Case one: Daniel, aged 14 years, is an Indigenous Australian who you have seen for minor ailments at the Aboriginal health centre where you work occasionally. He comes in today with a sore throat and feels 'a bit light headed'. Daniel is not currently in school, as is the case with many of the indigenous youth in the area. He is living with some cousins in a house on the outskirts of the town. Daniel is usually quiet, but appears to respect you, and over time you have developed a rapport with him and his family members. You note Daniel's hands and clothes are splattered with paint.

Answer 1

After enquiring into Daniel's current symptoms and his reasons for coming to see you, you proceed to do a brief HEADSS assessment. You are aware from previous encounters he is not currently in school or employed. You may wish to find out what he does in an average day, where and with who he lives with, and whether there are any responsible adults in the household. Having noticed the paint on Daniel's clothes and hands, you ask what he has been doing with the paint, and given an enigmatic response, raise the possibility of 'paint sniffing'.

In regard to solvent use, you need to determine how much, how often, for how long, with whom, where, with any other substances (highly likely), the particular effects Daniel likes and what he doesn't like about it.

You also need to consider the 'hierarchy of needs':

• safety
• accommodation
• good care
• education, and
• therapeutic intervention.

Your core aspiration as a GP is to keep the young person engaged, viewing the assessment process as continuous.

Answer 2

Solvent and aerosol sniffing (glue, petrol, lighter fluid, cleaning fluid, paint and paint thinner) is a popular form of drug experimentation for young adolescents - the next most common after smoking, alcohol and painkillers. About 1 in 4 school students have admitted to trying it, with equal involvement of boys and girls. Sniffing peaks at about age 13-14 years and is rapidly given up by most, while chronic abuse tends to occur only in deeply troubled young people.

The effects of sniffing include feelings of happiness, relaxtion and drowsiness (similar to extreme drunkenness), which last 1-3 hours. Adverse effects include drowsiness, agitation, flu-like symptoms (such as sneezing, coughing, rhinorrhoea), headache, disorientation, ataxia, slurred speech, salivation, nausea and vomiting, diarrhoea, unpleasant breath, nosebleeds and reckless behaviour. Sudden death by cardiac arrest can occur, even on the first occasion (probably due to cardiac arrhythmias).

Answer 3

Psychosocial risk factors make some adolescents more at risk of substance abuse; the greater the number of risk factors, the greater the risk (Table 7).

On the other hand, protective factors can cushion the effect of risk factors and decrease overall negative outcomes: happy families (consistent parental supervision and discipline and strong parent-child bond); high achieving role models; high degree of motivation for achievement; environments that encourage a healthy lifestyle; a supportive school environment where the young person likes at least one teacher; association with peers who hold conventional attitudes; good social skills and the ability to reject offers of substances by peers.

Answer 4

The hallmark for diagnosing either dependence or abuse is continued use of the drug despite harmful consequences (Table 8). For example, if Daniel continues to inhale paint thinner despite failing grades or dropping out of school, lack of motivation, disruption of family life, and/or previous legal problems because of inhalant use, he should be evaluated for a substance abuse disorder. If the primary care clinican is not familiar with making this diagnosis and assessing its severity, referral of the adolescent and his/her family to someone who specialises in the area of addiction medicine is appropriate. However, motivational interviewing can be extremely useful in terms of modifying drug taking, and you as the GP, are in a strong position to build on strengths and support liaison with drug and alcohol services.

Answer 5

If an adolescent is thought to have a substance abuse disorder, he/she should be assessed for the severity of the disorder by someone specialising in addiction medicine, as this will dictate the level of treatment needed. In Daniel's case, as an indigenous young person who sniffs substances, he is likely to require more than counselling. Optimally he should have a case management plan that takes into consideration his physical and mental health, together with his welfare needs as assessed by the HEADSS. Often there is a breakdown in the connections between the young person and their family, school, friends and the community.

A referral to a drug and alcohol treatment service could provide this type of case management, but as there are not many services for adolescents under 16 years of age, you may need to monitor the uptake of recommended services and supports more rigorously. Further management should be based on a balanced interpretation of the systematic history, clincial condition and results of investigations, as well as focusing on keeping the young person engaged in the treatment process. Recognition that relapse is possible, and not entirely unexpected, is important in providing ongoing support for the patient and their family.

Feedback

General information about adolescent drug use

• Teenagers know more about drug use, which is glorified in popular culture. The use of needles has been demystified and has less of a 'junkie' association than in the past - young people are less afraid of it.
• Young people are more commonly polydrug users (eg. mixing caffeine loaded energy drinks such as Red Bull with alcoholic drinks such as vodka).
• Teenagers abuse easy to access over-the-counter drugs such as cough medicine (containing codeine), analgesics, antihistamines and decongestants.
• Young people sometimes steal drugs from the family medicine cabinet and sell them as party drugs.
• Common household products are being inhaled by teenagers and can be deadly.
• Many high school students take tranquillisers such as oxazepam (Serepax) and diazepam (Valium) for stress related symptoms (frequently abused by teenagers whose parents use them).
• Prescription drugs such as methylphenidate hydrochloride (Ritalin) and dexamphetamine are being abused as stimulants by adolescents who don't have attention deficit hyperactivity disorder.
• Cannabis and LSD now exist in forms more potent than in the 1960s and have serious side effects such as mental illness.
• Dance parties are characterised by the use of drugs such as ecstasy that can cause severe psychological problems and occasionally death.
• Home laboratories for manufacturing metamphetamine (speed) have made this drug much more available for illegal use.

Acknowledgment

Thanks to Dr Bessie Lampropoulos, Popi Zappier, Teen Link, Department of Adolescent Medicine, The Children's Hospital at Westmead, New South Wales, for reviewing this case.