In England, rates of self-reported drug use are higher in young people than in the general population. In 2013-14, 3.1% of people aged 16-59 used drugs frequently (more than once a month in the past year) compared to 6.6% of young people aged 16-24 years (Her Majesty's Government, 2014). Figure 1 presents annual estimates of drug use in young people aged 11-17 in England, using figures from the Census 2011, the Crime Survey for England and Wales (2013-14) and the survey ‘Smoking, Drinking and Drugs in Young People’ (2013). As shown in this figure, between 2009 and 2013, frequent drug use reduced in this age group by 2.04 percentage points.
Figure 1: Proportion of 11-17 year olds in England who used drugs frequently (if aged 16-17) or in the last month (if aged 11-15): 2009 to 2013.
Sources: Fuller & Hawkins (2013) and Her Majesty’s Government (2014)
In terms of alcohol, findings of The Smoking, Drinking and Drug Use in Young People survey (Fuller & Hawkins, 2013) suggest that since 1988 there has been a statistically significant reduction in the proportion of pupils aged 11-15 who report having consumed alcohol at least once (see Figure 2). In 1988 approximately 60% of young people aged 11-15 had ever consumed alcohol, compared to 40% in 2013. Of those young people in this age group who ever drank alcohol, the proportion that report drinking in the last week has also reduced over time, from 25% in 2003 to 8% in 2014 (Fuller & Hawkins 2013).
Figure 2: Proportion of pupils aged 11-15 years who have ever had an alcoholic drink: 1988 to 2013.
Source: Fuller & Hawkins (2013)
In relation to alcohol use in young people aged 16-24 years, it is estimated that 46% of young people in this age group have consumed alcohol in the last week, and 2% will have consumed alcohol on at least five days during the last week (Office for National Statistics, 2016).
Drug and alcohol use: differences in relation to age, gender, ethnicity and deprivation
The proportion of young people who report illicit drug use increases with age. As shown in Figure 3, approximately 24% of 15 year olds report having used drugs in the last year, compared to 12% of 14 years olds and less than 10% of 13, 12 and 11 year olds. Reported drug use is though declining and the most rapid reductions have been observed in the 13, 14 and 15 year old age groups (Fuller & Hawkins, 2013). Data from the most recent Crime Survey for England suggests that the level of any drug use in the last year across all groups, is highest in young people aged 16-19 years (18.8%) and in 20-24 year olds (19.8%) (Home Office, Drug Misuse: Findings from the 2014/15 Crime Survey for Engalnd and Wales 2nd Edition., 2015).
Age at which a person first drinks alcohol has been shown to be associated with risk of dependence in adulthood, with people who start drinking at 11-12 years being almost 10 times more likely to develop dependence issues (DeWit et al., 2000). Whether or not a young person aged 11-15 consumes alcohol is not associated with gender, but there is a strong association with age. Again based on the Smoking, Drinking and Drug Use in Young People Survey, the proportion of pupils who report consuming alcohol in the last week increases from 1% of 11 year olds to 22% of 15 year olds (Fuller and Hawkins 2013). The same source also provides evidence to suggest that the number of units consumed by young people in this age group has reduced overtime. In 2008, the average units of alcohol consumed by young people aged 11-15 was 14.6 per week, reducing to 8.2 in 2013.
Figure 3: Proportion of pupils aged 11-15 years who have taken drugs in the last year: 2001-2013.
c Estimates since 2010 are based on weighted data.
Figure 4: Proportion of pupils aged 11-15 who have consumed alcohol in the last week: 2001-2013
Estimates since 2010 are based on weighted data.
As shown in Figures 5 and 6, levels of self-reported drug and alcohol use in young people aged 11-15 years are similar for both males and females (Fuller & Hawkins, 2013). However gender differences are seen in older young people and according to data from the most recent crime and drugs survey, 24.9% of males aged 16-24 report having used illicit drugs in the past year compared to 13.8% of females (Crime and Drugs Survey 14/15). Gender differences in reported alcohol use in the last week are though less marked, with 43% of young women aged 16-24 reported having consumed alcohol in the last year compared to 49% of young men (ONS – see http://www.ons.gov.uk/ons/taxonomy/index.html?nscl=Alcohol+Consumption#tab-data-tables ).
Figure 5: Proportion of pupils aged 11-15 years who used drugs in the last year by gender: 2001-2013
c Estimates since 2010 are based on weighted data.
Figure 6: Proportion of pupils aged 11-15 years who consumed alcohol in the last week by gender: 2001-2103.
b Estimates since 2010 are based on weighted data.
In terms of alcohol, there is evidence of variation in use according to ethnicity. In young people aged 11-15 for example, 42% of white young people reported ever having consumed alcohol, compared to 32% of young people who described their ethnicity as mixed, 21% of young people who identify as black and 10% as Asian. The same study did not though find any differences in relation to ethnicity and drug use. (Health and Social Care Information Centre 2014 http://www.hscic.gov.uk/catalogue/PUB17879/smok-drin-drug-youn-peop-eng-2014-rep.pdf).
Overall (not just specifically for young people), drug use is highest in areas classified as urban, with 9.3% of people living in urban areas reporting drug use in the past year, compared to 6.5% of people living in rural areas (Home Office, Tables for 'Drug misuse: findings from the 2014 to 2014 Crime Survey for England' Illicit drug use by personal, household and area characteristics and lifestyle factors., 2014). Also those living in areas classified as being most deprived are more likely to report drug use in the past year compared to those living in the most affluent areas (12.1% compared to 7.2%). Interestingly, use of Class A drugs is similar in those with lowest and highest income, with 3.4% of people with an income of less than £10,000 per annum reporting Class A use in the last year, compared to 2.8% of people whose income is in excess of £50,000 per annum. There is also evidence of variation in alcohol use in relation to deprivation, with people living in the most deprived areas being more likely to binge drink (defined as drinking at least double the guideline limits in a single day during the previous week) (Fone DL, 2013).
Factors that increase the risk of alcohol or substance misuse in young people:
A number of factors have been shown to be associated with increased risk of young people developing substance misuse problems. These include having a member of the family with drug or alcohol problems, being a victim of violence, having been sexually abused or witnessing violence (Kilpatrick, 2000).
In terms of young people and alcohol, a large scale study in the UK found a number of factors associated with drinking behavior in those aged 13-16 years (The Joseph Rowntree Foundation, 2011). Drinking behavior was found to be heavily influenced by degree of parental supervision and exposure to close family members or parents drinking or getting drunk. Young people who reported that a close family member drank alcohol on three to six days of the week were just over twice as likely to report drinking in the previous week compared to those whose family members did not drink alcohol. Ease of access to alcohol also influenced use, as did having peers who drank (The Joseph Rowntree Foundation, 2011).
Health and Social Consequences of Substance Misuse
Adolescence is a time of change and is also often the time where people will start misusing drugs and/or alcohol. It is a time of significant brain development and as such substance misuse is likely to have a comparatively greater effect during this period of the life course (Hagell, 2013). The impact of alcohol and drug use in young people can be both physical and psychological. The Department of Health recommends that alcohol is not consumed below 15 years of age (Donaldson, 2009) and more than 27% of deaths in 16-24 years old males have been linked with alcohol consumption (Department of Health, 2011).
Physical health implications of alcohol misuse in young people
Globally it is estimated that 9% of 2.5 million deaths that are directly attributable to alcohol occur in young people aged 15-29 years (World Health Organization, 2011). The physical health implications may be seen in the short term or in the longer term. Longer term health problems are likely to be associated with patterns of drinking established in adolescence, as problematic use in later adolescence can continue into adulthood and has been associated with increased risk of dependence (McCambridge J, 2011). Specific risks associated with alcohol consumption are described below.
Alcohol has a high calorific value and as such can be associated with weight gain. Five pints of lager each week for example, equates to 44,200kcal per year. In terms of young people, there is evidence to suggest that alcohol intake in young people is associated with weight gain during adolescence (Berkey CS, 2008) and with having a higher percentage body fat (Vagstrand K, 2007).
Alcohol interferes with sleep patterns by reducing the amount of rapid eye movement sleep, leading to feelings of exhaustion (Drinkaware, 2015a). There is some evidence to suggest that alcohol use, particularly binge drinking is associated with sleep disturbance in young people. A study of 14,000 young people and adolescents found binge drinking to be significantly associated with both ability to fall and then stay asleep (Popovici I, 2013).
Young people who drink alcohol are at increased risk of injury. A multinational study of almost 50,000 young people aged 11,13 and 15 found that young people who reported excessive drinking (being drunk) were significantly more likely to have had an injury in the previous 12 months. Young people from England who reported excessive alcohol intake were 1.57 times as likely as those not reporting excessive drinking to have had an injury during the last 12 months (Pickett W, 2002).
Increased Blood Pressure (Hypertension)
Alcohol is a contributory factor in the development of hypertension (a form of sustained high blood pressure). Hypertension increases the risk of stroke, heart disease, vascular dementia and chronic kidney disease if untreated and costs the NHS more than £2 billion every year. Consuming more than three alcoholic drinks a day increases the chance of developing hypertension by up to 75% (Alcohol Concern, 2015b). In terms of young people, there is some evidence to suggest that differences in blood pressure are associated with variation in alcohol intake. In a study of 316 young people aged 18-26 years and adjusting for a number of factors including age, sex and BMI, the highest systolic and diastolic blood pressure values were observed in young people who reported drinking 3 or more alcoholic drinks each day (Gillman MW, 1995).
Alcohol is a known cause of seven types of cancer including cancer of the liver, bowel, breast, mouth, throat, esophagus and larynx. In 2011, alcohol was responsible for 3,000 breast cancer cases in the UK which account for 6% of all diagnoses. Every drink consumed per day increases the breast cancer risk in women by 7-12% (Alcohol Concern, 2015c).
Excessive alcohol consumption can lead to liver disease. It can cause a build-up of fat in the liver, leading to alcoholic fatty liver disease and continued misuse can lead to inflammation of liver tissue. Cirrhosis, the final stage of liver disease, caused by scarred liver tissue is largely irreversible and has a significant impact on life expectancy (NHS, 2013). Figure 7 shows that mortality from liver disease is increasing in England whilst mortality from other conditions, including diabetes, is reducing (Public Health England, 2014f).
Figure 7: Percentage change in mortality rates (England, 1995-2012) Source: Public Health England (2014f)
Physical health and drug misuse
Smoking cannabis irritates the lungs and those who smoke cannabis on a frequent basis are likely to develop lung problems that are similar to tobacco smokers. Consequences of frequent cannabis smoking can include coughing, lung illness and increased risk of lung infection (National Institute on Drug Abuse, 2015).
Smoking cannabis increases the heart rate for up to three hours and thereby increases the risk of heart attack (National Institute on Drug Abuse, 2015). Cocaine also leads to increased heart rate and can lead to heart attacks and strokes which may cause sudden death (National Institute on Drug Abuse, 2013). Chronic heroin use can lead to collapsed veins, heart lining infections and pulmonary complications (National Institute on Drug Abuse, 2014).
Drug misuse in pregnancy
Approximately 70% of infants born to drug dependent mothers are affected in some way. Heavy use of cannabis during pregnancy can cause babies to startle more easily. Use of amphetamines and ecstasy may lead to decreased birth weight and increased risk of cleft palate and heart defects. Cocaine may be associated with placental abruption, prolonged rupture of membranes, intra-uterine growth retardation and differences in organisational responses and interactive behavior. Heroin use in pregnancy can lead to low both weight and premature birth. Infants may also show signs of heroin withdrawal which is treated with barbiturates and methadone (Nottingham Neonatal Service, 2014).
Research has shown that the use of cocaine and alcohol is significantly associated with aggression. The causal pathway of cocaine use, alcohol use and violence is currently unclear however; this evidence suggests that people who use these substances are more likely to display aggressive behavior (Macdonald, et al., 2008).
Blood borne viruses
HIV diagnoses associated with injecting drug use have been low in recent years. Based on extrapolated data (Public Health England, 2013) it is estimated that there are 20 HIV Positive injecting drug users in Nottingham, two of which may be undiagnosed.
Hepatitis C remains a key area of concern in injecting drug use due to the levels of infection, transmission, the lack of a vaccine, low levels of treatment engagement and the serious effects that it has on health. It is estimated that between 130 and 150 million people globally are infected with chronic hepatitis C (World Health Organisation, 2015).
Injecting drug use remains the main route of hepatitis C infection in the UK, with 90% of those acquiring the infection having done so through injecting drugs. Approximately 50% of injecting drug users in England have been infected with hepatitis C. Around 25% of these will go on to clear their infection naturally, it is therefore estimated that around two in every five injecting drug users in the UK currently have a hepatitis C infection. Furthermore, Public Health England estimates that around half of the injecting drug users in the UK who are infected remain undiagnosed, either because they have not been tested or have been infected since their last negative test.
In England, only 3% of those who have a hepatitis C infection access clinical treatment. It is estimated that in the UK, 215,000 individuals have a chronic hepatitis C infection and hospital admissions and death as a result of hepatitis C are rising. This equates to approximately 2,000 people within Nottingham with a chronic hepatitis C infection. The rate of infection is highest in those aged 25-44 and is higher in males; these characteristics accurately reflect the local opiate using population (Public Health England, 2014).
A process for recording and investigating drug-related deaths within Nottingham City continues to be co-ordinated by the Crime & Drugs Partnership. The local investigator receives reports of potential drug-related deaths occurring within the City and liaises with the Coroner’s office to establish the cause of death, and where a death is found to be drug related; investigate the circumstances and background that led to the death.
All deaths are reported to the Confidential Inquiry Review Group; a multi-agency group that receives the investigation reports and identifies any learning points that might arise from them. All learning points are widely circulated across a range of treatment services and partner agencies in order to allow them to be implemented and acted upon to prevent further deaths in future.
A bi-annual report is produced by the Crime & Drugs Partnership summarising City drug-related deaths and identified learning points that arose from the investigations. In the 2011-13 drug-related death report, it was identified that there were ten confirmed drug related deaths in the city.
Mental health and alcohol misuse
Mental health problems directly affect 25% of the population during any given year (Singleton, Bumpstead, O’Brien, Lee & Meltzer, 2001) which was equivalent to 76,420 Nottingham citizens in 2013-14 (according to population statistics reported in the 2011 Census). For people dependent on alcohol, the prevalence of mental health problems is significantly increased to 45% (Coulthard, Farrell, Singleton & Meltzer, 2002). Whilst alcohol is known to have a negative effect on mood and memory (NHS, 2014a) and therefore might contribute to the manifestation of mental ill health, there is also evidence to suggest that alcohol is used to self-medicate existing mental health conditions (Mental Health Foundation, 2014).
In terms of young people, there is evidence to suggest that alcohol use is common amongst young people with a diagnosed mental health problem. A study of 2122 young people accessing mental health treatment reported that approximately one third with depression drank at least weekly, as did approximately 40% with a diagnosis of psychosis (Hermens DF Scott E, 2013).
Mental health and drug misuse
Drug use is commonly reported by young people with a diagnosed mental health problem, with just under a quarter of young people aged 12-17 reporting daily or almost daily cannabis use, rising to approximately one third by age 18-19 years (Hermens DF, Scott E, 2013) .
A considerable proportion of people with schizophrenia also smoke cannabis, although for many years the causal pathway for cannabis and schizophrenia has been unclear. Evidence suggests that cannabis consumed in high doses may lead to mental illness and psychosis (McLoughlin, et al., 2014).
Smoking cannabis has been linked to temporary hallucinations which manifest as sensations or images that seem to be real (National Institute on Drug Abuse, 2015). Hallucinations may lead to increased risk of accident or injury.
Cannabis smokers often experience a sense of paranoia which leads sufferers to distrust others (National Institute on Drug Abuse, 2015). Feelings of paranoia may lead to increased risk of injury of both the sufferer and those around them.
Approximately one third of young adults in the criminal justice system have an alcohol misuse problem (Prison Reform Trust, 2012), and of all 91,000 offences committed by young people in England and Wales between 2013 and 2014, approximately 8000 were drugs offences (The Ministry of Justice, 2014).
Drug misuse is associated with crime in a number of ways. People who are dependent on drugs may steal in order to fund their addiction. It is estimated that for this reason up to half of all acquisitive crime is drug related. Violent crime is also often associated with drug and alcohol misuse (DrugScope, 2015). Research has shown that effective treatment interventions significantly reduce drug related offending (Keen, et al., 2000).
Drug misuse is a known cause and consequence of homelessness. The misuse of drugs can be a causal or contributing factor to becoming homeless and drug misuse can also be used as a coping mechanism for dealing with homelessness. The prevalence of drug misuse is considerably increased amongst homeless people; approximately 80% of people who become homeless start using at least one new drug. Furthermore, the misuse of drugs and alcohol accounts for more than a third of deaths amongst homeless people. The lack of stable accommodation is considered a barrier to recovery for many homeless people and this group is recognised as more difficult for intervening services to access (Crisis, 2011).
Drug and alcohol dependent parents can pose a risk to both themselves and their children. Substance misuse can reduce a parent’s capacity to provide the necessary practical and emotional care to their children and this may result in reduced educational attainment, mental health problems and increased risk of drug misuse in the child. Whilst living with a child has been considered a preventative factor for developing severe substance misuse problems, substance misuse treatment has been shown to be effective in improving the lives of the families affected (The National Treatment Agency for Substance Misuse, 2012).
Wider determinants and risk of substance misuse
A number of factors that either directly or indirectly may increase risk of misuse of drugs and/or alcohol. Nottingham has higher than average incidence of some of these factors, including:
A higher than national proportion of delivery episodes for a mother aged under 18 years (2% compared to 1.3% respectively);
A higher than national proportion of children living in poverty (34% compared to 19.2% nationally);
A higher than national rate (per 100,000 population) of sexually transmitted infections including chlamydia which has increased from 32 in 2011 to 40 in 2012;
A significantly higher than national proportion of people aged 16-18 that are not in education, employment or training (6.3% compared to 5.3% respectively); and
A higher than national proportion of school exclusions in Nottingham are attributable to substance misuse (4.9% in Nottingham compared to 3.5% nationally, 2012/13).