National Guide

Chapter 7 | The health of young people

Substance use in adolescence







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      5. Substance use in adolescence

The health of young people | Substance use in adolescence

Dr Marguerite Tracy  

Key messages

  • Adolescence is a time of profound neurodevelopment and social transition. Experimentation and risk taking are common during this phase of development, including substance use.1
  • Substance use, especially use at an early age, can have serious detrimental impacts on development and life trajectory.
  • ‘Substances’ includes legal substances such as alcohol and nicotine (although the underage use of these is not legal) and illicit substances, such as cannabis, amphetamines, opioids, hallucinogens and sedatives.
  • GPs and primary care teams are well placed to provide health promotion, screening and early intervention to prevent harms from substance use in young people.
  • Providing accurate information on substances can reduce the risk of harms.2,3
  • Protective factors that reduce the risks of substance use in young people, including Aboriginal and Torres Strait Islander young people, are those associated with strong social support and positive social and emotional wellbeing (SEWB), including cultural connection, good family relationships, having supportive friends, positive role models and school attendance/employment.4,5
  • Harm and trauma due to adverse childhood experiences (ACEs), intergenerational trauma and increased social disadvantage and racism faced by Aboriginal and Torres Strait Islander young people are linked to increased risk-taking behaviours, including substance use.5
  • Supporting families, providing trauma-informed, healing-focused care and supporting the overall health of young people, including their mental health, are all examples of primary prevention possible in general practice.6–8
  • Family members or support people should be allowed and encouraged to be present during healthcare interactions, if appropriate.9
  • A strengths-based approach to engaging and caring for Aboriginal and Torres Strait Islander young people in preventing illicit and harmful substance use, and in supporting those who use, is a strong theme across the available literature.
Type of preventive activity - Immunisation
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All young people Hepatitis B immunisation (and all immunisations) As per the National Immunisation Program (NIP) Schedule Strong NIP Schedule10 Immunisation for viral hepatitis can reduce the transmission of blood-borne viruses
Young people who inject drugs Hepatitis A immunisation Opportunistically and as part of the NIP Schedule in Queensland, Northern Territory, South Australia and Western Australia Strong National guideline11
NIP Schedule10		 Immunisation for viral hepatitis can reduce the transmission of blood-borne viruses and the risk of liver damage
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Young people aged 12–17 years  Explore risk factors for use, as well as current use of substances, using a validated screening tool, such as HEEADSSS (Home; Education and employment; Eating and exercise; Activities; Drugs and alcohol; Sexuality and gender; Suicide, depression and self-harm; and Safety).

See Useful resources)		 Opportunistically Good practice point National and Aboriginal and Torres Strait Islander-specific guidelines12–14 Identification of harmful alcohol and other substance use and dependence is essential to minimising the harms where support and treatment can be provided

Although US guidelines report insufficient evidence for whole-population screening for those aged 12–17 years,22,23 sensitive and appropriate exploration using a tool such as HEEADSSS may identify early issues with alcohol and other substance use, providing opportunities for intervention
Young people aged 18–24 years Ask about alcohol and other substance use using a validated screening tool, such as IRIS (Indigenous Risk Impact Screen) or, for alcohol only, AUDIT-C (Alcohol Use Disorders Identification Test – Consumption) Opportunistically Strong National and Aboriginal and Torres Strait Islander-specific guidelines12–14 Identification of harmful alcohol and other substance use and dependence is essential to minimising the harms of alcohol and other substance use
Young people who inject drugs Screen for blood-borne viruses (hepatitis B, hepatitis C, HIV) Opportunistically, then 3–12 monthly depending on risk assessment Strong National guideline15 People who inject drugs are at high risk of treatable blood-borne viral infections
Young people aged 12–24 years with identified risk factors or who are at harm from their substance use To assess for risks and harms, as well as the need for supports, further assessment and/or treatment, assess substance use using validated tools such as:
  • CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) screening tool (for ages ≤21 years)
  • IRIS tool (for ages ≥18 years)
 As clinically indicated Good practice point National and Aboriginal and Torres Strait Islander-specific guidelines12–14 Further assessment of substance use using validated tools should be undertaken when there are supports available to help the young person
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Young people with multiple risk factors for drug use Encourage prevention programs developed with/by the community, which include substance use education, skills development or increased cultural knowledge Opportunistically Good practice point Systematic review2 There is some evidence that programs with the listed features have the potential to reduce the frequency of use and the intention to use substances in young people
Young people who are using illicit drugs Provide brief interventions (eg in conjunction with the administration of one of the screening questionnaires listed above) As clinically indicated Good practice point Aboriginal and Torres Strait Islander-specific guidelines14,16 Brief interventions have shown a reduction in substance use, although there are limited data in Aboriginal and Torres Strait Islander people
Young people who are using illicit drugs Offer dental and general preventive medical care Opportunistically Good practice point National report17
Cohort study18		 People with substance use disorder have a reduced lifespan (15 years), mostly due to non-communicable diseases
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 a reduction in parent–adolescent conflict Opportunistically Good practice point Single study7 Families and communities can support young people more effectively when they are supported
Young people who are injecting drugs Refer to needle and syringe exchange programs and supervised injecting centres where available Opportunistically Strong Narrative review19 Harm minimisation reduces short- and long-term harms from injecting drug use
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Health services and practices Promote school attendance and completion Opportunistically Good practice point Systematic review2  
Health services and practices Promote access to community and school-based drug education programs Opportunistically Good practice point Systematic review2  
Health services and practices Promote youth-friendly, culturally aware primary healthcare services Opportunistically Good practice point Jurisdictional resource6 General theme across literature
Health services and practices Support community-driven illicit drug use prevention programs Opportunistically Good practice point Systematic review2 Community-led responses and services are more culturally appropriate and acceptable. and generally more effective
Health services and practices Advocate for needle and syringe programs and supervised injecting centres Opportunistically Strong Studies evaluating Australian safe-injecting facilities19–21 There is clear evidence that needle and syringe programs are an effective harm minimisation strategy

There is clear evidence that supervised injecting rooms are an effective harm minimisation strategy and that they are used by young people and Aboriginal and Torres Strait Islander people

Clinical guidelines

Assessment tools

Professional development

Illicit drug use includes either the use of illegal drugs or the inappropriate use of other substances.24 This topic also has some material regarding the use of legal substances (alcohol and tobacco) by minors. Over-the-counter medication and prescription drug misuse is not covered specifically in this topic.

The prevention of harm from illicit substance use in Australia utilises reducing demand (primarily education), reducing supply (law enforcement) and harm minimisation (eg safer use of smoking and injecting equipment, blood-borne virus screening and treatment, and access to needle and syringe programs). It should be acknowledged that the criminalisation of substance use disproportionally affects Aboriginal and Torres Strait Islander people through high incarceration rates and adverse outcomes.25

This topic is focused on individual- and family-centred support. The potential for concerns around the safety of children/minors and implications for the involvement of child protection services, including making notifications, is fully acknowledged. Specific guidance on this is not included in this topic (see Chapter 4: Child and family safety, Child maltreatment: supporting families to optimise child health and wellbeing and refer to jurisdictional requirements).

Substance use by young people in Australia

The 2018–19 National Aboriginal and Torres Strait Islander health survey found 72% of Aboriginal and Torres Strait Islander people aged over 15 years reported they had not used an illicit substance in the previous 12 months and that daily smoking rates almost halved between 2012–13 (18%) and 2018–19 (9.7%).27 Data from the 2017 Australian Secondary Students Alcohol and Drug survey show that, compared with non-Indigenous Australians students, Aboriginal and Torres Strait Islander students were 1.9-, 1.4- and 1.97-fold as likely to smoke tobacco, drink alcohol and have used cannabis in the past month.1 In addition, compared with non-Indigenous Australian youth, Aboriginal and Torres Strait Islander youth are more likely to first use substances at a younger age.27

Cannabis is the most common substance used among Aboriginal and Torres Strait Islander and non-Indigenous Australians who use illicit drugs.26 In 2022–23, 24% of Aboriginal and Torres Strait Islander people reported using marijuana, hashish or cannabis resin (31.4% of males and 17.7% of females) in the previous 12 months compared to 11.5% of the Australian population. 26 In addition, cannabis use in a few non-urban Aboriginal and Torres Strait Islander communities has been described as ‘endemic, with over 70% of males and 20% of females being current users’.28

Factors behind risk behaviours

Experimental substance use in young people is common in adolescence, as noted above. However, the risk of a young person using substances and being harmed is determined by multiple personal and environmental factors that can either be protective or increase risk.4 Intergenerational trauma, social inequality and racial discrimination are known to increase young Aboriginal and Torres Strait Islander peoples’ risk behaviour.5 Conversely, cultural strengths, education and employment and community and family cohesion are protective for young people.4,5 There is a strong cultural practice in many Aboriginal and Torres Strait Islander communities around sharing, which can increase the risk of substance use.5

 

Much of the literature of preventive/protective factors for illicit substance use is not specific to Aboriginal and Torres Strait Islander young people. Systematic literature reviews published in 2013 (Lee et al) and 2018 (Geia et al) both concluded that there is weak and often inconsistent evidence for specific preventive activities that minimise use and harms for Aboriginal and Torres Strait Islander young people who use substances.29,30 What has been discussed in the published literature is that programs should be initiated by or co-designed with local community and delivered in a culturally safe way.30

A recent international review published in 2019 of 26 indigenous prevention programs in the US, Canada, Australia and New Zealand found that programs developed in partnership with community had potential to reduce substance use through education about substances, skills development and enhancing cultural knowledge.2

Strong and Deadly Futures is an example of a co-designed program for Aboriginal and Torres Strait Islander high school students being implemented in school settings, and is being evaluated at scale following positive pilot outcomes.3 Providing young people with accurate information about the health effects of substance use, harm-reduction strategies if using substances and the health benefits of not using substances can be done in primary care settings.
Engaging young people, including those with substance use issues, can be improved by healthcare professionals having a flexible and friendly approach, such as making time for social yarning before asking about sensitive issues.6,16,31–33

Immunisation

Immunisation against hepatitis A and B is a harm-minimisation strategy to protect against the potential consequences of injecting drug use with contaminated needles.11 (Refer to Chapter 13: Sexually transmissible infections and blood-borne viruses.)

Hepatitis B immunisation is on the NIP10 for all children. Hepatitis A immunisation is part of the NIP in Queensland, the Northern Territory, Western Australia and South Australia for children at 18 months and four years of age.10 Hepatitis A immunisation is currently not covered under the NIP in other states and territories.

Screening for substance use

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.4 Hence, all these domains should be assessed. Assessment should be performed in a non-judgemental, trauma-informed and healing-focused manner. In addition, illicit drug use questions are less threatening when asked in the context of a general health interview in a practice that is ‘youth friendly’.6 This is best done via a comprehensive SEWB assessment, such as the HEEADSSS assessment.34,35 Such assessments can either be done in a programmatic manner (eg during annual health checks) or opportunistically in young people presenting with other issues (refer to Chapter 7: The health of young people, Social and emotional wellbeing in adolescence).

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 aged under 21 years, but has not been specifically validated for use in Aboriginal and Torres Strait Islander young people.36 CRAFFT 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. (Refer to Useful resources for a link to the English version).
  • IRIS is a 13-item, two-factor screen that assesses alcohol and other drug use and associated mental health issues.37 It has been validated for use with Aboriginal and Torres Strait Islander people aged ≥18 years16,37 (see Useful resources).
  • The SACS-ABC is a tool developed in New Zealand and validated for use in people aged 13–18 years,38 but, again, not specifically validated for use in Aboriginal and Torres Strait Islander young people. The SACS-ABC can also be used for repeat measures to assess change over time (see Useful resources).

Behavioural preventive activities

There has been some research conducted to address the lack of evidence for prevention and treatment for Aboriginal and Torres Strait Islander young people who use alcohol and other drugs.29 As with all young people, the majority of problematic illicit drug use occurs among those with high levels of risk factors. Risk factors may include personal characteristics (eg a mental health condition, ACEs),26,39 family factors (eg family substance use)5 or, at a community/environmental level, racial discrimination, community attitudes, availability of drugs, peer substance use and settings that may be attended by groups who use drugs or are at risk of using drugs.5,40

Protective factors have been described above. The provision of promising local co-designed programs, including online resources, is currently being trialled in schools.2 Connection to family is important for wellbeing; including key family members or other carers in support or treatment, where appropriate (as guided by the young person), can be helpful.9 Supporting the Aboriginal and Torres Strait Islander young person’s SEWB and that of their family is essential to their overall health and healing from the harms of substance use.7,8

Brief interventions, such as those that form part of the culturally validated IRIS program, are recommended, although evidence that motivational interviewing reduces substance use is still limited in Aboriginal and Torres Strait Islander people.16

Environmental preventive activities

The legacy of colonisation and public health interventions involving forcible isolation, incarceration and punitive measures need to be considered in addressing illicit and harmful drug use. Improved access to youth-friendly primary care services is important, and resources are available to support general practices to achieve this.6

Community support and engagement are particularly important for illicit drug use programs because of multifactorial risks and the need for multidisciplinary resources.8 Strategies that are devised without community input run the risk of being ineffective.2 Successful community engagement strategies include mentorship, encouraging school participation and completion, encouraging a positive school ethos and youth sport and recreation programs.2

There is good evidence to support needle and syringe exchange programs and medically supervised injection centres/rooms,20 although access to the latter is only available in very few settings.

  1. Department of Health and Aged Care. Australian secondary school students alcohol and drug survey. Australian Government, 2017 [Accessed 5 May 2024].
  2. Snijder M, Stapinski L, Lees B, et al. Preventing substance use among indigenous adolescents in the USA, Canada, Australia and New Zealand: A systematic review of the literature. Prev Sci 2020;21(1):65–85. doi: 10.1007/s11121-019-01038-w.
  3. Stapinski L, Routledge K, Snijder M, et al. A web-based alcohol and other drug prevention program (Strong & Deadly Futures) for Aboriginal and Torres Strait Islander school students: Protocol for a cluster randomized controlled trial. JMIR Res Protoc 2022;11(1):e34530. doi: 10.2196/34530.
  4. Heris C, Guerin N, Thomas D, Chamberlain C, Eades S, White VM. Smoking behaviours and other substance use among Indigenous and non-Indigenous Australian secondary students, 2017. Drug Alcohol Rev 2021;40(1):58–67. doi: 10.1111/dar.13130.
  5. Snijder M, Lees B, Stearne A, et al. An ecological model of drug and alcohol use and related harms among Aboriginal and Torres Strait Islander Australians: A systematic review of the literature. Prev Med Rep 2020;21:101277. doi: 10.1016/j.pmedr.2020.101277.
  6. Queensland Health. Providing safe and quality care to young people – a practice guide to adolescent and young adult (AYA) care. Queensland Government, 2023 [Accessed 7 May 2024].
  7. Gendera S, Treloar C, Reilly R, et al. ‘Even though you hate everything that’s going on, you know they are safer at home’: The role of Aboriginal and Torres Strait Islander families in methamphetamine use harm reduction and their own support needs. Drug Alcohol Rev 2022;41(6):1428–39. doi: 10.1111/dar.13481.
  8. Reilly R, Gendera S, Treloar C, et al. Identifying risk and protective factors, including culture and identity, for methamphetamine use in Aboriginal and Torres Strait Islander communities: Relevance of the ‘communities that care’ model. Soc Sci Med 2020;266:113451. doi: 10.1016/j.socscimed.2020.113451.
  9. National Indigenous Drug and Alcohol Committee. Alcohol and other drug treatment for Aboriginal and Torres Strait Islander peoples. Australian National Council on Drugs, 2014 [Accessed 5 May 2024].
  10. Department of Health and Aged Care. National Immunisation Program schedule for all Aboriginal and Torres Strait Islander people. Australian Government, 2023 [Accessed 5 May 2024].
  11. Australian Technical Advisory Group on Immunisation. Australian immunisation handbook. Australian Government, 2022. Available at immunisationhandbook.health.gov.au [Accessed 5 May 2024].
  12. National Health and Medical Research Council (NHMRC). Australian guidelines to reduce health risks from drinking alcohol. NHMRC, 2020 [Accessed 5 May 2024].
  13. Haber P, Riordan B. Guidelines for the treatment of alcohol problems. 4th edn. Specialty of Addiction Medicine, Faculty of Medicine and Health, The University of Sydney, 2021 [Accessed 5 May 2024].
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  15. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Testing portal. ASHM, 2020 [Accessed 5 May 2024].
  16. Tracy M, Freeburn B, Lee K, Woods J, Conigrave K. Review of alcohol and drug treatment for Aboriginal and Torres Strait Islander peoples. Journal of the Australian Indigenous HealthInfoNet 2023;4(1):1–32. doi: 10.14221/aihjournal.v4n1.1.
  17. Australian Bureau of Statistics (ABS). Deaths, Australia 2019. ABS, 2020 [Accessed May 2024].
  18. Lewer D, Jones NR, Hickman M, Nielsen S, Degenhardt L. Life expectancy of people who are dependent on opioids: A cohort study in New South Wales, Australia. J Psychiatr Res 2020;130:435–40. doi: 10.1016/j.jpsychires.2020.08.013.
  19. Stam NC, Cogger S, Schumann JL, et al. The onset and severity of acute opioid toxicity in heroin overdose cases: A retrospective cohort study at a supervised injecting facility in Melbourne, Australia. Clin Toxicol (Phila) 2022;60(11):1227–34. doi: 10.1080/15563650.2022.2126371.
  20. Van Den Boom W, Del Mar Quiroga M, Fetene DM, et al. The Melbourne safe injecting room attracted people most in need of its service. Am J Prev Med 2021;61(2):217–24. doi: 10.1016/j.amepre.2021.02.018.
  21. Fetene DM, Hall C, Dietze P. Characteristics of people who used the Melbourne and Sydney medically supervised injecting facilities surveyed in the Illicit Drug Reporting System 2019. National Drug and Alcohol Research Centre, 2019 [Accessed 5 May 2024].
  22. U.S. Preventive Services Task Force (USPSTF). Unhealthy alcohol use in adolescents and adults: Screening and behavioral counseling interventions. USPSTF, 2018 [Accessed 7 May 2024].
  23. U.S. Preventive Services Task Force (USPSTF). Unhealthy drug use: Screening. USPSTF, 2020 [Accessed 7 May 2024].
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  26. Australian Institute of Health and Welfare (AIHW). Alcohol, tobacco & other drugs in Australia. AIHW, 2024 [Accessed 7 May 2024].
  27. Australian Indigenous HealthInfoNet. Overview of Aboriginal and Torres Strait Islander health status 2021. Australian Indigenous HealthInfoNet, 2022 [Accessed 5 May 2024].
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  37. Schlesinger CM, Ober C, McCarthy MM, Watson JD, Seinen A. The development and validation of the Indigenous Risk Impact Screen (IRIS): A 13-item screening instrument for alcohol and drug and mental health risk. Drug Alcohol Rev 2007;26(2):109–17. doi: 10.1080/09595230601146611.
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