Substance use across the lifespan

Question 1

Defining Adolescence

Answer 1

“The children now love luxury; they have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise. Children are now tyrants, not the servants of their households. They no longer rise when elders enter the room. They contradict their parents, chatter before company, gobble up dainties at the table, cross their legs, and tyrannize their teachers”.

Question 2

Developmental transitions influencing risk and use levels

Answer 2

Puberty: Negative affect, sexual activity, neurocognitive skills
Independence: Driver’s license, moving out of home
Autonomy: Financial independence, transition to college
Social roles: Martial status, parenthood

Question 3

Why focus on adolescents?

Answer 3

Adolescence is the most common time for onset of substance use

Risk taking feature during adolescence
Use in adolescence mediates use on adulthood

Adolescent Tx approaches rely on adult Tx approaches but must take into account:
adolescent drug misuse is different from adult drug misuse
patterns of use
assessment
anticipated effects and consequences of substance use
developmental differences and issues
social and emotional contexts of use
risk factors contributing to the onset
trajectory
level of skill, experience and realities

Question 4

Prevalence

Answer 4

National Drug Strategy Household Survey
Australian Secondary Schools Students Use of Alcohol in 2005, 2011, 2016
Australian Secondary School Students Use of Over-the-Counter and Illicit Substances in 2005, 2011 & 2016

Question 5

Tobacco

Answer 5

Initiation 14.9 (20+ 15.9yrs)
Regular smoking begins 16 -19 yrs ~ rare 20+
Females:
More have ‘ever smoked’
Initiation at earlier age
more likely to continue smoking
Intention to smoke is a predictor of future smoking behaviour in secondary school students
Major determinants:
social factors (peer/parent smoking) and
emotional problems (anxiety, depression)
rather than an addiction to nicotine

Question 6

Statistics

Answer 6

In the last year:
-Younger women more likely to smoke in adolescents
-Percentage of people using tobacco increases with age
Smoked in last 7 days
-Males more prevelant in 16/17 year age group
Smoked more than 100 cigarettes in lifetime:
-More males in 16 and 17 age
-Smoking isn’t as common- rates are dropping

Question 7

What is the most common drug used by adolescents

Answer 7

Analgesics

Question 8

Alcohol

Answer 8

Risk of alcohol related harm increases rapidly with age
Lifetime use by the age of 19 is 60%
Trends in drinking has not changed
Majority use alcohol infrequent; binge or risky for short term harms
Young females drink at levels of greater risk than young males
Males tend to drink more frequently on a weekly basis
Most commonly drinking for social reasons
Younger prefer spirits; Older males prefer beer (then wine); older females prefer wine
Low awareness/understanding of the harms associated with excessive alcohol use
Faster/heavier consumption patterns – “to get drunk”
If experiencing harms, more likely short term harms – e.g., hangovers, amnesia
Up to 20% report alcohol aggression or sexual risk taking

Question 9

Analgesics

Answer 9

The reported use of substances such as Disprin, Panadol or Nurofen among students was extremely high - only 5% had never used these medications. Over two-thirds of all students had used analgesics in the past month

The main reason for analgesic use was to help ease the pain associated with a headache/migraine (52%). For the majority of students (90%) parents were the main source of analgesics

At all ages, females were significantly more likely to have used analgesics in their lifetime, in the past year and past month

Question 10

Illicit drugs - Cannabis

Answer 10

The most commonly used illicit substance, with 16% of students aged 12-17-years ever using the drug at some time in their lives.
The proportion of use increased with age, with 4% of 12-year-olds and 31% of 17-year-olds reporting lifetime use
There were no significant differences in the proportion of students using cannabis in the past week, past month or lifetime between 2008 and 2014. However, reported lifetime use continued to increase amongst the older age groups
Age of initiation = 15yrs (20+ = 19 yrs)
Heavy cannabis users - more likely to experience a range of difficulties
Hazardous situations; Legal, social, interpersonal; LT cognitive impairment (Ashton 2002); Respiratory side effects (Hall 1998); Precipitation to psychosis (Hall and Degenhardt 2000); Depression
Approx 10% of regular users develop dependence in early adulthood

Question 11

Inhalants

Answer 11

“How many times, if ever, have you deliberately sniffed (inhaled) from spray cans or deliberately sniffed things like glue, paint, petrol or thinners in order to get high or for the way it makes you feel …”

Inhalant use was related to age – with use decreasing significantly from the youngest to the oldest students – 19% of 12-year-old students had ever used and 10% for those aged 17 years

Question 12

Other Illicit Drugs

Answer 12

Use of illicit drugs, other than cannabis, was uncommon. For all drugs, however, the proportion of students using these substances increased with age
Ecstasy replaced hallucinogens (LSD, acid, trips, magic mushrooms, datura, angel’s trumpet) as the second most commonly used illicit substance by students behind cannabis, with 3% of 12-17 year-olds reporting lifetime use
While the proportion of 12-17-year-olds using ecstasy in the past month in 2014 was significantly lower than in 2008 it was significantly higher than in 2011

Question 13

Risk Factors for 12-17 years

Answer 13

-Low involvement in activities with adults
-Perceived high level of community drug use
-Community disadvantage & disorganisation
-Availability of drugs
-Positive media portrayals of drug use
Parental
- Adolescent conflict
-Favourable attitudes to drug use
-Parental AOD problems
-Parental rules permitting drug use
-Not completing school
-Peers who use drugs
-Delinquency
-Sensation seeking and adventurous personality
-Favourable attitude towards drug use

Question 14

Protective factors

Answer 14

• Attachment to family
• Low parental conflict
• Parental communication and monitoring
• Religious involvement

Question 15

Impact of alcohol on brain development

Answer 15

Complex changes in brain wiring during adolescence, especially in the frontal lobe:
planning, 
decision making, 
impulse control, 
voluntary movement, 
memory, 
speech production

Question 16

Impact of Alcohol on Brain Development

Answer 16

Like other drugs, alcohol produces its effects by altering the actions of neurotransmitters
modifies actions of two major neurotransmitters – GABA and glutamate
these found throughout the brain – hence alcohol has widespread effects on behaviour – i.e., intoxication
greater effect on developing areas of the brain, compared to those fully developed – evidence suggests that the damage could be permanent

Question 17

Alcohol on the adolescent brain

Answer 17

Alcohol impacts on two areas of the brain that undergo major changes in adolescence
the hippocampus deals with memory and learning - suffers the worst damage. Those who drink more and for longer have significantly smaller hippocampi (up to 10% smaller)
the prefrontal area undergoes most change during adolescence - teen drinking could cause severe changes, affecting the formation of adult personality and behaviour

Question 18

Different effects of alcohol on the brain

Answer 18

Young people are far more likely to experience complete absence of memory with no possibility of retrieval
due to effects of high alcohol concentrations on brain centres related to memory (particularly the hippocampus)
uncommon in adults, but relatively common among adolescents
consistent with greater susceptibility of adolescent memory centres to disruptive effects of alcohol

Question 19

Young people and alcohol

Answer 19

Young people are able to drink for longer than adults due to them being less susceptible to the sedation effect
brain mechanism of this effect not known, likely that it has to do with GABA
GABA system implicated in alcohol’s sedative and motor-impairing effects
final levels of GABA receptors are not reached until early adulthood - adolescents have fewer GABA receptors on which alcohol can act
reach a certain age (i.e., early 20s), you just can’t quite drink the way you used to ….

Question 20

Treatment

Answer 20

Dual focus:
1.Immediate issues (e.g., accommodation, legal, financial, health)
2.Development of insight into functions of drug use, personal strengths & new ways of coping
Engagement & development of a therapeutic relationship
Comprehensive biopsychosocial assessment
A motivational and empowering approach
Building protective factors & reducing risk factors
Education about drug abuse, dependence & harm reduction
Involving family & significant others

Question 21

Treatment #2

Answer 21

Promoting and strengthening relationships with at least one positive adult
Support experiential learning opportunities
Optimising life choices and opportunities
Consider use of medications
Age-appropriate and accessible
Ensuring safety
Continuity of care and follow up
Range of services:
Outpatient services - individual and family
Day patient - groups
Residential services - withdrawal, rehabilitation

Question 22

Other findings

Answer 22

Use in adolescence can predict use in adulthood
Earlier the initiation leads to higher use and more harmful alcohol use (Christchurch cohort)
Taking any type of drug increases the likelihood of taking another type of drug
Structural equation approaches measuring poly drug use show that drug use at 13/14 is an unique and important predictor of drug use and adjustment problems at 21/22 and 25/26

Question 23

Substance use and the elderly:Overview

Answer 23

Drug use in early life is a strong predictor of later drug use
Rate of drug use typically declines with age
Morbidity and mortality associated with alcohol and tobacco use become common after age 50
Management of substance abuse and dependence will emerge as an increasingly important public health problem in the coming decades - impact of baby boomers

Question 24

Prevalence elderly

Answer 24

Confounds:

Definitional problems of misuse: underuse, overuse, erratic use
Few studies have focused on elderly populations
Inappropriate diagnostic criteria and screening tools

Question 25

Prevalence – Tobacco

elderly

Answer 25

Major cause of drug-related mortality:15000 deaths per annum
More males smoke, however difference is decreasing
Tobacco-related morbidity greatest impact on elderly men e.g. cancers and cardiovascular disease common after the age of 50

Question 26

Elderly alcohol consumption

Answer 26

Lower consumption than the general population

Daily drinking occurs more frequently - 17% of people aged 60+

1000 deaths per annum

Light patterns of use are protective – est prevented 5000 deaths per annum

Harmful and hazardous use more common in males

Harms - Falls, diseases of the gastrointestinal, cardiovascular and central nervous systems

Question 27

Illicit drugs in the elderly

Answer 27

Includes illegal drugs, prescriptions/over counter used for illicit purposes, ‘other’ used inappropriately

Low prevalence rate in the elderly

Baby boomers have continued illicit drug use - higher age-matched cohorts to previous generations

Expected larger number of current drug users to reach age 65 - impact on treatment and resources

Question 28

Prevalence – prescribed medications elderly

Answer 28

Use of multiple prescribed medications increases with age
Use of prescription medications approx 3 times as frequently as the general population
Use of over the counter medications is even more extensive

Question 29

Prevalence elderly

Answer 29

Proportion who reported using pharmaceuticals in the previous week or month was generally higher in the older age groups, with 1.5% of those aged 60 or older reporting using in the past week and 2.6% using in the past month
Benzodiazepines are frequently prescribed – women; anxiety; depression; insomnia
More likely to be prescribed medications for longer periods of time compared to younger patients
Associated with considerable morbidity
25% of all hospital admissions in the elderly related to medication problems
Interaction with alcohol and other medications are more common, and a major cause of falls

Question 30

The Effects of Aging on Substance Misuse

Answer 30

Biological variables

Gender
Psychosocial variables
Psychiatric co-morbidity
“Maturing out” theory

Question 31

Risk factors: Older age 65+

Answer 31

• Loneliness and reduce social support
• Continuation of high levels of non-problematic use
• Retirement- SES, sense of role, unrealistic expectations
• Negative life events
• Health

Question 32

Assessment

Answer 32

Specific issues to check for in elderly people who are thought to consume alcohol or other drugs include:
falls and accidents
nutritional adequacy
family problems and social isolation
medical problems
ability to attend to activities of daily living
fitness to drive a car
Poly-pharmacy

Question 33

Best practice approaches to address the needs of older people (NDS 2016) include:

Answer 33

Early identification of issues in primary care settings
Maintenance of social connections
Promotion of community inclusion, positive environments and full and active lives
Age appropriate treatment components
Longer treatments
Physically accessible services (hand rails, appropriate seating, transport etc)
Outreach and home visits
Workforce development to enable care for more complex co-morbidities.

Question 34

Treatment considerations / strategies

Answer 34

Avoid prescribing to help cope with stressful life events

Prescribed sedative drugs (with/without alcohol) are commonly used as a method of suicide in the elderly

Explore other ways of managing stressful events

Prescriptions used as a short-term strategy only

Recommended to use only short-acting drugs (e.g., SSRI’s rather than benzodiazepines)

Question 35

Summary

Answer 35

Alcohol, tobacco, cannabis and increasingly prescription medications, are the most commonly misused substances across age groups.

Pattern of use and the salient impact vary depending on life stage.

AOD most commonly is initiated during adolescence

Peaks during adulthood

While AOD use is less common among older adults, the risk for health complications associated with use increases.

Question 36

Summary 2

Answer 36

Health outcomes - all ages are at risk for overdose, accidental injury, and attempted suicide.

Adolescents more likely to be in vehicular accidents; older adults at greater risk for damaging falls.

Adulthood has the highest rates of associated medical conditions (e.g., cancer, sexually transmitted disease, heart disease) and mental health conditions (e.g., bipolar disorder, anxiety disorders, antisocial personality disorder).

Differing treatment considerations related to developmental stage