Substance Abuse among Youth: A Harsh Reality

Substance abuse is a public health problem globally. The prevalence of substance abuse among youth is alarming. The problem not only harms individuals but also negatively affects families and society. Method: A review was carried out in 2013 and 2014 using various databases, including: Science direct, PubMeds and CINAHL and other health sciences journal within 10 years were used. Finally 11 research based articles and other authentic reports were included. Research articles and reports were on magnitude of substance abuse among youth, determinants of drug abuse, and harmful effects of drug abuse and framework of STAR project. Results: Globally, the numbers of drug-related deaths among youth were 211,000 in 2011. Predisposing factors for substance abuse among adolescence are age, gender, family structure and relations, poverty, and the affordability and accessibility of drugs. This problem is common across developing and developed countries. However, developing countries are more vulnerable due to poor socioeconomic conditions. Conclusion: There are risk factors for substance abuse and its understanding can help community at large to address substance abuse among youth. Project STAR was an example of an effective community-based effort to address substance abuse among adolescents in United States of America.


Introduction
Kyrgyzstan is a landlocked central Asian country. It borders Kazakhstan, China Uzbekistan and Tajikistan. It is extremely mountainous. Its population is more than 5.6 million in 2012 [1]. Before 1991 the country was depending on Soviet Union for economic support. After getting independence in 1991, country had to face economic crises, such as increase in unemployment, poverty, and decrease standard of living. Although the country is gradually improving economically but Kyrgyzstan is still considered a lowincome country with 27% population living below poverty line [2]. Substance abuse is a public health issue in Kyrgyzstan and is a threat for the health of youth. The country has 30% young people aged 14 -28 years [3]. There are many risk factors, which exist in Kyrgyzstan but poverty and accessibility of drugs remained the most significant risk factors for substance abuse.
Substance abuse includes the frequent use of illegal drugs or the misuse of legal drugs [4]. Widespread drugs include hashish, charas, bhang, opium, alcohol, tobacco and psychotropic drugs. However, heroin is the most commonly used drug worldwide [5]. Substance abuse is particularly debilitating for young people. According to WHO, young people as those age 10-24 [6].
This paper highlights the background and magnitude of substance abuse among young people, determinants of drug abuse among youth and harmful effects of drug abuse. The STAR project is provided as a case study of a comprehensive, community-based programme to control and prevent drug abuse among adolescents. The literature search has been carried out in 2013-14 using various databases, including: Science direct, PubMeds and CINAHL. In addition, public health, community health journals and other health sciences journal, full text and other publication within 10 years were used to get recent, relevant and complete articles. However some old articles, which were classic, also integrated. Finally research based articles and important reports related to the topic, in the English language included in this paper. Finally 11 research base articles and other authentic reports related to the topic from international organizations were included.
During literature search following key terms were used, substance abuse, drug abuse among youth, drug abuse in Kyrgyzstan, drug abuse in Pakistan, effects of drug abuse, framework for determinants of drug abuse, drug abuse, drug abuse a public health problem etc.

Background and Prevalence of Substance Abuse
Afghanistan is a key opiate producer. From Afghanistan, the substance is supplied to neighbouring countries. From Central Asian countries such as Tajikistan, Kazakhstan, Kyrgyzstan and Uzbekistan, drugs are transported to Russia and Europe [7]. Drug traffickers also use Pakistan's transport corridors to move illegal drugs out of the country, causing a serious problem in Pakistan [2]. Drug abuse is a public health problem globally and the prevalence of substance abuse among youth is alarming.
According to US national survey; 78% of adolescents used alcohol. Out of these, 47% reported regularly drinking alcohol [8]. In 2012, approximately 1,700 deaths were attributed to drug abuse in the United Kingdom and Island; out of which over 70% of the casualties were male [9]. In Kenya, lifetime substance abuse among college and university students was reported at about 70% [10]. In 2011, there were 9.6 million drug addict in Pakistan [11]. Forty percent of drug abusers live in urban areas and 60% live in rural areas [5]. Globally, the number of drug-related deaths among youth was 211,000 in 2011 [12]. In 2006, there were 90,082 registered drug abusers in Central Asia, excluding Turkmenistan [13]. In 2011, there were 10171 registered cases of drug abuse in Kyrgyzstan, and out of these 73% were injecting drugs [14]. In 2011, 60% of new HIV cases in Kyrgyzstan were attributed to injecting drugs [14].

Determinants of substance Abuse among Youth
There are risk factors that contribute to substance abuse among youth include age, gender, poverty, peer pressure and media, family structure and relations, and the affordability and accessibility of drugs. Understanding the risk factors can help health professionals as well as the community at large, to address the increase demand of substance abuse among youth.

Age and gender
Underage drug abuse is prevalent globally [15] and impacts the growth and development of youth. The median age for the onset of youth alcohol use in the United States is 14 years [8]. One study in the United States reported that 43% of adolescents aged between 13 and 14 had used alcohol, this increased to 78% among 17 and 18 year olds [8]. Among 13 and 14 year olds, 10% reported regular alcohol users; this increased to 47% among 17 and 18 years old [8]. In the United States, more male students are abusing alcohol regularly than female students [8].
Drug abuse is more common among males than females. In Kenya, about 43% male and 37% female adolescents are using cigarettes, , this finding is statistically significant with p-value <0.05 [6]. Onset of smoking in Kenya was reported at 15.5 years for boys and 16 years for girls; a statistically significant difference with p-value 0.033 [10]. One of the studies conducted in USA at large scale reported that parents provide more supervision and monitoring to the girls than boys [16]. Similarly, in some of the Asian countries, parents provide more supervision to the girl child. This could be one of the reasons that females consume less substance abuse due to parental supervision [16].

Poverty
Poverty is another risk factor for adolescent drug abuse. The prevalence of substance abuse is significantly greater among middle and lower socioeconomic sectors of youth and is increasingly prevalent in poorer parts of the world [17]. Poverty affects the wellbeing of a person, and has important physical and psychological consequences. People living in poverty engage in substance abuse to deal with multiple stressors, such as unemployment, inadequate housing, lack of affordable day care, and social indifference. In Pakistan, 24% of the population is living below poverty line, especially in rural areas. Seventy four percent of children and young adults living on the street are drug addicts [18]. Drugs such as cocaine, hasish, heroine, opiates and cannabis are used more by poor people than wealthy people, particularly those who are unemployed, and have low literacy level [18].

Peer pressure and media
Peer pressure and exposure to drug-related marketing activities are predisposing factors for adolescents to initiate drug abuse. Almost 75% of Pakistani medical students perceived that living in a hostel is a risk factor for drug use because they are vulnerable to more peer pressure (65%), easy access to drugs (59%), and lack of parental influence (58%) [19]. In 2009, Kenyan study reveals that 75% of adolescents admitted that their friends introduced them to drug use [10]. In popular media and marketing activities, drinking is depicted positively, sending the message that drinking is common and acceptable in our society [15].
One study conducted at large scale in Maryland, USA, reported that 28% of adolescents exposed to movies depicting alcohol use or involved in alcohol related marketing activities, started drinking alcohol, and 20% reported binge drinking [15]. Marketing activities include using branded merchandise or wearing T-shirts or using any other items having poster of smoking or drinking alcohol or any other drugs.

Family
Family structure also affects the use of drugs among youth. One of the studies conducted in United States reported that youth of single parent are at high risk for drug abuse as compare to adolescent with dual parents [16]. One of the reason identified in the study was, single parents may have more financial crises and have less time to monitor their children. Less parental supervision could cause peer dependency for information related to appropriate behaviours, therefore they are at high risk to substance abuse [16]. A study of risk factors related to drug abuse in Pakistan identified bereavement in families and relationship difficulties [20]. A study in Bishkek Kyrgyzstan found that a poor relationship between children and parents leads to increased alcohol consumption among youth [21]. Up to 35% of the young drug abusers in Pakistan reported their parents are also abuse drugs [22].

Availability and accessibility of substances
In Central Asian countries, alcohol and tobacco are both easily available and affordable. Many adolescent report starting smoking or alcohol or drug use at the age of 11 and younger, they have access to substances at home, from friends, or from shops or street vendors [23]. Accessibility to alcohol at home and parents drinking are risk factors for the onset of alcohol use in adolescence [23]. In Kyrgyzstan and other post-soviet countries, it is acceptable for adolescents to drink alcoholic beverages during celebrations [21]. This attitude can facilitate early alcohol use and later, drug abuse [21]. In some countries, there are few restrictions, and drugs can be bought from a pharmacist or chemist without prescription. It is very important to address this concern related to drug demand and its supply with adequate resource allocation to prevent this hazard.

Effects of Drug Abuse
Drug abuse is increasing morbidity, mortality and crime rates worldwide. UNDOC estimated 200,000 drug related deaths in 2011 [12]. Globally Hepatitis C is more common among those who inject drugs; in 2011 about 7.2 million people were diagnosed with Hepatitis C, 1.2 million people were living with hepatitis B virus, and 1.6 million with HIV who injected drugs [12]. HIV rates among children and adolescent drug users are increasing alarmingly due to sharing needles [24]. Injecting drug is a source of potential exposure to different health conditions, such as HIV, hepatitis B and C, and lung cancer [12]. Drug abuse has a heavy cost on communities. This cost is not only of buying expensive drugs very frequently but drug use can lead to them for multiple hospital admissions, accidents, disease, death and disabilities.
According to the Salt Lake County Division of Substance Abuse in the United States, alcohol and drugs are associated with 45% of rapes, 51% of assaults, 70% of teen suicides, 50% of traffic fatalities, 52% of murders, 51% of thefts and 80% of child abuse [25]. In Tajikistan's school based health survey indicated that students of grade 7-9 faced physical and mental problems due to drug use; 12% made a plan to attempt suicide, 21% were involved in fights in the past year, 25% physically harm themselves unintentionally and 0.3% had first sexual intercourse before the age of 13 years [23].

Project STAR: An Effective Model for Intervention
Project STAR (Students Taught Awareness and Resistance) was a community-based programme in the United States, designed to reduce the number of new cases of drug user and decrease the frequency of drug use in communities [26]. The programme was initially implemented in Kansas City from 1984 to 1990 and replicated in Indianapolis in 1987 [26]. It is a universal substance abuse prevention programme, with an initial emphasis on tobacco, alcohol and marijuana use. The target population was adolescents aged between 10 and 14 years [27]. Results proved that Project STAR was cost effective, reduced drug use, and impacted related risk behaviours [26]. Project STAR included interventions in the following areas at different times during the campaign: mass media, school curriculum, parents' participation, community organisation and policy change [27]. The Project intervention takes between three to five years.

Media
The media can play an influential role in changing society. In the campaign of reducing substance abuse in adolescent, media needs to involve from beginning till the end of the campaign. Local media could be involved as partners in this campaign. Media can do marketing by showing positive influence for prevention of drug abuse. Details of the entire project need to be shared with the media, and their role is to share messages with the entire community about children education program. They need to telecast talk shows, announcements related to the program, conferences, story making, newspaper article coverage and commercial to prohibit substance use among youth.

School curriculum
Project STAR's school programme includes 18 educational sessions delivered over two years. Teachers need to be trained to lead students through the sessions. These sessions prepares youth to resist substance abuse [27]. Peer leaders also need training to act as role models and demonstrate prevention skills to their class mates. The curriculum helps build youth knowledge and understanding about the consequences of drug abuse, and improve their problem solving skills [27]. Students also get homework to do with a parent or guardian, to enhance positive communication between them. Social bond and attachment with parents could decrease the consumption of drug among youth [21]. The youth could be the active part of the campaign against drug use.

Parents
A parent group has an active role in the second year of programme [26]. Task groups are formed, including parents, students and teachers; they are prepared for their role. They are actively involved in planning, conducting sessions on parenting skills, and reviewing and refining school policy regarding drug abuse [26]. They also monitor school, home, and community environment to prevent drug use.

Community
Engaging community leaders is the next step. They include representatives from various sectors, such as education, health, government, and media who receive training and commit to be involved for at least two years [26]. Their role is to identify community needs related to drug abuse prevention. Then they plan, gather resources, and implement interventions to support the programme.

Policy change
Policy change is a critical part of the programme and is implemented by subcommittee of the community coalition. This group focuses on policy changes at school, in the community, and at the city and country levels to reduce access to drugs, and increase support for the programme.

Conclusion
Substance abuse is a significant public health problem around the world, with particular consequences for youth. Risk factors for substance abuse are related to individual, social and economic vulnerabilities. Young substance abusers are prone to serious, sometimes fatal, physical and mental health problems. Family and community life are also adversely impacted. The fight against substance abuse cannot be effective without the involvement of a range of community stakeholders and the proper allocation of required resources. Project STAR is a good example of a community-based programme to mobilise individuals and communities to reduce drug abuse among youth.