An illustrative picture of Irish youth substance use.Dear Editor,
This letter describes recent exploratory research in Ireland, which was undertaken to provide a snapshot of the perspectives of youth, community, addiction, educational and health service providers, in youth substance use and current service provision.
Drug and alcohol prevalence trends and patterns of use in Ireland have become increasingly diverse in drug type, poly substance use, drug availability and demographics of users. National prevalence surveys indicate increasing drug and alcohol use among young people and suggest that substance use is increasingly accommodated into adolescent lives and culture (NACD, 2007). Ireland is ranked the highest among the thirty-five European countries in the number of adolescents who regularly binge drink and second highest for reported general drunkenness, with Irish school-going students showing a higher than average prevalence of lifetime use of an illicit drug (EMCDDA, 2007). These patterns of youth substance use were traditionally confined to marginalized communities or vulnerable youth, but are now increasingly common in both urban and rural locations across Ireland (Mayock, 2002). Parker et al., (2002) have argued, "experimentation with substances" must be viewed as one of the developmental tasks of early adolescents (p. 45). However, in public health and social harm, youth substance use and, indeed, problematic use, potentially contribute to compromised health and well-being, difficulties in maturation, and to many problems for the individual with "academic difficulties, declining grades, absenteeism, truancy, and school drop-out" (Sutherland and Shepherd, 2001).
Prevalence patterns of youth substance use are most commonly characterized by "acute local variation and clustering of trends" within the national setting (NIDA, 1995, p90). These small numbers of drug users such as adolescents are usually hidden within general surveys and are thus difficult to understand in "their backgrounds, lifestyles and the social contexts in which they consume their drugs" (NIDA, 1996, p89). Current Irish research lacks a social profile of adolescent drug and alcohol use, particularly in regional and local clustering of trends. It is hoped that this research will add to the current research base on youth substance use in Ireland and guide the implementation of proactive and timely community and youth interventions.
In research methodology, interviews were undertaken with a self selecting sample (based on availability, n=78) of youth, community, addiction, educational and health service providers in the South Eastern region of Ireland, which covers 13.5% of the State area and represents 20% of the national population. In order to provide complete anonymity, due to the regional context of the research making identification of som individuals possible, it is not possible to provide detailed information on individuals. The interview schema was used in a previous study by Mayock in 2002 and included the following themes: the prevalence of adolescent substance use, drug activity in the area, reasons for substance experimentation, alcohol use, drug use, initiation of drug use, first time experience, reasons for not continuing, subsequent drug use and the peer context for reinforcement, current drug use, adolescent attitude and meaning of drug use, maturing out of drug use, risk perception of drug and alcohol use, drug information and service provision and treatment for adolescent substance abuse. Interviews lasted on average 45 minutes, were audio taped with permission, and participants were allowed to withdraw at any stage. As themes arose, they were explored in a "lengthy conversation piece" (Simons, 1982, p. 37). The research is firmly grounded in the information gained. The qualitative nature of the research meant that, although the researcher had a list of themes to guide data collection, not every participant discussed a particular issue and each was encouraged to raise his or her own. Therefore, the typicality of these perceptions and experiences cannot be assessed (Fountain and Griffiths, 2002). Transcripts were read several times at the end of each interview to allow the researcher to revise and develop an understanding of the "themes" of responses, and also to allow the interviewees to elaborate or clarify their responses. All interviews were analysed thematically, according to the themes that most consistently arose and were pertinent to the research aims. This consisted of generating "a list of key ideas, words, phrases, and verbatim quotes; using ideas to formulate categories and placing ideas and quotes in appropriate categories; and examining the contents of each category for subtopics and selecting the most frequent and most useful illustrations for the various categories" (Zemke and Kramlinger, 1985, p89).
The research yielded an illustrative picture of Irish youth substance use in substances used, the potency of the peer and family setting for use and gaps and deficits in targeted service response. Most interviewees felt that youth drug and alcohol uses were increasing and of greater concern due to higher levels of experimentation across all age groups and genders, with increased potential for the development of problematic use. Drug use among young people in Ireland has also increased due to greater levels of disposable income (pocket money and part time employment), greater freedom or lack of parental monitoring (both parents working, single unit families), increased drug availability (urban and rural), and increased normalisation of drug and alcohol use within neighbourhoods. Drug activity, both using and dealing, was considered to be common in communities, schools, and within groups of young people. This increasing contact with drug use, whether within peer groups or social crowds, was reported to increase normalisation of drug use within the adolescent sub culture. One must note the potency of the school in addition to the neighbourhood in providing access to drugs and raising positive attitudes or norms to drug use and peer drug taking. Some service providers commented on heightened levels of teacher supervision at schools to prevent drug dealing and drug taking during recess. In addition, youth substance use, both licit and illicit, was observed to be increasingly common for those young people experiencing family crisis, home disorganisation and stress. In this context substances are used as a stress coping mechanism and have greater potential for progression toward problematic use.
For alcohol use, most service providers commented on the increasing social accommodation of drink within Irish culture and common acceptability of drinking to excess. Young people in Ireland are usually introduced to alcohol at a young age, whether by parent, older siblings or friends, and usually within the context of a family celebration or public house. The service providers voiced concerns about binge drinking and the fact that alcohol may provide the context for further drug experimentation. Others commented on parental alcohol abuse and older siblings encouraging alcohol use in younger adolescents. Some reported that binge drinking often takes place outside and during summer holidays or weekends when parental monitoring is low. It appeared that the unstructured leisure context was providing opportunities to experiment with alcohol and other drugs, particularly in areas with poor youth and poor leisure facilities. It was observed that young people actively involved in sports or other after school activities did not experiment with or use drugs and alcohol to the same extent as youth with higher levels of leisure boredom and stress.
Young people were observed purchasing their drugs in groups, usually hash, cannabis, ecstasy and amphetamine, thus indicating the potency of social networks among young people and the peer setting for use. It appeared to be most commonly within the context of the best friend network or close peer group; but as the substance abuse becomes problematic, the young person gravitates to wider social networks or social crowds for drug availability. The service providers commented that drug and alcohol uses were often part of adolescence, moving toward the peer group and away from the family, and that these behaviours were also facilitated by high levels of leisure boredom, low parental monitoring, part time employment, and lack of positive free time activities. In general, drug and alcohol uses were considered to occur in fields, on the streets, and at friends' houses. The increasing levels of substance use at weekends were evidenced by behavioural and cognitive difficulties at school. Those working with particularly vulnerable or at-risk young people observed the prevalence of solvent use at a young age and also increased prescription medication abuse.
Most young people were observed with positive attitudes to alcohol use and facilitating attitudes to peer drug use, whether using drugs or abstaining. This was of direct concern to increasing perceptions of peer use and the potential for increased experimentation. The service providers commented on the strength of the peer group whether best friend or group of friends or peers, in providing the user with drugs, knowledge of drug taking, and how to improve the experience and norms for use. It appears that young people's attitudes to drug use and drug related knowledge are becoming increasingly normalised and accommodated into the adolescent's "rite of passage". It was reported that young people often portray high levels of drug awareness and knowledge and also appear willing to accept peer drug use even if they are abstaining.
Drug use was reported to present at ages 10 to 12 years with alcohol as the most common precursor to drug initiation. Some remarked that boys were likely to experiment at earlier life stages than girls; but other service providers commented that girls were now presenting with increased levels of experimentation. In general, it was reported that young people do not perceive their substance use to be of any risk to them and that often the risk adds to the thrill of drug taking. It appears that negative first time experiences do not deter the young individuals from using again, and that drug decisions are stimulated and encouraged by the strength of the relationship with the peer group in learning new drug taking behaviours, attaching meaning to the drug experiences, and providing the context for drug use. For patterns of use, it was observed by those working closely with young substance users that internal sanctions for use were present and served to control levels of drug taking and combining, certain ways to behave and levels of drug use. It appears that young substance users do not want to appear either addicted or out of control, and that youth substance use is increasingly a social activity and not a criminal one. In addition, there is a reported "hierarchy" of drugs in causing potential harm and social accommodation within youth culture, with heroin at the top of the scale and cannabis/hash at the lower end. Of some concern was the perception by some young people that heroin was safe if smoked and not administered intravenously. Most young people considered cannabis to be as safe as smoking cigarettes and were not concerned with any future health impact.
Considering the varying nature of youth drug and alcohol use, education, and prevention programmes, it was emphasized that initiatives must be designed to reflect the multiple reasons for substance use in the young person. According to Parry et al., (2004, p5), "interventions should be designed for the particular communities they are meant to reach, that is, generic programmes may not be effective. Life skills programmes should be designed to address the attitudes of young persons towards drug and alcohol use, specifically attempting to modify adolescents perceptions regarding the positive consequences of substance use and to introduce less risky alternative activities which are also likely to lead to positive outcomes". For drug and alcohol awareness, it was reported that misinformation or lack of information could undermine investment in current harm reduction programmes and had the potential to contribute to the stigmatisation of the individual drug user and his or her family. This was observed to occur from lack of implementation of drug education at school and the community levels, causing poor drug related knowledge in some cases in addition to poor or lack of timely support for families suffering from drug and alcohol abuse in the home. It was also observed that interventions were short lived, and that drug educational campaigns must be sustained over a prolonged period of time in order to have maximum impact on the target audience, particularly in relation to timetabling constraints, levels of school absenteeism, and age appropriate intervention planning (Van Hout and Connor, 2008). Other recommended elements for potential success included the targeting of drugs of first use, information and help for parents, teachers and sports coaches, and the maintenance of a consistent message through the coordination of media efforts with other initiatives in schools, youth groups, and communities.
In contrast, service providers remarked on the "maturing out of substance use" for most young people by middle twenties. Other service providers directly involved with youth addiction counselling and treatment observed that, for the most part, young people experiment with both drugs and alcohol, and that few progress along the addiction continuum toward dependency and problematic disorder. This appeared to coincide with the development of other interests, relationships, and career aspirations. Only a small percentage would seek treatment for problematic substance use. The assessment of adolescent alcohol and drug abuse is a complex task, which was reported to be regularly inhibited by lack of professional knowledge of maturational level of the young person and the severity of substance dependency. In addition, criteria for diagnosing alcohol and other drug abuse or dependence among adolescents were reported to often be derived and practiced from adult models of addiction. This emphasized the need for specific adolescent assessment and appropriate adolescent interventions. The apparent younger age of initiation into drug misuse and potential development of dependency have created a corresponding need for the development of multi component treatment types, catering specifically to the needs of young people less than 18 years of age. It was recommended to introduce some leniency in the drying out period prior to admittance to residential addiction treatment as this was often impossible for parents to achieve without targeted outreach support
It was commented that young substance abusers were often not ready to change or comply with counselling when referred by juvenile courts, and that this was a drain on the addiction services. It was reported that young substance users were often defensive and difficult to engage and therefore required specific and measured responses. For mental health, most reported concern at the potential negative impact that early and destructive substance use has on the individual's maturation in physical, social, and psychological health. The consequences of failing to intervene early and of not providing age-appropriate substance abuse treatment, and, indeed mental health treatment, are substantial and long-term. Lastly, adolescent focused treatment initiatives must include supportive and timely family therapy, outreach support, and community integration phases for those attempting to access treatment and post treatment. Some commented on the issues raised for the young person upon return to old situations and stimuli after residential treatment. There appears to be a great need for improved aftercare support for those young addicts post treatment.
In order to devise and implement successful youth orientated drug education and treatment programs, it was universally stated that policymakers need to recognize the local nature of youth drug use in the South East of Ireland. Due to funding and staffing restraints, most current Irish programmes assume similarities in drug use prevalence and the factors that contribute to it, regardless of geographic location in the area. The identification of local factors pertaining to adolescent drug and alcohol use, and understanding how services can encourage or discourage drug use, is of practical importance. Local multiagency service providers must incorporate existing information from multiple sources, including treatment data and research such as this, to study the development and growth of adolescent substance use and related problems. Perhaps most importantly, adolescents' attitudes have become more liberal and somewhat normalized towards alcohol and drug use. As a result current prevention campaigns may be aiming at a "dynamic target" of culturally and regionally held youth opinions about substance use. Research such as this becomes vital in creating networks of health professionals using combined information to target and programme for young people.
The research provides a key insight into the opinions, thoughts and knowledge relating to youth drug and alcohol use from the viewpoints of service providers, from their varied levels and types of contact with young people. One must note that this information can only be perceived as "perceptions" from the viewpoints of these service providers and therefore are limited as they represent anecdotal evidence. However, the information garnered in this study is useful in presenting the regional situation and guiding resources for timely drug and alcohol prevention strategies and community initiatives. In light of the information provided in this snapshot of service providers' perspectives of youth substance use, it is recommended that a multi disciplinary approach involving individuals, health services, parents, schools, and local communities offer the most success in dealing with youth substance use trends.
European Monitoring Centre for Drugs and Drug Addiction EMCDDA (2007). Annual Report on the State of the Drugs Problem in the European Union 2007. Luxembourg: Office for Official Publications of the European Communities.
Fountain, J. and Griffiths, P. (2002) Synthesis of qualitative research on drug use in the Europe. EMCDDA, 2000.
Mayock, P. (2002). Drug Pathways, transitions and decisions: the experiences of young people in an inner--city Dublin community. Contemporary Drug Problems, Spring, v29, il, p117 (41).
NACD (National Advisory Committee on Drugs/Drug and Alcohol Information and Research Unit) (2007)_Drug use in Ireland and Northern Ireland. 2006/2007 Drug prevalence survey. Health Board (Ireland) & Health and Social Service Board (Northern Ireland). Results (revised). Bulletin 2. Dublin, NACD/Belfast, DAIRU.
National Institute on Drug Abuse (1995) RESEARCH MONOGRAPH SERIES Qualitative methods in Drug and HIV research U.S. Department of Health and Human Services * Public Health Service * National Institutes of Health, p3-90.
Parker H, Williams L, and Aldridge. J (2002). The normalization of 'sensible' recreational drug use: further evidence from the North West England longitudinal study. Sociology, November, v36, i4, p941(24)
Parry C D H, Myers B, Morojelea NK, Flisher AJ, Bhanac A, Donsond H and Pl.uddemann, A (2004). Trends in adolescent alcohol and other drug use: findings from three sentinel sites in South Africa (1997-2001). Journal of Adolescence, 27, p5-6.
Simons, H. (1982). Conversation piece: The practice of uttering, muttering, collecting, using and reporting talk for social and education research. London: Grant McIntyre.
Sutherland, I. and Shepherd, J. P. (2001). Social dimensions of adolescent substance use. Addiction, v96, pp445-458.
Van Hout, M C and Connor, S (2008). Drug Use and the Irish School Context: A Teachers Perspective? Journal of Drug and Alcohol Education. April, 2008, vol 52.
Zemke, R., and Kramlinger, T. (1985). Figuring things out. Reading, MA: Addison-Wesley.
Marie Claire Van Hout, M.Sc, BA
Nine Mile House
Carrick on Suir
The author is attached to the Faculty of Health Sciences of Waterford Institute of Technology, Ireland and lectures in the area of Substance Use and Delinquency.