3. Problematic Use & Harms: Risk Factors and Vulnerable Groups
The vast majority of people who use drugs and alcohol do not develop problematic alcohol or drug use. The tendency to develop problematic use, and to experience harms, is associated with a number of risk factors and vulnerabilities. This section explores the literature on these risk factors, before identifying particularly vulnerable population groups and key periods of risk.
Problem alcohol and drug use among children and young people has been widely accepted to be multifactorial, with, typically, an interplay of various aspects of a young person’s life contributing to their problematic use of substances. Recent decades’ bio-psychosocial model emphasises the interconnected and interactive nature of individual (biological and psychological), environmental (psychosocial, and contextual) and structural (societal and institutional) determinants in contributing to problematic alcohol and drug use. There is also a varying degree of reverse causation across each of these particular risk factors; mental health issues, for example, can both contribute to and be exacerbated or caused by alcohol and/or drug use. The determinants presented here are not exhaustive.
Figure 3.1 – Bio-psychosocial Determinants of Problem Alcohol and Drug Use among Children and Younger People
- Structural (eg. Socioeconomic and political determinants)
- Environmental/contextual (eg. Interpersonal relations)
- Individual level determinants (eg. Psychological, biological)
3.2 Risk Factors
3.2.1 Structural Risk-Factors
Socioeconomic Deprivation and Poverty
When including recreational, occasional or experimental use, findings from the international and UK literature suggest a weak or non-existent relationship between background socioeconomic position and alcohol and drug use in children and adolescents, and in younger adults. Two Scottish school-based studies of adolescents, for example, found no association between family SES and either lifetime or regular drug use.
However, as the individual ages, a far stronger relationship emerges between deprivation and harms from alcohol and drugs, with this relationship stronger for current rather than background socioeconomic position. Studies conducted internationally show a clear and persistent socioeconomic gradient in acute and chronic alcohol- and drug-related morbidity and mortality. Analysis of Scottish Health Survey data between 1995 and 2012 found that deprivation was associated consistently with strikingly raised alcohol-attributable harms. Importantly, harms experienced by those of lower socioeconomic position were greater than those of higher socioeconomic position even after accounting for factors such as weekly consumption, drinking patterns, obesity and smoking status. Further, this study showed that reverse causation – that is, high-risk consumption leading to social disadvantage – did not explain these findings.
The latest data on alcohol- and drug-related hospital admissions across all ages (data is not available by age) shows demonstrates these socioeconomic inequalities;
- Alcohol-Related Hospital Admissions (Stays) – Individuals in the most deprived areas were seven times more likely to be admitted to general acute hospitals for an alcohol-related condition in Scotland in 2019/20 than those in the least deprived (1,078.7 per 100,000 population compared to 155.0).
- Drug-Related Hospital Admissions (Stays) – Individuals in the most deprived areas were more than sixteen times more likely to be admitted to general acute hospitals for an drug-related condition in Scotland in 2019/20 than those in the least deprived (742.42 per 100,000 compared to 45.65).
Source: ISD, Drug-Related Hospital Statistics (PHS, 2021)
These figures were also starkly apparent in the latest drug-related death data for 2020; after adjusting for age, people in the most deprived areas were 18 times as likely to have a drug-related death as those in the least deprived areas. That ratio has almost doubled in 20 years, from around 10 times in the early 2000s.
While the majority of harmful alcohol and problem drug users have experienced deprivation and poverty, individuals who are experiencing deprivation will not necessarily become problematic drug users. Poverty itself is not the primary driver of harmful alcohol or problematic drug use, but it increases the risk of exposure to a range of associated risk factors. Further, it reduces access to a range of factors that support recovery, including education, secure housing and secure employment. A Welsh study found excess consumption to be higher among those in non-deprived areas but that those in deprived areas were more likely to binge drink, suggesting that patterns of use may also play a role. Findings from the qualitative literature in the UK suggest that the individual’s motives for alcohol and drug use play a role in linking deprivation to problematic but not recreational use, with harmful drinking and problem drug use forming a mechanism of escape or coping mechanism for those most excluded from society.
3.2.2 Environmental and Contextual Risk-Factors
Environmental and contextual risk factors play an important role in shaping the likelihood of developing problematic alcohol and drug use among children and young people. It is important to note that these risk factors are shaped by the wider structural determinants outlined above. While focus is placed here on psychosocial risk factors, it is important to note that other environmental risk-factors, such as aspects of the neighbourhood environment, have been found to exert an effect.
Adverse Childhood Experiences
Adverse Childhood Experiences (ACEs) can be defined as stressful or traumatic experiences that occur during childhood (between 0 and 18 years of age). The ten most widely recognised ACEs include: domestic violence; physical or sexual abuse; emotional neglect; parental separation; household alcohol and drugs misuse; mental illness, suicide or imprisonment affecting a household member. Analysis of data collected in the Growing Up in Scotland (GUS) cohort study suggests that by age 8, two-thirds of Scottish children will have experienced one or more ACE-related factors and one in ten will have experienced three or more ACE related factors. In the Scottish Health Survey 2019, over three-quarters (77%) of those aged 18-24 years reported one or more ACEs, while 15% reported having experienced 4 or more ACEs. Previous analysis of routine data suggests that a high proportion of individuals experience one or more ACEs when growing up in Scotland.
Strong, graded associations between ACEs and future problematic alcohol and drug use have consistently been found across the literature. An English survey found that, in comparison with those with no ACEs, those with 4 or more ACEs were twice as likely to currently binge drink and eleven times more likely to have used heroin or crack cocaine. A 2015 Welsh study found even higher margins; those with 4 or more ACEs were 4 times more likely to be a high risk drinker, 11 times more likely to have smoked cannabis, and 16 times more likely to have used crack cocaine or heroin. While such data is limited in Scotland, The Scottish Health Survey 2019 found that the prevalence of adults with an AUDIT score of 8 or more (indicating hazardous, harmful or possibly dependent drinking behaviour) was higher among those reporting one or more ACEs (17-19%) than those reporting no ACEs (11%).
A systematic review of the relationship between childhood socioeconomic position and ACEs concluded that there is a clear relationship between SEP in childhood and the risk of experiencing ACEs.
A number of aspects associated with interpersonal family and peer relations play a substantial role in shaping problematic alcohol and drug use.
The family environment may influence a young person’s substance use behaviour through a range of mechanisms.
- Family Structure – A number of studies in Scotland have found greater alcohol and drug use, both in adolescence and lifetime, among those from single-parent or step-parent families.
- Caring Responsibilities – Among both age groups in SALSUS 2018, those who had caring responsibilities were more likely to have drunk alcohol in the last week and to have taken drugs in the last month than those who did not.
- Family Substance Use – Children model their behaviour on those around them. A 2009 Scottish study showed that almost half of S1 pupils who reported having used illegal drugs stated that someone within their family was also using illegal drugs, compared to only one in ten of the non-using pupils. In the majority of cases, the drug using family member identified was a sibling or a cousin, although in one fifth of cases it was a parent, uncle or aunt.
- Family Relationships – The quality of family relationships appears to have an important influence on young people’s substance use. Adolescents who have strong bonds with their parents are less likely to engage in problem substance use. The Edinburgh Study of Youth Transitions and Crime showed that those who did not use alcohol or drugs had significantly higher parental supervision than those who used substances, and that those who used a single substance had higher parental supervision than those who used multiple substances. Parenting styles that exhibited the closest relationship to increased alcohol and drug use were lack of parental monitoring, high levels of parent/child conflict and a child’s lack of willingness to disclose information to their parents.
As younger people become more autonomous so the influence of the peer group becomes more important and family relationships become less influential. International, UK and Scottish research has consistently found that peer substance use practices are a robust predictor of substance use in adolescence and emerging adulthood. The SALSUS 2018 found that, for 13 and 15 year-olds, the greater the number of unsupervised evenings with friends, the greater the likelihood they had drunk alcohol in the last week and used drugs in the last month. Peers may influence other young people to engage in or refrain from substance use directly or indirectly, through peer group structure; peer substance use; socialising norms, or; peer pressure. Data from the Edinburgh Study of Youth Transitions and Crime showed a dramatic incremental rise with age in the proportion of young people who said that most or all of their friends drank or took drugs. This may be increasingly due to ‘social norms’ as opposed to overt ‘peer pressure’.
3.2.3 Individual-Level Risk Factors
A number of individual-level risk factors have also been identified across the literature. It must be noted that these are shaped within the structural contexts described above.
Experience of Mental Health Disorders
The experience of mental health issues is correlated with psychoactive substance use among adolescents and young adults. It is well established that externalising disorders (including conduct disorder, oppositional defiant disorder, and attention-deficit and hyperactivity disorder) in early or middle childhood predict problematic alcohol and drug use and dependence in adolescence and young adulthood. A longitudinal study of 11-15 year-old pupils in Scotland found that conduct disorders were the main predictor of hazardous alcohol use. For internalising disorders (including depression and anxiety), the evidence is less clear. Some report independent effects upon substance use or dependence (particularly in females), while others do not or report only weak or inconsistent effects.
Importantly, the COVID-19 pandemic and associated policies have likely contributed to a greater mental health burden. A longitudinal survey of over 2000 young people (13-25 years) with experience of mental health problems was undertaken in the UK by Young Minds across three periods in 2020. The July survey found that 80% had found their mental health worsen due to the pandemic. The proportion reporting ‘much worse’ mental health had risen from 32% in March to 41% in July.
Early alcohol and drug use (prior to the age of 15 years) increases the risk of problematic use in later life. Research exploring early onset of drug use with a representative sample of the US population has shown that;
- individuals who initiate drug use before the age of 14 years are at greatest risk for drug dependence and have a 34% prevalence rate of lifetime drug use disorders;
- as individuals continue to mature between 13 and 21 years, the likelihood of lifetime substance abuse and dependence drops 4-5% for each year that initiation of substance use is delayed, and;
- early onset drug use was a significant predictor of the development of lifetime alcohol dependence.
It is likely, however, that individuals with risk factors for early-initiation of substance use are also exposed to correlate risk-factors which contribute to the greater likelihood of developing problem substance use.
Reasons for Use
Research suggests that the motives underpinning the use of alcohol and drugs predicts the likelihood of younger people developing problem use. A 1992 study formulated 3 motive types; coping motives, enhancement motives and social motives. A range of research has found that coping motives – the use of substances to cope with negative experiences or emotions (particularly when coupled with poor emotional control or regulation) – is associated with the development of problematic alcohol and drug use. A qualitative study in Northern England which focused on the transition from recreational drug use to problem drug use in young people found that recreational users described their use as offering “leisure and pleasure”, those with problem drug use spoke of “not having a care in the world” after using heroin, about it “taking all [their] worries away” and it “wiping away all the bad things that have happened”.
3.3 Vulnerable Groups
The literature highlights a number of groups more likely to develop problematic alcohol and drug-use and experience harms.
- Care Experienced Children and Younger People – While relatively dated, a 2001 study of young people leaving care (14-24 years) in Glasgow found that 84% and 60% had used cannabis and ecstasy at least once, respectively, and 14% were drunk almost every day. Two-thirds had started taking drugs (31%) and drinking alcohol (29%) while in care. Use was attributed to being ‘stressed out in care’ and as an attempt to forget negative experiences. Another showed that 45.8% of individuals resident in children’s units had used drugs in the last month. Those in foster care consume less alcohol have been found to be less likely to misuse drugs than children in residential care due to those in residential care being exposed to factors including frequent movement of care placements, and rejection by adoptive or foster parents.
US research found that care-experienced younger people were five times more likely to have received a ‘drug dependence diagnosis’ in the past year. In the UK in 2011/12, approximately 7% of young people accessing specialist alcohol and drug services reported that they were in care.
- Homeless Younger People – Homelessness forms both a risk factor for and a consequence of harmful alcohol and problem drug use. Substance use in this population has been reported as two- to three-times higher than that of non-homeless young adults. Four out of five people start using at least one new drug after becoming homeless. Estimates across European countries range from 30-70% prevalence rates for problematic drug use among homeless populations. While data is not available by age, in Scotland 12% of people accessing specialist drug treatment in 2018/19 were recorded as being homeless; likely an under-estimate, as it may not include less severe forms of housing insecurity and levels of missing data were high.
- Young Offenders – Again, criminal offending may predate and lead to problematic alcohol and drug use, or may be caused by it. As aforementioned, Scottish prison surveys have shown that a large proportion of individuals serving sentences engaged in problem drug or alcohol use on the outside.
- Younger People with ACEs – As highlighted in the section on risk-factors, younger people who have experienced traumatic experiences in childhood are at substantially greater risk from developing problematic alcohol and drug use.
- Children in Families with Problem Drug Use – Children of substance misusing parents face particular problems; chaotic domestic circumstances, poverty, poor housing conditions, violence and maltreatment, and can be vulnerable to not having their social, emotional or physical needs met.
- Children and Young People Experiencing Deprivation – Children and young people experiencing deprivation are exposed to a range of risk factors which increase their likelihood of developing problematic alcohol and drug use both in the short- and longer-term.
- Younger People Experiencing Unemployment - Empirical evidence has consistently suggested that unemployment may lead to psychiatric problems including substance use. Three lines of thought have emerged; the stress hypothesis; the income loss hypothesis, and the social selection/drift hypothesis.
- Early School-Leavers – A study in Ireland showed that substance use is significantly higher than among school-attending students, with early school-leavers up to 1.2 times more likely to drink alcohol, between 2.4 and 4.4 times more likely to use cannabis, and between 3.7 and 14.4 times more likely to use other drugs.
- Children Excluded from School – In SALSUS 2018, those who had ever been excluded were, for 13 year olds, five times and, at 15 years, twice as likely to have used drugs in the last month, as well as being more likely to have drunk alcohol in the last week.
3.4 Vulnerable Periods
While there is a large body of literature exploring risk factors and vulnerable groups, there is comparably little evidence on the periods at which younger people are most at risk from transitioning towards problematic alcohol or drug use. However, from the available evidence on risk factors and vulnerable groups, it is possible to determine a number of key trigger points and vulnerable periods within which younger people are likely to transition towards problematic alcohol and drug use, and to experience harms. This is not exhaustive, particularly given that different groups will experience different vulnerable periods and triggers.
- Childhood and Early adolescence – As highlighted above, a wide range of research highlights that early initiation of alcohol and drug use, particularly prior to 14 years of age, increases the risk of problematic alcohol and drug use, independent of other risk factors.
- Early School Leaving – As noted above, research among 15-18 year olds in Ireland found that those leaving school early were considerably more likely to engage in the use of other drugs than those still attending school.
- Transition to Independent Living from Care – The period of leaving the care system represents a critical point in the development of problematic substance use. A review found that, while drug use may have developed while in care, the transition towards independent living forms a critical period within which such use may develop towards problematic use.
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