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Clinical guidelines

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

Illicit drug use

Author Dr Annapurna Nori 
Expert reviewer Professor Sherry Saggers

Background

Young people most commonly acquire illicit drugs through a friend, acquaintance or relative. Curiosity, peer pressure and wanting to do something exciting are the most common reasons for initiating illicit drug use. Reasons for not initiating drug use are not being interested, and concerns over health, addiction and the law. When compared with non-Indigenous people, Aboriginal and Torres Strait Islander people are twice as likely to be recent users of illicit drugs (25% compared to 14.7%), are more likely to engage in risky drug use and polydrug use, experience greater drug related harm and are more likely to begin using illicit drugs at a younger age.40–42

There are social, legal and health related harms associated with illicit drug use. Polydrug use is not common among youth in general, but when it occurs it is a major risk factor for subsequent drug related harm.43,44 The 2010 National Drug Strategy Household Survey 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.40 There was a statistically significant rise in the proportion of recent users with a mental illness between 2007 and 2010.

Cannabis use is associated with lower educational attainment, use of other illicit drugs and criminal offending. Regular intoxication may interrupt crucial psychosocial development such as identity formation, and interpersonal and occupational skill development. 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 chronic ill health cycle.45 There has been conflicting evidence that cannabis use leads to mental health disorders. Authoritative reviews conclude that cannabis only exacerbates symptoms and precipitates psychotic episodes in vulnerable individuals.44 The most serious long term effect of inhalant abuse is irreversible neurological damage leading to cognitive impairment. Prenatal exposure is associated with low birthweight, prematurity, developmental delays, neurobehavioral problems and physical malformations.45 There is also emerging evidence that substance use is associated with periodontal disease.46 Risk factors for problematic drug use are highlighted in Table 3.2. Factors that reduce the risk of illicit drug use include a high degree of family attachment, effective parental communication and supervision, and religious participation.

Table 3.2. Risk factors for illicit drug use
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
Community influences
  • Perceived and actual level of community drug use
  • Community disadvantage and disorganisation
  • Availability of drugs within the community
  • Positive media portrayal of drug use
Sources: Loxley W, Toumbourou J, Stockwell T, Haines B, Scott K, Godfrey C, et al 2004 and Australian Institute of Health and Welfare 200544,53

In the general population, the 2010 National Drug Strategy Household Survey Data found 21.5% of young people aged 14–19 years had ever used cannabis and 15.7% had used in the previous year.40 Youth in this age group are more likely to be recent users of cannabis than recent users of tobacco.47 In the Aboriginal and Torres Strait Islander population cannabis is the most commonly used illicit drug, followed by amphetamines.48 Aboriginal and Torres Strait Islander youth are also more likely than non-Indigenous youth to smoke cannabis. Since the mid 1990s, there has been a rapid and significant increase in cannabis use within some Aboriginal and Torres Strait Islander communities.42 In the 2004–05 National Aboriginal and Torres Strait Islander Health Survey, 23% of non-remote Aboriginal and Torres Strait Islander people aged over 17 years reported using cannabis in the previous 12 months.49 This may in part be due to increased local trafficking, supply reduction measures to combat petrol sniffing and alcohol dependence and the larger context of the consequences of colonisation such as social and cultural alienation, boredom and a perceived lack of a meaningful future.42,50,51 In the general population, approximately 9% of those who ever use cannabis will develop dependence. Risk factors for cannabis dependency in adolescents are earlier age of initiation and frequency of use. There is almost a fivefold 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, shorter duration between first exposure and dependence, and shorter intervals between first and second drug diagnosis.41

Injecting drug use prevalence is comparatively low in young people (0.3% among 14–19 year olds and 0.9% among 20–29 year olds).40 A study commissioned by the Aboriginal Drug and Alcohol Council of South Australia involving an urban Aboriginal population found no significant differences between those over 25 years and those younger than 25 years in terms of drug use patterns. However, there is still the problem of injecting drug use and the related harm. The report states ‘the implication of this finding is that those under 25 years may have comparatively poorer outcomes in future years compared to their older counterparts’.52 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%).40

Young people aged 14–19 years are more likely than those in other age groups to have used inhalants or volatile substances (prevalence 1.2%) and are more likely to use it frequently (once or more per month).44 Seventy-five percent of inhalant use occurs in a person’s own home or at a friends.53 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. In some Aboriginal and Torres Strait Islander communities, one study found that young people used sniffing as an expression of power (eg. through its ability to provoke outrage and to control body weight through suppressing appetite).45

The inaugural 2010 National Indigenous Drug and Alcohol Conference recommended the following strategies to address the rising prevalence of illicit drug use among Aboriginal and Torres Strait Islander youth:

  • include in preventive health and chronic disease agendas for Aboriginal and Torres Strait Islander people a substantial focus and specific funding for addressing substance use
  • greater resources to increase the level of ongoing training and capacity of Aboriginal and Torres Strait Islander health workers in the substance use sector
  • greater investment for a wider variety of sports and other cultural activities for Aboriginal and Torres Strait Islander youth.54

Evidence of effectiveness of preventive interventions

Australia is an international leader in addressing drug related problems with the three-pronged approach of supply reduction, demand reduction and harm reduction/minimisation. This chapter 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.55 (See Chapter 8: Sexual health and bloodborne viruses.)

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.41 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 psychosocial assessment.1,11,41 Such assessments can either be done in a routine manner11 or opportunistically in young people presenting with respiratory disorders and mental health problems since these are common among cannabis users.41 Assessment should be done in conjunction with a psychosocial assessment (see psychosocial assessment section).

The following 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.56 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. (See 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 over and is included in the Australian Department of Health and Ageing Alcohol treatment guidelines for Indigenous Australians.57 In July 2009, the Australian Government extended funding for the IRIS program to support a national training rollout. Training is a necessary prerequisite to use of the IRIS tool.

The Substances and Choices Scale is a tool developed in New Zealand and validated for use in people aged 13–18 years.56,58 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 (Table 3.2). Prevention programs to prevent initiation of illicit drug use should commence with younger children.43,44 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.44 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.44 Examples include the Multisystemic Treatment and Children at Risk programs in the USA. 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 which form part of the IRIS program are supported and recommended as a culturally validated tool.59

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 youth friendly 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.60

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.61 Strategies that are devised without community input run the risk of being rejected.62 Successful community engagement strategies include mentorship, encouraging positive school ethos, and youth sport and recreation programs. 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.44 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.63-65

Successful school based drug education programs are those based on social learning theory and which 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.44

There is strong evidence to support needle and syringe exchange programs and supervised injection centres.66–70 (See Chapter 8: Sexual health and bloodborne viruses.)

Recommendations: Illicit drug use
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Immunisation All young people aged 12–24 years Review hepatitis B immunisation and immune status and offer vaccination where indicated (see Chapter 8: Sexual health and bloodborne viruses) As per Australian standard vaccination schedule GPP 55
Screening All young people Assess for presence of risk factors for illicit drug use (see Table 3.2) As part of an annual health assessment GPP 1,5,7,11
Young people with risk factors for drug use (see Table 3.2) Administer one of the following questionnaires to ascertain drug use:
  • CRAFFT screening tool (≤21 years)
  • IRIS tool (≥18 years)
  • Substances and Choice scale (13–18 years (see Resources)
Opportunistic IIIB 1,5,7,11,56–58
Behavioural Young people with multiple risk factors for drug use (see Table 3.2) Refer for preventive case management where services are available* Opportunistic IB 44
Young people who are using illicit drugs Provide brief interventions (eg. in conjunction with administration of one of the above screening questionnaires). (See also the 5As framework Chapter 1: Lifestyle, introduction) Opportunistic IIIB 47,57
Refer to drug education programs based on social learning theories (eg. life skills program, peer education, youth sport/recreation program) Opportunistic IIB 44,61,62
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 63–65
Young people who are using injecting drugs Refer to needle and syringe exchange programs where appropriate Opportunistic IB 66
Environmental N/A Promote school completion N/A GPP 71–73
Promote access to community and school based drug education programs (based on social learning theories) IB 44,74
Promote youth friendly, primary healthcare services
Support increased access to youth workers
GPP 1,44,60,75
Support community driven illicit drug use prevention programs (especially valuable for inhalant abuse) IIB 61
Support and promote community engagement strategies such as mentorship IB 44
Support supervised injecting centres IIB 67–70
* 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 counseling. The approach therefore will involve 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.44 This can be similar to developing a care plan for people with chronic conditions

Resources

CRAFFT tool for clinicians
www.ceasar-boston.org/ CRAFFT/pdf/CRAFFT_English.pdf

CRAFFT tool for self administration
www.ceasar-boston.org/ CRAFFT/pdf/CRAFFT_SA_English.pdf

Substances and choices scale manual
www.sacsinfo.com/ docs/SACSUserManualNoPrint.pdf

Substances and choices scale questionnaires
www.sacsinfo.com/ Questionnaires.html

IRIS (Indigenous risk impact screen) tool and brief intervention. The screening tool is made available only after participation in a training workshop
www.health.qld.gov.au/ atod/prevention/iris.asp.

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