in adolescents are earlier age of initiation and frequency of use. There is almost a five-fold increased risk of developing dependence in those using at least weekly. Compared to adult users, young people have higher rates of binge and opportunistic cannabis use, a shorter duration between first exposure and dependence, and shorter intervals between first and second drug diagnosis.69

Risk factors for problematic drug use are highlighted in Box 1. Factors that reduce the risk of illicit drug use include a high degree of family attachment, effective parental communication and supervision, and religious participation.
The resolutions from the 4th National Indigenous Drug and Alcohol Conference in 2016 include the following recommendations to address the problem of illicit drug use among Aboriginal and Torres Strait Islander youth:65

  • the Australian Government Department of Prime Minister and Cabinet and Department of Health set aside funding for primary prevention activities that is available to organisations as separate core funding
  • funding for alternatives to youth detention be made available as a matter of urgency
  • specific funding for youth (12–18 years) programs such as youth residential rehabilitation be made available as a matter of urgency
  • the Australian Government reinstate funding for education programs, similar to those identified in the previous National School Drug Education Strategy.


Interventions

Evidence of effectiveness of preventive interventions

Australia is an international leader in addressing drug-related problems with the tri-pronged approach of supply reduction, demand reduction and harm reduction/minimisation. This section focuses on primary and secondary prevention interventions in the domains of demand reduction and harm minimisation. Supply reduction strategies are generally beyond the scope of primary healthcare services and are therefore not addressed here.

Immunisation

Immunisation against hepatitis B is a harm minimisation strategy to protect against the consequences of injecting drug use with contaminated needles (refer to Chapter 14: Sexual health and blood-borne viruses).70

Screening

Screening can be performed to assess individuals at risk of illicit drug use or to identify use. Illicit drug use is initiated and maintained by a complex array of biological, cognitive, psychological and sociocultural processes. Hence all of these domains should be assessed. Adolescent self-reporting of cannabis use is generally reliable, but reporting of other illicit drugs may be less reliable.69 Assessment should therefore be performed in a non-judgemental manner. In addition, illicit drug use questions are less threatening when asked in the context of a general health interview. This is best done via a comprehensive social emotional wellbeing (SEW) assessment.1,27,69 Such assessments can either be done in a routine manner17 or opportunistically in young people presenting with respiratory disorders and mental health problems, which are common presentations among cannabis users.69

The following specific screening tools have been developed to identify substance use.

The CRAFFT screening tool is a behavioural health screening tool for use with children and young people under the age of 21 years.71 It is recommended by the American Academy of Pediatrics’ Committee on Substance Abuse for use with adolescents. It consists of a series of six questions developed to screen adolescents for high-risk alcohol and other drug use disorders simultaneously. It is a short, effective screening tool meant to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted. The tool can be self-administered or administered by a clinician. It has been translated into six languages (refer to ‘Resources’ for links to the English versions).
The Indigenous Risk Impact Screen (IRIS) and brief intervention is a 13-item, two-factor screen that assesses alcohol and other drug use and associated mental health issues. It has been validated for use with Aboriginal and Torres Strait Islander people aged ≥18 years and is included in the Department of Health and Ageing Alcohol treatment guidelines for Indigenous Australians.72 Training is a necessary prerequisite to use of the IRIS tool and is currently being provided through Queensland Health.

The Substances and Choices Scale is a tool developed in New Zealand and validated for use in people aged 13–18 years.71,73 It can also be used for repeat measures to assess change over time.

 

Behavioural

The majority of problematic illicit drug use occurs in young people with high levels of risk factors (Box 1). Programs to prevent initiation of illicit drug use should commence with younger children.60,67 There is evidence supporting the implementation of drug education, especially if based on social learning theories. Although there is limited evidence, preventive case management tailored to a young person’s developmental needs is an appealing approach for those with multiple risk factors for illicit drug use.60 Important aspects of this approach are to assess needs, identify relevant services, coordinate service delivery and monitor outcomes. It requires complex coordination across a range of service types.60 Examples include the Multisystemic Therapy (MST) and Children at Risk (CAR) programs in the US. Key elements of these programs include developing service delivery objectives in consultation with the young person and their family; collaboration between various services (eg community health, juvenile justice, drug abuse, education); and ongoing monitoring of progress. They typically require intensive case management, coordinating family intervention, after-school activity, mentoring, tutoring, individual psychiatric assessment and counselling.

Brief interventions, such as those that form part of the culturally validated IRIS program, are cautiously supported and recommended, as there is limited evidence that motivational interviewing reduces substance use.74,75 There is no evidence currently, to support brief school-based interventions.76

Environmental

The legacy of colonisation and public health interventions involving forcible isolation, incarceration, and punitive measures needs to be taken into account in addressing illicit drug use. Improved access to youthfriendly primary care services is important and has been recommended by the National Indigenous Drug and Alcohol Committee. Youth workers also have potential to positively impact on Aboriginal and Torres Strait Islander young people’s resilience, although this strategy has not been formally evaluated.77

Community support and engagement is particularly important for illicit drug use programs, because of multifactorial risks and the need for multidisciplinary resources. Such factors are especially critical in addressing inhalant use, in particular petrol sniffing.78 Strategies that are devised without community input run the risk of being rejected.79 Successful community engagement strategies include mentorship, encouraging school completion, encouraging a positive school ethos, and youth sport and recreation programs.80–82 Mentorship is aimed at developing positive social relationships between young people and adults in order to support healthy role modelling. This is a promising approach and warrants further research.60 Parenting programs and other family-based interventions aimed at encouraging healthy family development and reducing parent–adolescent conflict show promise but also need further research.83–85 Youth worker brokerage programs in Central Australia are currently being evaluated.86

Successful school-based drug education programs are those based on social learning theory and that take into account causes of drug use and adolescent developmental pathways. The Life Skills Training program, peer education, and youth sport/recreation programs are recommended approaches that warrant further research.60

There is good evidence to support needle and syringe exchange programs and supervised injection centres87–91 (refer to Chapter 14: Sexual health and blood-borne viruses).
 

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National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (PDF 9.8 MB)

 Evidence base to a preventive health assessment in Aboriginal and Torres Strait Islander people (PDF 9.4 MB)

 National Guide Lifecycle chart (child) (PDF 555 KB)

 National Guide Lifecycle chart (young) (PDF 1 MB)

 National Guide Lifecycle chart (adult) (PDF 1 MB)