Video series on adolescent drug and alcohol use
15yo girl sitting in doctor’s office with her mum
Mum: I’ve brought Becky in today about her acne, she’s been on a number of different treatments but they’re not working.
Dr: Sure - we can definitely address the acne. Whenever I see a young person, I like to spend some consultation time talking directly with them. It’s a chance for them to chat with me and ask any questions. I think it helps young people learn to feel confident communicating with health professionals and take responsibility for their health. Would it be okay with you both if I saw Becky on her own for a few minutes?
Becky: nods in agreement
Mum: Sure- I’ll just be in the waiting room. (Mum leaves).
Dr: Thanks Becky. I wanted talk with you today to get a better picture of your overall health by asking you about lifestyle issues including alcohol and other drugs. These are questions that I ask all my patients, including young people. What you tell me will be kept confidential– I won’t tell your parents or anyone else without your permission. The only time I’d break confidentiality is if I’m seriously concerned about your welfare and wellbeing or anyone else’s. Then I have a duty to keep you and others safe. Is that okay with you?
Becky: Sure it’s okay.
Dr: You don’t have to answer any questions you don’t want to either – that’s fine.
Becky: ok thanks.
Dr: So Becky you’re 15 now. I’m guessing people in your class drink alcohol sometimes, maybe at parties. Do you drink alcohol?
Becky: Yeah I have. But not anything else.
Dr: That’s understandable. Would you mind if we had a chat about what you like to drink, and how to best protect your health?
Becky: yeah that’s ok.
Our focus is on young people aged between 14 -17 years, and how you as a GP can engage them in discussion on the top three drugs used by their age group: alcohol, tobacco and cannabis. Today we will be using the 5A’s Framework from the RACGP SNAP guide on preventative care to structure our consultation.
The 5As are:
- Advising/ Agreeing
- Assisting and
- Arranging care/follow up referral for patients
It is vital that GPs engage with young people and talk about alcohol and other drug use because:
- GPs are the most accessible primary health care provider for young people. You are often the first point of contact with the health system for young people and can help prevent future harmful use.
- There are known harms associated with all levels of use.
- The earlier the onset of alcohol and other drug use, the increase in later harms from substance use.
The engagement and process skills you will learn in this series can be used with all young people you see using alcohol and other drugs.
Experimenting with alcohol and other drugs is a relatively normal part of adolescent risk-taking behaviour. However GPs should be alert to substance use behaviour and the impact of substance use can have on the developing brain and later cognitive development. Most young people engage in adolescent-limited rather than life course persistent behaviour with AOD use, but some may develop chronic drug use and frequent harmful binge patterns.
Effectively communicating with young people is vital to engage with them and ask about substance use. When talking with a young person remember to:
- Assess the young person’s competency, especially where they are under 16 years of age.
- Be non-judgmental and avoid using stigmatising language.
- Help them identify the negative outcomes of continuing certain behaviours and relate these behaviours to their immediate concerns, e.g. effects on appearance, relationships.
- Consider culture and language; but be careful not to make assumptions about behaviours based on a young person’s cultural or religious background.
Remember, if they stop talking or appear disengaged to respect that. They need to develop trust with you to open up. Invite them back; make sure your door is open for them to see you again.
We’re now going to watch an example using the first A - Asking. We’ll highlight some consultation skills at the beginning, but you should reflect throughout on what you think the GP does well and how you could integrate these skills into your consultations.
You’ll notice that in this scenario, the GP’s focus isn’t on immediately trying to stop Becky from drinking, but on engagement and getting permission to mutually begin a conversation about her alcohol use.
Assessing, Advising and Assisting
We know that Becky is consuming alcohol, but this could be only one aspect of her AOD use. When assessing and advising a patient, it is important to have a holistic understanding of what they are consuming.
A general AOD assessment will cover:
What drug? (alcohol, tobacco, over the counter and prescribed medications (analgesics and benzodiazepines, cannabis, ecstasy, heroin, amphetamines (including methamphetamines), cocaine, hallucinogens, household products – glues, petrol, aerosols
How often? E.g. three times a day, daily, weekly
How much? E.g. standard drinks of alcohol, joints or cones bongs of cannabis
Method of use? E.g. ingesting, snorting, injecting, sniffing, smoking
Patterns of use? E.g. binge, recreational, dependent
Context of use? E.g. alone, with friends, socially, when depressed, stressed, angry
Effects of use? Physical, mood, behavioural, social
How they obtain and pay for the substance?
Any harms? Accidents, injuries, driving, assaults, unwanted sex
Outcome of previous attempts to stop use? What worked/what didn’t, how long for
What do they want to do about their substance use?
Remember to tailor your AOD assessment to the young person before you.
You can use AOD assessment tools such as:
- Alcohol - AUDIT C Questionnaire / SNAP Guide Alcohol
- Tobacco – SNAP Guide Smoking (recommends screening people from aged 10 upwards)
- Cannabis - Severity of Dependence Scale (SDS) for cannabis / CUDIT-R.
If your patient is under 18, maybe use the HEEADDSSS assessment. It takes a holistic approach with young people and can help with gaining their trust, engaging them in treatment and be a therapeutic intervention in and of itself.
It covers each of the items you can see on your screen:
- Eating and Exercise
- Activities and peer relationships
- Drug use including cigarettes and alcohol
For more information on how to conduct a HEEADDSSS assessment the following resources are available:
As videos, or in the youth health resourse kit on the Health NSW website.
As a GP, taking a patient’s history is a familiar skill - the question then becomes what you want to do with the answers. If your patient is using alcohol or other drugs, a brief intervention might be the next step.
Brief interventions are incredibly useful because they can be conducted by GPs within a consultation, and include screening and assessment, as well as information and advice that are designed to achieve a reduction in risky substance use.
A good brief intervention will:
- Provide information and education about the effects of substance use and how to reduce the harm associated.
- Monitor drug use and impact - ask the patient to keep a record of their use - its helps them to gain insight into how much they are using, their patterns of use and high risk situations.
- Assist in goal setting – develop some SMART (specific, measurable, achievable, realistic and timely) goals with the patient to support them to change their substance use if that is their aim. E.g. Trying for three cannabis free days a week for one month.
- Ask permission, e.g. Is it okay if I give you some websites to look at where you can read good information about the effects of alcohol?
- Take into account age, emotional maturity, level of understanding, culture, faith and beliefs.
- Encourage the young person to consider involving their parents/carers/other responsible adults if possible.
- Provide information on how the young person and their parents or carers can access help or advice whenever they require it.
- Relate your brief intervention back to one of your patient’s concerns, e.g. most young people will care a lot about what their peers think of them.
Note: Handouts can be useful but be aware that parents may not know about the use.
Here is an example of how I would do a brief intervention for Becky, having found out the only substance she consumes is alcohol on a social basis.
GP: Thank you Becky. So far you have told me about your alcohol drinking at parties and that when you have too much to drink - about five or six drinks - you have arguments with your friends and that you wish you didn’t. Would you be open to us bringing your mum into our conversation? If not we can just keep talking ourselves – it’s up to you.
Becky: no, I don’t really want mum to know.
GP: That’s fine- I appreciate you talking to me about it! Would you like to discuss ways you can be more in control of the amount you drink at parties? This might mean that you drink less and that would be good for your growing brain and for your friendships! Can I give your some tips on how to drink less at parties and with your friends and tell you about some websites for you to have a look at?
Becky: Ok - that sounds good.
GP: Great! A good thing to do that really helps keep track of how many drinks you have is only pouring them yourself and to set a limit on how many you will have at that night ahead of time. What limit do you think we could set together today?
Becky: Well if I’m having cruisers….. how about 3? And the same for vodka too.
GP: That sounds like a great start and that is a half of what you have been drinking! It would be good to pop a note in your phone so we can keep track of your progress and see what is working and what might not be working for you?
Becky: Yeah I can that and let you know how it’s going.
GP: Great! (Hands pamphlet over)- to help you learn about alcohol and the effects on your brain it would be good to head to this website made for people around your age- feel free to write down any questions you have and bring them to our next consultation.
A 2018 Cochrane review found that there is evidence that brief interventions in primary care settings can reduce alcohol consumption when compared to minimal or no intervention.
Where an adolescent is not convinced of the need to reduce their substance use, using motivational interviewing can be use d to progress your discussion with your patient. In the next video we will explain the basics of motivational interviewing, and give you another opportunity to review a consultation scenario.