Substance Use Disorder

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

  2. 2. White, V. B., & Bariola, E. (2013). E. 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. 3. Australian Institute of Health and Welfare 2011. Young Australians: their health and wellbeing 2011. Cat. no. PHE 140 Canberra: AIHW

  4. 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 Replication. Archives of general psychiatry, 62(6), 593-602.

  5. 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 Wellbeing. Australian and New Zealand Journal of Psychiatry, 44(8), 729-735.

  6. 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. 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. 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. 9. Bonomo, Y., Coffey, C., Wolfe, R., Lynskey, M., Bowes, G., & Patton, G. (2001). Adverse outcomes of alcohol use in adolescents. Addiction, 96(10), 1485-1496.

  10. 10. Masten, A. S., Faden, V. B., Zucker, R. A., & Spear, L. P. (2008). Underage drinking: A developmental framework. Pediatrics, 121(Supplement 4), S235-S251.

  11. 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 studies. The Lancet, 363(9421), 1579-1588.

  12. 12. Riggs, P., Levin, F., Green, A. I., & Vocci, F. (2008). Comorbid psychiatric and substance abuse disorders: recent treatment research. Substance Abuse, 29(3), 51-63.

  13. 13. Teesson, M., Slade, T., & Mills, K. (2009). Comorbidity in Australia: findings of the 2007 national survey of mental health and wellbeing. Australian and New Zealand Journal of Psychiatry, 43(7), 606-614.

  14. 14. Meyers, J. L., & Dick, D. M. (2010). Genetic and environmental risk factors for adolescent-onset substance use disorders. Child and adolescent psychiatric clinics of North America, 19(3), 465-477.

  15. 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 adulthood. Addictive behaviors, 37(7), 747-775.

  16. 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:

  • Substance often taken in larger amounts or over a longer period than was intended

  • Persistent desire or unsuccessful efforts to cut down or control substance use

  • Significant time spent trying to obtain substance, or recovering from its effects

  • Craving, or a strong desire or urge to use substance

Social impairment:

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

  • Continued substance use despite recurrent social or interpersonal problems related to substance use

  • Important social, occupational, or recreational activities are given up or reduced because of substance use

Risky use:

  • Recurrent substance use in situations in which it is physically hazardous

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

Pharmacological criteria:

  • Developing tolerance to the substance

  • 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

See the headspace psychosocial assessment interview for more details.

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 CRAFFT Screening Tool.

References

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

  2. 2. Martin, C. S., & Winters, K. C. (1998). Diagnosis and assessment of alcohol use disorders among adolescents. Alcohol Health and Research World, 22(2).

  3. 3. Winters, K. C., & Kaminer, Y. (2008). Screening and Assessing Adolescent Substance Use Disorders in Clinical Populations. Journal Of The American Academy Of Child & Adolescent Psychiatry, 47(7), 740.

  4. 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.

The Evidence Finder provides reference details for studies of prevention and treatment interventions for substance use disorders in young people.

References

  1. 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. 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. 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. 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. 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 review. Journal of consulting and clinical psychology, 79(4), 433.

  6. 6. Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). The comparative effectiveness of outpatient treatment for adolescent substance abuse: A meta-analysis. Journal of Substance Abuse Treatment, 44(2), 145-158.

  7. 7. Waldron, H. B., & Turner, C. W. (2008). Evidence-based psychosocial treatments for adolescent substance abuse. Journal of Clinical Child & Adolescent Psychology, 37(1), 238-261.

  8. 8. Deas, D. (2008). Evidence-based treatments for alcohol use disorders in adolescents. Pediatrics, 121(Supplement 4), S348-S354.

  9. 9. Bender, K., Springer, D. W., & Kim, J. S. (2006). Treatment effectiveness with dually diagnosed adolescents: A systematic review. Brief Treatment and Crisis Intervention, 6(3), 177.

  10. 10. Simkin, D. R., & Grenoble, S. (2010). Pharmacotherapies for adolescent substance use disorders. Child and adolescent psychiatric clinics of North America, 19(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:

More Info

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