Alcohol is ranked as the most harmful substance when compared to 20 other commonly used substances in the general population.1 In 2012, 43% of pupils (aged 11-15 years) reported having had an alcoholic drink in their lifetime - this is a marked decline from 2003 when the same survey reported 61% had done so.2 This trend is reflected in a reduction in those pupils who drank alcohol in the last week, which was 25% in 2003, reducing to 10% in 2012.
Further analysis reveals falling consumption particularly for young men and increasing abstinence rates for both genders. However theses overall trends are not mirrored by sub groups of young people who develop a problematic relationship with alcohol and the impact this has on their health and social circumstances.3
There are three broad groups of young people to be aware of in relation to alcohol: those who drink in a hazardous way, and those who drink in a harmful way, or those who are dependent (see Figure 1). There are specific risks that young people face when consuming alcohol. These risks can differ from those encountered by adults, compounded by a potential naivety in calibrating the amount of alcohol they can consume before becoming intoxicated or finding their judgement is impaired. The most serious and immediate risk is alcohol poisoning which can result in death, mortality rates for young people are higher than those for adults, on average over thirteen thousand children or young people are admitted to hospital with alcohol related problems every year in England.5 More routinely, as decision making is compromised, the potential for engaging in unsafe sex, including sexual exploitation, or becoming involved in anti-social behaviour is elevated.6
In addition to the risks young people face when drinking alcohol, there are 2.6 million children living with parents who drink alcohol in a hazardous way.7 This potentially exposes them to behaviours which role model alcohol use in a negative way and may influence their own relationship with alcohol, such as using alcohol to cope with stress or simply increasing access to alcohol.
Long-term impact on health
Alcohol is associated with more than 60 medical conditions. This, combined with the fact that young people are still developing physically and mentally, mean that there are good reasons to be concerned about the longer term impact alcohol will have on their health. Some health related problems include heart disease, liver cirrhosis, cancer, depression and high blood pressure.
At one time alcohol-related liver disease was considered an older persons issue, however there has been a significant increase in those under the age of 30 admitted to hospital with these problems.
Problematic alcohol use is associated with two common mental health problems, namely anxiety and depression. This is a bi-directional relationship in that anxiety and depression can be brought on by drinking too much alcohol in addition these mental health problems can lead to people using alcohol as a way of coping with the way they feel.8
The phenomenon of ‘discounting’ is a potential factor for young people. Even if they are aware of the health costs associated with alcohol, they might discount the impact of these in favour of the more immediate and desired effects of consuming alcohol in the present, in other words adopting a ‘live for today’ attitude.
A recent study suggests that alcohol use and intoxication before the age of 14 years is linked to problematic use of alcohol as an adult,9 however confounding factors such as mental health problems or social disadvantage can also influence this progression from early adolescence to problematic alcohol use as an adult.
Management and treatment
It can be useful to take an opportunistic approach to engaging young people in a conversation about their alcohol use, particularly when they present with alcohol related injuries, as this can be a catalyst to starting the process of contemplating a change in their drinking behaviour. Techniques known as ‘brief interventions’ have an emerging evidence base in primary care, as the name suggests these can be employed when there is limited time available and have shown to be effective in facilitating behaviour change.10 These interventions include giving advice, discussing risky behaviour, encouraging harm reduction and examining the perceived benefits and negative consequences of alcohol use. These interventions can be delivered in as little as five minutes, which fits well with the time constraints in contemporary primary care consultations.
It is interesting to note that after years of research in the field of addiction ‘therapist effect’ is the one component that consistently demonstrates improved outcomes irrespective of the type of intervention offered.8 These components include:
Being treated with respect.
Optimism that change is possible.
Show interest in the individual.
Not forming judgements about the person’s lifestyle.
Although these components can be viewed as intrinsic to any healthcare worker, they are less likely to be exhibited if we dislike or disapprove of an individual’s lifestyle including the way they use alcohol. Mirroring these qualities as a parent, by demonstrating warmth and communication, have also been found to be
protective against problematic alcohol use in young people in a
pan European study.
A range of assessment tools are available to determine the impact of alcohol on a young person. The Alcohol Use Disorders Identification Test (AUDIT) is a screening instrument designed to identify those at risk of problematic or harmful drinking over the last 12 months. This ten item screen has been shown to be both reliable and valid in detecting young people who are at risk.12 A score of eight or more on the AUDIT indicates a problem.
Careful consideration of potential drug interactions between alcohol and prescribed anti-depressants, such as selective serotonin reuptake inhibitors (SSRIs), needs to be taken due to the increased risk of sedation when these two drugs are combined.13 Problematic alcohol use can impair hepatic function therefore affecting the liver’s ability to metabolise drugs generally, so again the quantity and frequency of alcohol use will need to be considered in relation to any other prescribed medication and its likely efficacy.
For young people, the fact that alcohol is more widely available,
and is now 45% more affordable than it was in 1980, presents an increased opportunity to consume it even if their income is restricted.14
A pragmatic and targeted approach can be employed to screening for problematic alcohol use, for example by screening people who are newly registered or transferring in from another primary care practice. Also consider focusing on high-risk groups such as those who attend with alcohol-related problems. Practice nurses can effectively carry out screening, referring young people who are thought to have a problem based on the results. Referrals can be made to your local child and adolescent mental health (CAMH) team who will have a primary care mental health worker acting as a link between primary and secondary care services.
Some specialist substance use teams offer services specifically for young people however most are designed for adults and would be inappropriate for the assessment and treatment of adolescents. The marked variations in the way these specialist services are provided was recently acknowledged by Public Health England, recognising the specific needs that young people have and the importance of providing services which will encourage this group to make contact and seek help.15 This adds to the important role that primary care workers can take in engaging and treating young people with alcohol problems, particularly as the environment is less threatening, since they are likely to have accessed primary care at some point in their life and find it less stigmatising than a specialist addiction service.
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