Module B8: Substance use and misuse

Entry Scenario

The entry scenario addresses a variety of issues and problems associated with the module topic. It may be used at the beginning of the course to stimulate the students to identify their own needs and interests. The results may be utilized by the individual to assess own learning process, or be integrated with class objectives.

A fifteen year-old boy is brought to your clinic by his mother who says that her son is becoming more and more withdrawn at home. The parents are divorced and there are two younger siblings. The boy’s teachers complain that his schoolwork is growing worse, that he does not bother to do his homework, and he is absent from school more frequently. He stays out late in the evenings and does not want to go to school in the mornings. The mother does not like her son’s group of friends because they are known to be “into” drugs. You take a routine history with the mother present and there appear to be no specific health problems although the boy is reluctant to say much and the ‘history’ is mainly obtained from the mother. You arrange for his mother to leave the room and you question him about drug use. He gradually admits that he is smoking cannabis on a fairly regular basis and sometimes takes other drugs; he smokes cigarettes and occasionally tries alcohol, but he makes you promise you won’t tell any of this to his parents. He does realize that his school attendance and work are declining, but he does not want to give up his present group of friends. He has already been questioned informally once by the police about drug taking, although his parents do not know.

General Goals for Learners

by completing the module the participant will be able to :

1. Define the terminologies of adolescent Alcohol, Tobacco, and Other Drug (ATOD) use, and be able to understand and utilize the related epidemiological data
2. Understand the value of substance use from an adolescent’s viewpoint, and understand the consequences of substance use and misuse at the physical, cognitive, psychosocial and legal levels
3. Communicate effectively with an adolescent about substance use and implement an appropriate intervention plan as needed
4. Define the health professionals’ role in preventing adolescent substance misuse at the individual and community levels

Goal I : Define the terminologies of adolescent Alcohol, Tobacco, and Other Drug (ATOD) use, and be able to understand and utilize the related epidemiological data

Knowledge

Goal 2 : Understand the value of substance use from an adolescent’s viewpoint, and understand the consequences of substance use and misuse at the physical, cognitive, psychosocial and legal levels

Knowledge

Goal 3 : Communicate effectively with an adolescent about substance use and implement an appropriate intervention plan as needed

Attitudes

Skills

Goal 4: Define the health professionals’ role in preventing adolescent substance misuse at the individual and community levels

Attitudes

Knowledge

References

1. Schydlower M (ed). Substance abuse: a guide for health professionals. American Academy of Pediatrics, Oak Grove Village 2001.
   
   
2. Sussman S, Ames SL. The social  psychology of drug abuse. Open University Press, Buckingham/Philadelphia 2001.
   
   
3. Currie C et al. Young people's health in context. Health behaviour in school-aged Children (HBSC) study: International report from the 2001/2002 survey. WHO Europe, Copenhagen 2004.
   
   
4. Neinstein LS (ed). Adolescent  health care: a practical guide. 4th ed. Lippincott Williams & Wilkins, Philadelphia 2002 ; part XIV.
   
   
5. Bernstein GA et al. Caffeine dependence in teenagers. Drug and Alcohol Dependence 2002; 66: 1-6.
   
   
6. Koch, JJ. Performance-enhancing substances and their use among adolescent athletes. Pediatrics in Review 2002; 23: 310-317.
   
   
7. World Health Organisation. Neuroscience of psychoactive substance use and dependence. Geneva, WHO 2004, 286 pp. ( http://www.who.int/substance_abuse/publications/en/Neuroscience.pdf)
   
   
8. Boys A, Marsden J, Strang J. Understanding reasons for drug use amongst young people: a functional perspective. Health Educ Res 2001;16:457-469.
   
   
9. Lloyd B, Lucas K, Holland J, McGrellis S, Arnold S. Smoking in adolescence: images and identities. Routledge 1998.
   
   
10. Michaud PA, Blum RW, Ferron C. "Bet you I will!" Risk or experimental behavior during adolescence? Arch Pediatr Adolesc Med 1998; 152:224-226.
    
    
11. Parker H, Aldridge J, Measham F. Illegal leisure: the normalization of adolescent recreational drug use. Routledge 1998.
    
    
12. Shedler J, Block J. Adolescent drug use and psychological health. American Psychologist 1990; 45:612-630.
    
    
13. Macfarlane A, McPherson A. Drugs: the truth. Oxford, Oxford University Press 2003.
    
    
14. Dias PJ. Adolescent substance abuse: assessment in the office. Pediatr Clin N Amer 2002; 49:269-300.
    
    
15. Kandel DB et al. Psychiatric comorbidity among adolescents with substance use disorders: findings from the MECA study. J Am Acad Child Adolesc Psychiatry 1999; 38:693-699.
    
    
16. Schwartz RH et al. Urine testing for drugs of abuse: a survey of suburban parent-adolescent dyads. Arch Pediatr Adolesc Med. 2003; 157: 158-161.
    
    
17. Silberg J, Rutter M, D'Onofrio B, Eaves L. Genetic and environmental risk factors in adolescent substance use. J Child Psychol Psychiatry 2003; 44:664-676.
    
    
18. Clark DB, Bukstein O, Cornelius J. Alcohol use disorders in adolescents: epidemiology, diagnosis, psychosocial interventions, and pharmacological treatment. Pediatr Drugs 2002; 4: 493-502.
    
    
19. McCambridge J, Strang J. The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomized trial. Addiction 2004; 99:39-52.
    
    
20. Pbert L et al. The state of office-based interventions for youth tobacco use. Pediatrics 2003; 111: e650-e660. ( http://www.pediatrics.org/cgi/content/full/111/6/e650)
    
    
21. Ministry of Public Health of Belgium (ed.) Cannabis 2002 Report. Brussels, Ministry of Public Health (Tel. 00 32 (0) 2 210 48 07).
    
    
22. Strang J, Witton J, Hall W. Improving the quality of the cannabis debate: defining the different domain. Brit Med J 2000; 320:108-110.
    
    
23. Tarter RE et al. Neurobehavioral disinhibition in childhood predicts early age at onset of substance use disorder. Am J Psychiatry 2003; 160: 1078-1085 (helpful description in NIDA notes Vol. 19, No. 2, 2004:  http://www.nida.nih.gov/NIDA_notes/Nnvol19N2/New.html )
    
    
24. Cuijpers P. Three decades of drug prevention research. Drugs: education, prevention and policy 2003;10:8-19.
    
    
25. Ennett ST et al. Parent-child communication about adolescent tobacco and alcohol use: what do parents say and does it affect youth behavior? J Marriage Family 2001; 63:48-62.
    
    
26. Bond L et al. The Gatehouse Project: can a multilevel school intervention affect emotional wellbeing and health risk behaviours? J Epidemiol Community Health 2004; 58:997-1003.

Websites

1. http://www.teenagehealthfreak.org

Appendix 1

DSM-IV  Diagnostic Criteria for Substance Use Disorders
(adapted from American Psychiatric Association "Diagnostic and Statistical Manual of Mental Disorders. 4th ed." Washington D.C.: American Psychiatric Association 2000)

Criteria for Substance Abuse

1. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following occurring within a 12-month period:
   1. Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home (e.g. absences, suspensions, or expulsions from school)
   2. Recurrent substance use in situations in which it is physically hazardous (e.g. driving when impaired)
   3. Recurrent substance-related legal problems
   4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of substance use
2. The symptoms have never met the criteria for Substance Dependence for this class of substance

Criteria for Substance Dependence

Similar criteria to those for Substance Abuse, but include evidence for development of tolerance and withdrawal symptoms. In addition, important activities are given up and a great deal of time is spent in activities necessary to obtain the substance, use it, and recover from its effects.

Dependence is often accompanied by a persistent desire to cut down or control substance use.

WHO International Classification of Diseases
(downloaded from www.who.int/substance_abuse/terminology/who_lexicon/en/print.html)

Psychoactive substance use disorders

A shortened version of the term used in ICD-10: Mental and behavioural disorders associated with psychoactive substance use. The term encompasses

• acute intoxication (F1x.0)
• harmful use/problematic use/misuse (F1x.1): A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (e.g. hepatitis following injection of drugs) or mental (e.g. depressive episodes secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse social consequences; social consequences in themselves, however, are not sufficient to justify a diagnosis of harmful use. The term was introduced in ICD-I0 and supplanted "non-dependent use" as a diagnostic term. The closest equivalent in other diagnostic systems (e.g. DSM-IIIR) is substance abuse, which usually includes social consequences.
• dependence syndrome (F1x.2): A cluster of behavioral, cognitive, and physiological phenomena that may develop after repeated substance use. Typically, these phenomena include a strong desire to take the drug, impaired control over its use, persistent use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and a physical withdrawal reaction when drug use is discontinued. In ICD-I0, the diagnosis of dependence syndrome is made if three or more of six specified criteria were experienced within a year. The dependence syndrome may relate to a specific substance (e.g. tobacco, alcohol, or diazepam), a class of substances (e.g. opioids), or a wider range of pharmacologically different substances.
• withdrawal state (F1x.3),
• withdrawal state with delirium (F1x.4),
• psychotic disorder (F1x.5) and
• amnesic syndrome (F1x.6).

For a particular substance these conditions may be grouped together as, for example, alcohol use disorders, cannabis use disorders, stimulant use disorders. Psychoactive substance use disorders are defined as being of clinical relevance; the term "psychoactive substance use problems" is a broader one, which includes conditions and events not necessarily of clinical relevance.

Misuse, drug or alcohol: use of a substance for a purpose not consistent with legal or medical guidelines, as in the non-medical use of prescription medications. The term misuse is preferred by some to abuse in the belief that it is less judgmental.

Other useful headwords to be looked up in the WHO Substance Use Lexicon (also available in French and Spanish):  abstinence, abuse, addiction, drug, dual diagnosis, multiple drug use (in French: polytoxicomanie), overdose, psychoactive drug or substance

Appendix 2

‘Functions’ of substance use in light of adolescent developmental tasks
Adapted from Silbereisen RK and Reese A. Substanzgebrauch: Illegale Drogen und Alkohol.
In: Raithel J. Risikoverhaltensweisen Jugendlicher: Formen, Erklärung und Prävention. Opladen, Leske + Budrich 2001; 131-151.