Clinical toolkit: Alcohol and other drugs

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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, including alcohol.

Young people may use substances for many different reasons and with different patterns of use (such as bingeing, occasional or continual). Video: 'Young people's experience of substance use – why did you start using?'

  • Where use is prolonged, heavy, or creating social or personal problems, it may meet a diagnosis for a substance use disorder (see Assessment).
  • Management of substance use can involve harm reduction, counselling approaches and psychological therapy, detox, and pharmacotherapy (see Management).
  • There is a bidirectional relationship between substance use, mental health conditions, traumatic experiences, and sexual health risks (see Comorbidity).
  • Lapse and relapse are normal parts of substance use, while involving family can be helpful in enabling a young person to manage their use (see Continuing Care). 

        

Assessment

  1. Use of alcohol and other drugs may be identified during a psychosocial assessment such as HEADSS.
  2. Use of the formulation framework can also assist in understanding the broader context of the young person’s AOD use.
  3. Consider predisposing / risk factors which can increase the likelihood that a young person will develop a substance use disorder.
  4. Several screening tools have been validated for use with young people to identify SUDs including CRAFFT, ASSIST and AUDIT.
  5. Additional screening and probing questions from Domain 4: Alcohol and Other Drugs of the HEADSS assessment can explore AOD use.
  6. The DSM-5 provides diagnostic criteria for assessing a substance use disorder along with a severity scale.
  7. Patterns of substance use occur on a continuum and defining these substance use patterns will assist management of a SUD. Taking a drug history can help identify patterns of use.
  8. Cannabis use increases the risk of psychosis. Be aware of comorbidities when assessing a young person.
  9. Screening for anxiety and/or depression is recommended, as substance use often co-occurs with mental health conditions or trauma.
  10. If post-traumatic stress disorder is suspected, refer on to a specialist for further assessment – note that discussing past traumatic events can itself be traumatising.
  11. Assess for sexual health and substance use risks, which often overlap.
  12. Checking vaccination status is important for key vaccine preventable STIs including Hepatitis A and B and HPV (genital warts and cervical cancer).
  13. Assess for risks of harm to self or others. What do I do if I identify a high acute risk of suicide?
  14. The Public Health Model or Interaction Model also provide a frame of reference when assessing a young person’s substance use.



Videos:

 

 

Considerations when working with LBGTIQ young people

Trans, gender-diverse, and sexuality diverse young people use alcohol and other drugs at higher rates compared to cisgender, heterosexual young people which makes universal screening for substance use important. Guides exist for working safely and inclusively with sexuality diverse young people and trans or gender-diverse.

 

Video:

 

        

Management

  1. An accepting, non-judgemental approach is necessary to facilitate effective communication and management.
  2. Seek permission from the young person before giving information about substance use management strategies.
  3. Apply Shared Decision Making where possible.
  4. Even when an individual does not meet full diagnostic criteria, they may benefit from support to reduce their substance use.
  5. Treatment for substance use should take account of the young person’s biopsychosocial factors, patterns of substance use and readiness for change. Consider protective, precipitating, and perpetuating factors from the formulation framework.
  6. Monitor and respond to risks (identified during assessment] and collaboratively set goals with the young person. A safety plan can be a helpful tool when managing risk.
  7. Build motivation to reduce use with motivational interviewing and encourage commitment to change with change talk.
  8. Substance use during pregnancy can impact the developing child. Education on these impacts and available contraception options may enable a sexually active young person who uses AOD to protect their health and avoid harm to an unborn child. Use motivational interviewing to discuss these risks. Refer to the sexual health clinical toolkit for more information.
  9. If unvaccinated, support young people to obtain access to catch-up-vaccines including for vaccine preventable STIs including Hepatitis A and B and HPV (genital warts and cervical cancer).
  10. Provide information on harm reduction and psychoeducation on the effects of AOD use and management strategies.
  11. Help build skills to address lifestyle factors, encourage health-promoting behaviours (e.g. 7 tips for a healthy headspace, sleep, diet, exercise, relationship breakups), and educate on potential coping strategies.
  12. Raise awareness of personal supports or help engage supports with consent from the young person. The involvement of family and/or friends may facilitate a more successful outcome. Consider a support worker in AOD or a referral to a specialised service
  13. Detoxification or ‘detox’ options exist for heavy use and dependence, including home-based detox, residential detox, and medically supervised withdrawal. More information can be found at the YSAS website and the ADF website.



Videos:

 

Substance Specific Management

Comprehensive substance withdrawal and management information can be found within the YSAS Adolescent Withdrawal Guidelines 2016.

Some key withdrawal management principles from the above guidelines include:

  • Assess risk of withdrawal and note that high risk withdrawal may be a medical emergency (p60)
  • Care planning for resilience (p65)
  • Use of scales to assess need for medication such as diazepam (e.g. p67)

 

Harm minimisation for young people who inject drugs is another key principle.

 

Management of withdrawal for specific substances:

(Page numbers refer to YSAS Adolescent Withdrawal Guidelines 2016.

 

Resources for Young People

 

For Aboriginal and Torres Strait Islander young people

 

Videos:

Family Involvement – Young Person’s Experience of Substance Use

Outcomes of Help-Seeking – Young Person’s Experience of Substance Use

 

Resources for Friends and Family

        

Continuing Care

        

Comorbidity

Depression and anxiety

People with depression have high rates of comorbidity with other mental disorders and substance use disorders.  There is a high concurrence of substance use disorders and mental illness amongst young people. Young people may use alcohol or other drugs to cope with their depressive symptoms. This is often called ‘self-medication’.

The clinical toolkit contains more information on depression and anxiety including assessment and management.

Psychosis

Any use of cannabis can double the risk of psychosis in those who are vulnerable, and bring on a first episode up to two and a half years earlier. Use of cannabis at a young age and heavy use of cannabis are associated with up to six times the risk for schizophrenia; especially smoking three or more times per week before the age of fifteen. Cannabis has clearly been shown to make psychotic symptoms  worse in people who already have a psychotic disorder such as schizophrenia. 

Along with the traditional high, cannabis use can cause paranoia, delusions and hallucinations in people who don’t have a mental illness, even in small doses[1], although drug induced psychosis is uncommon and usually resolves with the cessation of marijuana.

This two-hour training module explores the many practical considerations and models for understanding and working with young people with co-occurring substance use and early psychosis. 

Borderline Personality Disorder

Borderline Personality Disorder (BPD) and SUD frequently co-occur. Care should be undertaken within a trauma informed care approach as childhood trauma or family dysfunction are very common among people with SUD and BPD.

More information and fact sheets can be found at:



Sexual Health Risks

Problematic drinking is associated with an increased risk of STIs and this risk is present for both men and women.

Alcohol and other drug use, particularly amphetamines, may be related to increased high-risk sexual practices because of increased arousal and decreased inhibitions.

More information can be found in the clinical toolkit for sexual health.


[1] Sane Australia. Cannabis and Psychosis.

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