Prevention, early intervention, and harm reduction of substance use in adolescents.

This paper presents a systematic review on the effectiveness of prevention, early intervention, and harm reduction including treatment of substance abuse among adolescents for tobacco, alcohol and illicit drugs. Taxation, public consumption bans, restriction on advertisements, and minimum legal age for consumption, are effective measures to reduce the use of tobacco and alcohol. School-based prevention and skill-training interventions are effective tools to reduce substance use among adolescents. Social norms and intervention to reduce substance use in adolescents do not have strong evidence of effectiveness. Road-side testing and reduction of injection related harm are effective. However, further research is needed to support it. Moreover, the available research evidence comes from the Western countries with questionable applicability in Indian setting. Research is needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in adolescents in India.

INTRODUCTION

Late childhood and adolescence are periods of experimentation, exploration, identity formation, risk taking, and assertion for independence in every person's life. Naturally, the incidence of drug abuse in children and adolescents is higher than the general population.[1] In the western world, drug abuse among youth is generally associated with particular youth subcultures and lifestyles. This causes an acceptance of drugs and their use by members of these subcultures.[2]

In developing countries like India, by the time they reach adolescence, the young people are already exposed to various stresses such as competition in the fields of education and employment likewise, alongside changing roles in the family and society, new-found responsibilities, and a changing identity, physically, mentally, and emotionally.[1] During this phase of transition, adolescents achieve developmental milestones from dependence to independence and new found intimate relationships.[3] Due to rapid physiological development during puberty, there is fast growth which can affect cognitive reasoning, emotional regulation, and risk-taking behavior. Adolescents progress through a phase with tremendous opportunity for access to drugs and exposure to the risks of substance use, given the state of heightened emotion and the importance of maintaining peers.[4] They are exposed to many drugs, especially those easily available drugs such as cannabis, tobacco, and alcohol. In a milieu where social and peer pressures are difficult to resist, youth often fall prey to abuse of drugs.[5]

EPIDEMIOLOGY

India has a huge “at risk” population vulnerable to substance abuse and addiction.[6] The children and adolescent population experiments with drugs for fun and amusement in the company of friends, particularly in the urban areas.[7] According to a prevalence study, 13.1% of the people involved in substance abuse in India are below 20 years of age.[6] A clinic-based survey revealed that 63.6% of the substance users seeking treatment were introduced to drugs at a young age when they were 15 years or younger. As the age advances, there is progressive decline in the initiation of substance use.[3] In the recent years, the age of starting use of drugs is progressively falling across the country and the initiation of drug use occurs much earlier, being during preadolescence and childhood periods. Early initiation of drug use is often associated with poor prognosis and lifelong pattern of disturbed behavior. Drugs can have long-lasting effects on the developing brain and may interfere with positive family and peer relationships and school performance.[89]

According to a study conducted by the National Commission for Protection of Child Rights, the common drugs of abuse among children and adolescents are tobacco and alcohol, followed by inhalants and cannabis. The mean age of onset was lowest for tobacco (12.3 years), followed by onset of inhalants (12.4 years), cannabis (13.4 years), alcohol (13.6 years), proceeding then to the use of harder substances – opium, pharmaceutical opioids, heroin (14.3–14.9 years) and then substances through injecting route (15.1 years).[10] In another study, 46.36% of slum dwelling adolescents used both smokeless and smoking tobacco in addition to alcohol and cannabis and started using drugs during their childhood itself.[11] A high percentage of adolescents in Assam were found using alcoholic drinks with a male preponderance. They begin taking alcoholic drinks at a very young age with parents’ indulgence in tobacco, alcohol, or both.[12] In a study conducted among school-going students, alcohol and heroin were the main substances of abuse.[7] An emerging trend is the use of cocktail of drugs through injection, and often sharing the needle, which increases their risk of HIV infection.[6] A high intravenous use of drugs among street children and working children has been reported.[10] There are one million registered heroin addicts in India and cannabis products, such as charas, bhang, or ganja, are abused throughout the country.[1]

Tobacco and alcohol are the most commonly abused drugs by Indian children and adolescents, which represents a significant drug threat. Both are gateway substances and are among the earliest drugs used by children or teenagers. A preadolescent or adolescent who smokes tobacco or drinks alcohol is 65 times more likely to use marijuana than someone who abstains.[3] The younger the age of experimentation, greater the risk of serious health problems. It is estimated that by the time boys reach the ninth grade, about 50% of them have tried at least one of the gateway drugs. A larger proportion of teens in West Bengal and Andhra Pradesh have been using gateway drugs (about 60% in both the states) than Uttar Pradesh or Haryana (around 35% each). Smokeless tobacco in the form of gutkha is commonly used by children and adolescents in certain states. Every day, of the 55,000 children in the country who take up tobacco use hail generally from low socioeconomic strata with poor social support and from broken homes. They are often victimized by deprivation and discrimination. Quite often tobacco use and the use of other drugs is associated with other psychiatric disorders.[13]

Substance use and criminal behavior are interrelated. Greater the involvement in substance abuse, more severe is the violence and criminality.[14] There is an increasing trend in serious crimes such as rape, murder/attempt to murder, and burglary committed by juveniles. Drug-crime correlation has been noted with the consumption of substances such as cannabis with murder, inhalants with rape, and opioids with snatching-related crimes.[15]

Although drug use initiation usually occurs during childhood and adolescence, the drug users seldom seek treatment in the clinics. Thus, community-based programs are more appropriate and beneficial for prevention and treatment of substance abuse in this group of population.[16]

There is limited evidence on the treatment and preventive strategies of drug abuse in adolescents, with very few studies from the developing countries and India, in particular. However, research shows that rates of tobacco use, harmful alcohol use, and illicit drug use can be reduced by a combination of regulatory, early intervention, and harm reduction approaches.[7] Therefore, the focus of responses is largely on prevention, early intervention, and harm reduction than intensive treatment of dependent use often done in adult substance users. Even the heavy substance using adolescents may not necessarily be dependent users. Therapeutic interventions in this age group population can be delivered through some unique platforms such as educational settings and mobile and online interventions. Intervention approaches in adolescents range from macrolevel population-based interventions such as legislation, regulation, and law enforcement to individual level interventions such as early intervention and harm reduction in those using drugs, who are at risk of acute adverse effects and treatment of problematic or dependent substance use.

FRAMEWORK FOR INTERVENTION

Intervention is done in accordance with the principles of Adolescent Substance Use Disorder Treatment Guidelines[17] based on extensive research and the clinical practice guidelines.[1819] Despite the fact that the adolescents are often aware of the harmful effects of substance use, they take up this habit and continue with it. This requires comprehensive prevention and control programs in schools and the community, targeted toward adolescents and their parents and other family members. Effective measures are required to encourage shaping the attitude of school children toward self-confidence and adequacy, as also to prevent risk behavior among adolescents and to develop effective and healthy coping mechanisms in times of need.[20]

To prevent adolescents initiating substance use: Prevention interventions are population-based interventions which may have the following aims:

Reduce adolescents’ interest in substance use by informing about the full picture with the harmful effects of the drugs and long-term adverse consequences

Limit the availability of substances to make them more difficult to obtain and use

Use criminal or other social sanctions to discourage adolescents from using substances.

To intervene early: The aim of early intervention is to identify adolescents who might be at risk or who show signs of problematic use and to reduce the use before it escalates

To reduce harm or treat substance use: Harm reduction approach aims at restricting or minimizing the effect of substance use on adolescents, their families, and peers.[21] Treatment is aimed at addressing heavy or dependent use.

Population-level intervention: preventing substance use and harm

Prohibition of use of controlled substances

The principle of preventing use of drugs, except for medicinal use, was adopted in the three international conventions on drug-related matters, namely, Single Convention on Narcotic Drugs, 1961,[22] Convention on Psychotropic Substances, 1971,[23] and the UN Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances (NDPS), 1988.[24] These conventions prohibit the nonmedical use of cannabis, opioids, amphetamines, and cocaine in the countries that have signed the conventions. India has signed and ratified these three conventions. India's commitment to prevention of drug abuse and trafficking predates the coming into force of the three conventions. The NDPS Act, 1985 (amendment in 2014)[25] was framed taking into account India's obligations under the UN Drug Conventions as well as Article 47 of the Constitution. This Act prohibits, except for medical or scientific purposes, the manufacture, production, trade, use, etc., of NDPSs.

However, there is no strong evidence to prove that the tough sanctions reduce the criminal offending in drug use. In the past decade, policy changes in several countries have permitted some observations on potential effects of moving away from criminalization of cannabis use to medical and nonmedical purposes. In a US study,[26] no increase in adolescent cannabis use was observed where medical cannabis use was legalized and even identified a reduction in cannabis use by eighth-grade students.

Availability and sale restrictions

Adolescents’ access to alcohol can be reduced by restricting the outlets where alcohol is sold.[27] Restricted access to alcohol is associated with stability in the harm caused by alcohol. Restricted access is applicable to people of all ages that drink. In India, there are some states such as Gujarat, Bihar, Manipur, Mizoram, and Nagaland and the Union Territory of Lakshadweep which prohibit the sale, purchase, and consumption of alcohol. Gujarat is the only state which awards death penalty to those found guilty of making and selling spurious liquor causing death. Despite the strict prohibitions, predictably, smuggling and sale of illicit alcohol are very common.[28] India also observes dry days on major religious festivals and national holidays such as Republic Day, Independence Day, and Gandhi Jayanti.[29] On these days, sale of alcohol is prohibited and the respective state government ensures its effectiveness.

Drunken driving and accidents are not so low in any of the dry states as most of the truck drivers consume the country alcohol during their trips, which is easily available in the states where alcohol is not prohibited. Ban on alcohol consumption has definitely led to decline in the number of accidents. It instills fear in the minds of the drivers for the payment of large sums of money as fine, if caught under heavy drunken conditions.[30]

Minimum legal age for consumption of alcohol and tobacco

Age restrictions are imposed for legal purchase of alcohol and tobacco in many countries. The legal age limits imposed by countries varies from 18 to 25 years with most requiring people to be at least 18 years or older to obtain their stuff.[31] In India where alcohol is a state subject, legal age for drinking varies from state to state – in the States where alcohol consumption is not prohibited. In some states, the permissible legal age for alcohol drinking is 25 years. This policy can be supported by training workers in hospitality sector in responsible service of alcohol and imposing fines on alcohol sellers. Raising of the minimum legal drinking age reduces hospital admissions for acute intoxication, alcohol-related motor vehicle accidents and mortality.[3233]

The Cigarette and Other Tobacco Products Act, 2003[34] prohibits the sale of cigarettes and other tobacco products to the people below 18 years of age making it difficult for young people in India to obtain cigarettes. It should end sale to children.[35] However, other provisions to obtain tobacco may not permit the desired reduction in use.[3637]

Taxation and maximum pricing

The most fundamental law of economics links the price of a product to the demand for that product. Increase in the monetary value of alcohol (i.e., through tax increases) would be expected to lower alcohol consumption and its adverse consequences.[38] There is strong evidence in favor of increased alcohol taxation or price and reduction in overall alcohol consumption. There is consistent evidence that raised alcohol prices produce moderate-to-large reductions in alcohol-related morbidity and mortality, crime, violence, and sexually transmitted diseases.[3233] Studies investigating such a relationship found that alcohol prices were one-factor influencing alcohol consumption among adolescents and young adults. Other studies determined that increases in the total price of alcohol can reduce drinking and driving and its consequences among all age groups; reduce the frequency of diseases, injuries, and deaths related to alcohol use and abuse; and reduce alcohol-related violence and other crimes.[39]

Increase in the price of cigarettes through taxation reduces cigarette consumption in adolescents who have already started smoking and are two-three times more responsive to price changes than the adults. However, in India, as per the current taxation practices, increasing the tax component is unlikely to reduce tobacco consumption unlike the developed countries.

The paradox becomes clear only if certain basic elements are understood. Cigarettes are available in five different lengths (<65 mm; 65–70 mm; 70–75 mm; 75-85 mm; >85 mm) in India. Chewing tobacco products such as pan masala are available in different quantities. Nine-eight percent of beedis available are handmade though mechanization is possible. There is a concomitant increase in households involved in beedi rolling. Tobacco companies have remarkable ingenuity and lobbying to make sure their customer base remains intact even when taxes are raised. Taxes have been low for beedis compared with other tobacco products. Handmade beedis are taxed just Rs. 12/1000 sticks while machine-made ones are taxed Rs. 30/1000 beedis. Handmade beedis constitute nearly 98% of those sold in Indian market.[40]

Restricting or banning of advertising substances

Higher exposure to alcohol advertising predicts drinking initiation and increased drinking in adolescents.[3] Power of advertising to influence children and adolescents is incontrovertible.[4142] Many advertisements use celebrity endorsers, humor, rock music, or attractive young models, all of which have been shown to be effective with children and adolescents.[4344] Advertising makes smoking and drinking seem like normative activities and may function as a “SUPERPEER” in subtly pressuring teenagers to experiment.[45] Adolescents exposed to tobacco advertisement are more likely to smoke than those who are not exposed. Research has revealed that advertising may be responsible for up to 30% of adolescent tobacco and alcohol use.[4647] Banning advertisement of alcohol is an effective approach to reducing and preventing problematic alcohol use and alcohol-related harm in adolescents.[48]

Bans on tobacco advertisements are gradually being implemented worldwide, with about 12% countries reporting advertisement restrictions in 2014.[49] These bans are consistently effective in producing an average of 7% reduction in smoking prevalence in these countries.[50] In India, the Cigarettes and Other Tobacco Products Act, 2003[34] under Section 5 bans the advertising of the use of cigarettes and other tobacco products. However, its impact on initiation and prevalence of tobacco use has not been systematically studied.

Mass media or public awareness campaigns

Mass media approaches aim to present positive role models who reject substance abuse and whose behavior the target audience may model.[3] These approaches are powerful means for disseminating health promotion messages among a wide and diverse audience through television, the internet, mobile phones, newspapers, and roadside advertising hoardings that serve as infotainment techniques. Advertisements against drugs may contribute to shaping patterns of drug use and the intention to use drugs, as well as modifying mediators such as awareness, knowledge, and attitudes about drugs.[51] In India, there have been continued and sustained efforts by the experts informing people through electronic and print media. Cyberspace and other forms of electronic media can play a vital role in educating people regarding drug abuse problems and its consequences.[52]

Prevention interventions delivered in educational settings

Educational institutions provide an opportune platform for prevention because of the ease of delivery of such powerful messages and access to young people in an ideal setting. Efficacy of these classroom interventions has been assessed by very few studies.[5354] Interventions focusing on general psychosocial development and life skills might be effective in reducing alcohol use[5556] but not in particularly reducing alcohol-related harm.[57]

Prevention interventions delivered for family or parents

Family plays an important and crucial role in preventing substance use in adolescents. Many family-based prevention interventions focus on psychosocial development rather than on prevention of target drug use. These interventions have the potential to improve several aspects of a person's development.[58] Parental monitoring, supervision, and improved child–parent communication act as preventive measures. Parent training, family skill building, and structured family therapy can prevent illicit drug use.[59] Parental education alone is not effective. In an Indian study, family intervention therapy helped significantly to reduce the severity of alcohol intake, improve the motivation to stop alcohol use, and change the locus of control from external to internal in the study group.[60]

Interventions with young people using substances: Early intervention and harm reduction

Interventions targeted at adolescents who have started using drugs aim at:

Addressing the risking patterns of substance use

Reducing the harm that might arise from substance use.

Interventions aimed at reducing the adverse effects of substance use are termed as “harm reduction interventions,” which could be delivered at the mass population level (random road-side drug testing to prevent drunken driving and accidents) or at individual level (needle and syringe programs to prevent infections).

Social norms interventions

“Social norms” is a theory and evidence-based approach to addressing health issues. Social norms interventions are successfully used to reduce alcohol and tobacco use in college and high school students.[61] “Social norms” theory describes situations in which individuals incorrectly perceive the attitudes and/or behaviors of peers and other community members to be different from their own when in fact they are not. This phenomenon is called “pluralistic ignorance.”[62] “Social norm” intervention aims to reduce risky alcohol use by providing correct information about their peers’ alcohol consumption generally overestimated by adolescents.[63]

Screening and brief intervention to reduce substance use and related harms

Screening of adolescents for problematic substance use is an effective approach to identify the individuals at high risk of substance-related harm.[64] For adolescents drinking at harmful levels, individual interventions delivered face-to-face that incorporates personalized feedback and motivational interviewing are most beneficial.

There is no sufficient evidence for the efficacy of screening and brief intervention for tobacco smoking in primary care setting.[65] Brief screening questionnaires can detect illicit drug use problems in adolescents in primary settings, but insufficient evidence exists on their efficacy in reducing drug use and associated harm in young people in these settings.[66]

Random roadside drug testing to reduce alcohol and illicit drug-related harms

This focuses on alcohol consumption. Drunken driving checkpoints have consistently shown to reduce alcohol-related vehicle crashes and fatal accidents attributable to alcohol.[3233] Reduction in the legal blood alcohol content seems to reduce alcohol-related injuries and deaths. In a study, authors expressed their primary concern with demand reduction, particularly that part which is concerned with identification, treatment, and aftercare of substance users. Salient features of supply reduction are found in the NDPS Act 1985,[25] and in the most recently announced National Policy on NDPS, approved in 2012. Harm reduction is not the direct focus of this document though it could be an important adjunct policy in selected cases.[67]

Reduction of injection-related harms

Adolescents who inject drugs are very vulnerable group with the greatest risk of incident infection in the early years of the onset of injecting drugs.[3] Needle and syringe programs reduce injection-related risk behavior and HIV transmission. However, the evidence for the effect of these programs on hepatitis C virus transmission is more tentative.[68] Vaccinations against hepatitis B virus are effective and safe methods to prevent hepatitis B virus infection and these should be routinely provided to the adolescents at risk of infection.[69]

Treatment of problematic substance use and substance dependence

Interventions targeting problematic or dependent substance use in adolescents involve several issues. These include stigma and confidentiality. Confidentiality cannot be assured in certain countries where it is legally mandated that the parents, guardians, and sometimes spouses provide permission to access help.

Motivational enhancement therapy

Motivation enhancement therapy is based on social learning theory and the transtheoretical framework of change.[70] It is designed to enhance intrinsic motivation for behavioral change through client-centered therapy.

Self-help intervention through written form or outline

Some positive change in adolescents using alcohol was noted through written information. Online smoking cessation interventions for adolescents typically deliver information through a website or e-magazine. The use of text messages to provide motivation, feedback, and support to quit smoking is gaining popularity because of high usage of mobile phones among the adolescents.[71]

Self-help intervention with peers

These interventions include manual 12-step programs such as alcoholics/narcotics anonymous. These approaches reduce drug use but poor reporting of outcomes, and a large lack of follow-up does not permit the size of any benefit to be established.[72]

Cognitive behavioral therapy

Some studies show evidence that cognitive behavioral therapy (CBT) increases abstinence in tobacco users;[7374] some other studies show its efficacy in cannabis users.[75] A recent study concluded poor efficacy of CBT in substance use disorder.[76]

Family-based treatments and multisystemic therapy

Some studies suggest that family-based treatments and multisystemic therapies reduce alcohol use in adolescents with alcohol use disorder.[77] No family-based intervention studies are available for tobacco users; these studies have significant effect on illicit substance use in adolescents.

Therapeutic communities

Therapeutic communities require complete abstinence on entry and operate as self-help participatory treatment groups providing a supportive environment, in which adolescents cease substance use and recover. Dropout rate from these programs is very high (up to 90%).[78]

Pharmacotherapy for substance dependence

Pharmacotherapies for alcohol dependence in adults – including naltrexone and acamprosate – are effective in preventing relapse to heavy drinking.[79] In adolescents, most of the studies target substance abuse disorder secondary to psychiatric disorders. Lithium is found to be effective in reducing alcohol use in young people with bipolar disorder.[80] Acamprosate was found effective in increasing abstinence rates in adolescent alcoholics. Naltrexone effectively reduces alcohol craving in young people with alcohol dependence.[81] In tobacco users, nicotine replacement therapy, bupropion, nortriptyline, and varenicline are used for smoking cessation.[82] Opioid substitution therapy in heroin using adolescents has lower dropout and self-reported heroin use.[77]

Juvenile courts and diversion

Adolescents charged with drug-related offenses are referred to juvenile drug courts which assess, refer, treat, monitor, and provide feedback on the progress of these young people during regular court appearances.[83] Studies show that the juvenile drug courts are less effective than standard care in the treatment of drug abuse.[3]

CONCLUSION

Adolescence represents an important phase of life during which substance use behaviors become established. To prevent these behaviors from occurring, it is important to reduce the escalation to heavy drug use and intervene to address the established problematic substance use.

With the fast growing newer technologies and communication systems, it is clear that innovations need to be tailored for delivery of the services to individuals and for identification of new responses to emerging psychoactive substances. Computer-delivered and mobile phone interventions to reduce substance use in adolescents are appealing because they allow users to manage the pace of intervention, ensure privacy, and have wider reach at a low cost.

Prevention efforts begin with the focus on the risk factors to avoid later substance use problems. In view of the available evidence to prevent and treat substance use in adolescents, following factors should be kept in mind:

Most evidence for effective interventions to reduce use, problematic use, and harm is for alcohol use – the most used substance, contributing to a large public health burden in young people

There is not much information on effective intervention in adolescent tobacco users. Tobacco becomes a key health issue later in life; long-term follow-up studies are required

A structural policy intervention (taxation, legal age limit control) could be most effective. These approaches are not available for illicit drugs. Innovations are required in preventive approaches for illicit drugs and research is needed to identify individualized strategies to reduce the use and harms associated with illicit drug use in adolescents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.