Young people experiencing harms from alcohol and drugs: literature and evidence review

5. Conclusions

This report has presented the findings from a rapid review of the existing literature and evidence base pertaining to younger people experiencing harms from alcohol and drugs in Scotland. While Scotland’s high levels of harms are driven primarily by those of older (although still young) age-groups, the data presented demonstrates that recent years have seen high (and, particularly in relation to drugs, increasing) harms from alcohol and drugs among younger people in Scotland. The evidence both from Scotland and from the wider UK and international literature allows for an understanding of the determinants which contribute to the development of problematic alcohol and drug use among younger people, and of approaches to treatment and recovery service provision which are effective for individuals of this age group. Importantly, this knowledge allows for a number of steps which should be taken in order to avoid the emergence of a cohort vulnerable to high levels of harms as they age. A number of recommendations for next steps, both in terms of policy and future research, are outlined below.

5.1 Recommendations

5.1.1 Next Steps

Given the emergence of concerning trends among younger people in relation to increasing harms from alcohol and drugs, coupled with the wealth of existing literature and evidence highlighting both the determinants of problematic alcohol and drug use among younger people and effective approaches to treatment and recovery, the implementation of policy to ameliorate these risks and improve both pathways into and quality of treatment and recovery should take priority over further research. A number of these recommendations are relevant to all ages, while others relate specifically to younger people.

Challenge the Determinants of Problem Alcohol and Drug Use

• Policies should be rooted in tackling the structural determinants of problem alcohol and drug use – Poverty and socioeconomic deprivation form the primary determinant of harms from alcohol and drug use, and cause a range of contextual and individual-level risk factors which increase the likelihood of developing problem alcohol and drug use and experiencing harms throughout the individual’s life. The reduction of socioeconomic inequalities are therefore essential and must be the priority for policy. While a number of fiscal policy levers remain under Westminster control, a range of measures are available within Scotland, and it is paramount that all opportunities available are taken to do so. Such measures have been outlined elsewhere, and should include;
  • an economic strategy with the reduction in socioeconomic inequalities at its core;
  • the provision of incentives to employers in order to attract employers to areas with high youth unemployment;
  • progressive (wealth and asset, and income and corporate) taxation policies to reduce inequalities;
  • policies to reduce inequalities in ownership of capital;
  • the strengthening of the social security system to ensure that younger people receive necessary help, and;
  • policies to address the costs of living (including the development of an ‘anti-poverty childcare system’, the reduction of the ‘poverty premium’ in goods and services; the implementation of a ‘living rent’, and; reducing transport costs.
• Following recommendations made elsewhere, the Scottish Government should introduce a ‘poverty-proofing’ approach to all policies and major spending decisions, as well as a ‘health in all policies’ approach to address issues relating to the social determinants of health and health inequalities in Scotland.
• Strengthen the transition from school to further education and/or employment – A range of measures have been evidenced^[118] to reduce the amount of individuals not in education, employment or training. These include;
  • the provision of early-intervention measures (including investment in quality early childhood education and care; identifying and targeting at-risk individuals; offering mentoring and one-to-one support; offering financial support to those from low-income households, and; introducing more vocational and technical education;
  • re-integration measures targeted at younger people currently or at-risk of becoming not in employment, education or training, including outreach services, intensive support (from trained advisers), financial support and tailored education, employment and training solutions;
  • tracking systems to identify at-risk individuals and to target these measures;
  • active labour market measures to encourage firms to hire younger employees, including offering wage and training subsidies, or tax and national insurance breaks/credits to employers;
  • improvement in the quality of jobs available to younger people (both through provision of the living wage and the provision of guaranteed working hours) in order to reduce the number of younger people not in employment, education or training (NEET).^[119]
• Develop training and employment opportunities to younger people in recovery from problematic alcohol and drug use – Policies to encourage employers to take on younger people in recovery from problematic alcohol and drug use have been shown to promote the maintenance of abstinence.

Treatment and Recovery Services

Improve Access to Treatment and Recovery Services

• Prioritise engagement with young people – With younger people less likely than older age-groups to engage with drug and alcohol treatment services, work should be undertaken to increase engagement with services.
• Improve awareness of pathways into treatment – A lack of knowledge of available services forms a barrier to their uptake. Work should be undertaken to ensure that pathways into treatment and recovery services are well-known by young people.
• Improve access to mental health services in schools – A large proportion of schoolchildren feel that mental health services are not adequate at their school. Improving access to mental health services in schools and other universal settings is essential.

Improve Provision of Treatment and Recovery Services

• Develop residential and community treatment and recovery services tailored towards the different drug-profile and developmental needs of younger groups – The lack of treatment and recovery services addressing the needs of younger people was identified as an issue within the 2009 Audit Scotland report on alcohol and drug services in Scotland^[120], and is a more pressing today given the transition towards a markedly different drug profile causing harms among younger people across the decade since. This should be prioritised as a lack of suitability of existing services has been identified as a barrier to uptake of services among younger people. Development of such services should include the development of both residential rehabilitation and community treatment and recovery services which cater for the specific needs of younger people, as well as ensuring existing services are well funded.
• Encourage flexibility in (particularly age-related) admission criteria – While tailoring services towards the needs of individuals of particular ages is desirable, excluding individuals who fall narrowly outside of the age-range (and who feel that they do not feel they fit elsewhere) is counterintuitive to the primary aim of engaging younger people in treatment and recovery from problematic alcohol and drug use. Where possible, admission criteria should be flexible in order to most effectively attract and retain younger people in treatment and recovery services.
• Improve access to treatment for those with co-occurring mental health and substance use issues – Existing reports suggest that many with co-morbidity are unable to attend mental health services due to substance use, and unable to attend substance use treatment and recovery services due to complex mental health conditions. Measures to improve access to this particularly vulnerable population of younger people should be prioritised.
• Reduce waiting times for treatment and recovery services – Waiting times for CAMHS and for adult mental health and alcohol and drug services should be reduced considerably, given the typically short windows of opportunity within which individuals are able to engage in the transition from problematic use of alcohol and drugs towards treatment and recovery.
• Embed a human rights approach within all services - Alcohol and drug-treatment services should have a rights-based and person-centred approach embedded in their service delivery. The needs of the younger person (and their personal choices regarding which services they feel they require) should be at the heart of service delivery. Work should be undertaken with professionals working with children and younger people to counter stigmatising attitudes towards those engaging in problematic alcohol and drug use, as this forms a substantial barrier to youth engagement.
• Encourage the growth of recovery communities for younger people – Existing recovery communities may not be suited to younger people’s specific needs. The Scottish Government should continue to fund those facilitating the development of recovery communities, and should particularly seek to fund the development of such groups for those of younger ages.
• Develop safer injection facilities and supply drug-testing kits at points of use – Safer-injection facilities should be available, particularly in areas where younger people are more likely to inject drugs. Particularly given the relatively large contribution of younger people to overall deaths from ecstasy, drug testing kits should be made readily available, including at venues where ecstasy-type drugs are likely to be taken.

Systematic and Regular Monitoring of the Harms Experienced by Younger People and their Access to Services

• Systematic monitoring of need for alcohol and drug services – The ratio of the number of people in need of treatment to the number of people receiving treatment is a vitally important measure of the effectiveness of alcohol and drug treatment.
• Systematic monitoring of provision of alcohol and d/rug treatment services across Scotland – Systematic monitoring of alcohol and drug treatment services – particularly Tier 3 and Tier 4 services – should be undertaken at ADP level.
• Monitor and report on wider harms caused by alcohol and drugs among younger people – ScotPHO’s analysis of alcohol-attributable hospital admissions and deaths demonstrated the far greater level of harms from alcohol experienced by younger people than is apparent from routine measures. Up-to-date monitoring and reporting of alcohol- and drug-attributable hospital admissions and deaths would provide a greater indication of the actual level of harm experienced among younger people.

Systematic Approach

• Ensure that ADP and Community Planning Partnership agencies work effectively – ‘Systems thinking’ should be adopted, with ADPs and agencies working closely with all individuals in communities to improve outcomes, particularly in disadvantaged communities where younger people are at risk of harms from alcohol and drug use.
• An inclusive and collaborative approach with third-sector and private organisations – With a large proportion of tier 3 and 4 services provided by non-statutory providers (particularly third-sector providers), collaborative working and meaningful inclusion must be at the heart of local policy and service delivery.
• Ensure proportionate funding across ADPs – Currently, there is wide variation in funding of alcohol and drug-services across ADPs, including among those who have similar rates of drug-related harms. Work should be undertaken to ensure that funding is standardised and appropriate to levels of need (both in relation to deprivation profiles and existing alcohol- and drug-related harms).
• Encourage systematic links between settings and agencies where younger people are present – A focus should be placed on strengthening links between agencies and settings within which younger people vulnerable to problematic alcohol and drug use are present – including education, care, and community alcohol and drugs services – in order to provide appropriate and tailored support.
• Monitor and provide proactive outreach during vulnerable transition periods – Young people in periods within which they are vulnerable to transitioning towards problematic alcohol or drug use – those leaving school early and who are not transitioning to further education or employment, and those who are leaving care, for example – should be monitored, with proactive outreach and tailored support made readily available.

5.1.2 Future Research

The literature review and exploration of the Scottish data has also outlined a number of areas where our knowledge may be improved.

Improve monitoring of prevalence rates and harms

• Consider wider harms in estimates of problem drug use – Existing measures incorporating opioids and benzodiazepines should be maintained, but alongside an additional measure incorporating a wider range of drugs in recognition of the distinct profile of drugs causing harms among younger individuals.
• Collect data on narrower age-categories for younger people – Alongside the existing main categories, separating prevalence data into narrower ranges age-categories would increase the utility of data; particularly for younger people given that younger people go through a number of developmental stages within existing age-categories. This is particularly so for those aged 0-14 years, as including a number of years at which prevalence of alcohol and drug use is near non-existent among those aged 12-14 (at which initiation often begins) weakens the utility of the data, particularly in comparing prevalence rates with older age-groups.

Risk Factors

• Undertake further research into ‘vulnerable periods’ at which younger people are at greater risk of transitioning towards problematic patterns of alcohol or drug use – While there is existing data on risk factors and vulnerable populations, comparatively little data identifies the transitional periods at which individuals are at most risk of developing problematic alcohol and/or drug use.
• Research on the relationship between ACEs and problematic alcohol and drug use in Scotland among children and young people – While work elsewhere in the UK has demonstrated the strength of association between ACEs and future problematic alcohol and drug use, existing data in Scotland is weak.

Treatment and recovery

• Co-produce research with younger people with lived experience of alcohol and drug use and treatment to establish what works in treatment – The insights of younger people, as well as their families, with experience of (or at risk of) problematic alcohol and/or drug use should be meaningfully incorporated into research in order to gain a greater understanding of the barriers and enablers in relation to engaging with and maintaining engagement with alcohol and/or drugs services.
• Research into the effectiveness of alcohol and drug treatment and recovery services for younger people in Scotland – Linked to this, research which explores what kinds of treatment and recovery services are most effective with different population groups (including those of different ages, genders, ethnic backgrounds, socioeconomic backgrounds, those with co-morbidities, etc.) would help to improve outcomes of such treatment.