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N.B. While smoking is an important issue for all ages, including adolescents, it is not covered in the following article.
Substance misuse is a significant problem in New Zealand
Each year in New Zealand, a large proportion of adolescents are likely to experiment with alcohol, cannabis or other
drugs. For some this will be an isolated incident, but for many, this experimentation may be the beginning of a much more
Alcohol consumption among New Zealand adolescents is high by international standards.2 It is estimated that
90% of New Zealand adolescents will have tried alcohol before age 14 years.2 Excessive use of alcohol is also
common, with a major study reporting that one-third of secondary school students admitted to binge drinking (more than
five drinks in four hours) in the past four weeks.3 Drinking is also particularly problematic among Māori
The 2007/08 Alcohol and Drug survey revealed that the most common illegal drug used by New Zealanders aged between 16
and 17 years was cannabis.5 Almost one quarter of females and 15% of males in this age group had also used
benzylpiperazine (BZP or “party pills” - now banned) and approximately 5% of 16 and 17 year olds had used
either stimulants or hallucinogenics, with sedatives, nitrous oxide and injected drugs being less common.5
Although the causes of such behaviours are complex, what is clear, is that the earlier that adolescents experiment with
alcohol and other drugs, the more likely they are to develop substance misuse issues later in life.2
Alcohol is commonly misused by adolescents
In the 2007 National Survey of Health and Wellness among New Zealand secondary school students, it was identified that:3
What does the law say?
People aged under 18 years can be supplied with alcohol for responsible consumption in a private home or function by
a parent, or legal guardian. People aged under 18 years cannot buy alcohol, or ask anyone else to buy it for them, or
drink in a public place, or enter a pub or bar without their parent or legal guardian. It is also illegal for any person
aged under 20 years to have a blood alcohol concentration above zero while driving.
The Alcohol Reform Bill was passed in September 2011. This Bill provides further guidelines for reducing the impact
and harms from drinking in New Zealand.
For full details of the laws around alcohol, see: www.parliament.nz
- 34% had undertaken binge drinking within the previous four weeks
- 22% had received an alcohol related injury
- 16% had been told by family or friends to “cut-down” on their drinking
- 14% had unsafe sex due to alcohol
- 7% had unwanted sex due to alcohol
Motivations for adolescent drinking fall into three broad categories:6
- Social facilitation - increased social and sexual confidence
- Individual benefits - escapism, getting a “buzz”, having something to do
- Social influences - peer pressure, wanting respect, image, accepted culture
Short-term effects of alcohol
Alcohol consumption increases risk behaviours by reducing inhibition and motor control and impairing judgement. Among
adolescents alcohol consumption has been shown to increase the risk of sustaining serious injury, having a fatal motor
vehicle accident, committing or being the victim of crime (including sexual assault), contracting a sexually transmitted
disease and becoming pregnant.2
The lethal dose of alcohol is 5 - 8 g/kg. In a 60 kg person this would equate to approximately 1 L of spirits or four
bottles of wine drunk over a short period of time.7 Adolescents who binge drink are most at risk of alcohol
toxicity. Symptoms of acute alcohol intoxication include nausea, vomiting, dehydration, slowed respiratory rate and loss
Harm reduction when drinking
Encouraging adolescents to plan ahead for any social occasions involving alcohol may reduce the risk, or severity of
intoxication. Specific advice for adolescents who will be drinking alcohol may include:
- Eating before going to a party and during the event if food is available
- Drinking slowly and alternating alcoholic and non-alcoholic drinks
- Making prior arrangements for safe transport home
- Looking after friends
Long-term effects of alcohol in adolescents
Excessive drinking is a health problem at any age, however, alcohol misuse during early adolescence is of particular
concern as it is a risk factor for alcohol dependence later in life.8 Māori males are particularly at
risk as they are twice as likely to consume a large amount of alcohol when aged 14 years or younger than other New Zealand
males.8 A 2009 Australian study reported a lifetime prevalence of alcohol dependence of 47% amongst individuals
who began drinking before age 14 years compared to 9% among those beginning after age 21 years.9 Early and
persistent use of alcohol during adolescence increases the risk later in life of anxiety, eating disorders, suicide, cirrhosis
of the liver, cancer, coronary heart disease and stroke.10 Māori are four times more likely than non-Māori
to die of an alcohol related condition.11
Cannabis is the most widely used illegal drug in New Zealand
It is now estimated that by the age of 21 years, 80% of New Zealanders will have tried cannabis on at least one occasion,
with 10% developing signs of dependence.2 Previous figures from the 2007/08 New Zealand Alcohol and Drug use
survey showed that almost half (46%) of people aged 16 to 64 years reported using cannabis at some point in their life.5 Cannabis
use was higher amongst Māori with almost two-thirds (63%) of Māori aged 16 to 64 years reporting having used
Short term effects of cannabis
The main psychoactive component of cannabis is delta-9 tetrahydrocannabinol (THC). The effects of THC are wide ranging
- Relaxation and laughter
- Increased appetite
- Confusion, paranoia and hallucinations
There have been no reported fatalities from cannabis overdose. However, in the 2007/08 Alcohol and Drug use survey,
one in six people reported having experienced a harmful effect with cannabis and 2% reported having sustained an injury
in the past 12 months due to cannabis use.5 Cannabis is also reported to be a major contributor to road deaths.12
Long term effects of cannabis
Evidence is increasing that the adolescent brain is particularly sensitive to the effects of heavy cannabis use.13 The
following long-term adverse effects have been reported in adolescent cannabis users:
Poor educational outcomes are more common amongst adolescents using cannabis than those that are not. Adolescents who
use cannabis are more likely to drop-out of school, less likely to enter University and less likely to earn a University
Other illegal drug use has been shown to be approximately 70 times higher amongst weekly cannabis users, compared to
non-users.14 Cannabis is described as a “gateway drug” as its use often precedes the use of other
illicit substances.15 Tobacco use prior to cannabis experimentation is also common.
Mental disorders such as depression, anxiety and suicidal thoughts are more common amongst adolescents who are heavy
Adolescents who are heavy users of cannabis are two to 2.5 times more likely to develop psychosis or schizophrenia than
Young people who start using cannabis before age 18 years are eight times more likely to develop symptoms of dependence
later in life. This is of particular concern for Māori, who are significantly more likely to have tried cannabis
before the age of 14 years than non-Māori.5,17
Other drugs of misuse
Until BZP based “party pills” were banned in 2008, they were a significant source of drug misuse among adolescents,
particularly young females.5 While BZP is still illegally available in some areas, it is likely that in the
absence of an easy supply of this drug, alternative substances are now being used more frequently. It can be helpful for
clinicians to be familiar with current drug trends among adolescents and the street names used to describe these drugs
(see Table 1).
|Table 1: Illicit drugs reportedly used by adolescents in New Zealand
||Street name(s) / notes
P (pure methamphetamine)
Ice (crystal methamphetamine)
Speed (amphetamine sulphate)
Cocaine (cocaine hydrochloride powder for inhaling)
Crack cocaine (freebase form for smoking)
Pseudoephedrine based decongestants
LSD (d-lysergic acid diethylamide): Acid, Trips
N.B. usually prepared for ingestion by infusion into blotting paper
Magic mushrooms (Blue Meanies, Gold Tops - contain psilocine and psilocybine)
Datura and angel’s trumpet (Solanaceae - contain atropine-like substances)
Morning glories (Ipomoea - contain psychogenic alkaloids)
Peyote cactus (contain mescaline)
||Special K, Vitamin K, Kitkat
Has both stimulant and hallucinogenic properties. Main component is generally MDMA, but active constituents can
vary considerably, e.g. BZP, mephedrone, methylone, caffeine
GHB, Fantasy, Grievous Bodily Harm, Liquid E, Liquid X
||Kava (Piper methysticum)
||Also widely used in Pacific communities for ceremonial purposes
Barbiturates, benzodiazepines, zopiclone
Downers, Reds, Purple Hearts
NOS, Laughing Gas
Heroin, poppy seeds (tea), homebake (monoacetylmorphine)
Morphine sulphate (MST, Misties), oxycodone, methadone
||Amyl nitrite, butyl nitrite
||Aerosols, glue, petrol, butane, paint thinners, paint, methylated spirits
Roids, Juice, Gear
N.B. Used for image enhancement and sporting performance
Identifying the problem
Assess for substance use and mental health problems using HEEADSSS
In general, adolescents, especially young males, do not frequently consult with a primary care provider. Therefore,
every encounter should be regarded as an opportunity to perform a mental health assessment and in particular, to ask about
substance use. New Zealand guidelines recommend that every adolescent’s psychosocial welfare should be routinely
assessed using a standardised interview format such as HEEADSSS (see below).18
It is preferable to conduct the interview when the patient is otherwise well. However, the acute distress of a crisis
may assist in revealing important information.
Identifying substance misuse or dependence
During a HEEADSSS assessment, if an adolescent discloses alcohol or drug use, this should be assessed further with more
direct questioning.18 Verbal or physical aggression, academic under-performance, impulsivity, hyperactivity,
depressed mood and poor social skills may also be indicators of substance misuse.19
CRAFFT is a set of questions designed to detect alcohol and substance misuse in adolescents:20
- Have you ever been in a Car driven by someone (including yourself) who had been using alcohol or drugs?
- Do you ever use alcohol or drugs to Relax, feel better or “fit in”?
- Do you ever use alcohol or drugs when you are Alone?
- Do you ever Forget things you did while using alcohol or drugs?
- Have Family or friends ever told you to cut down your use of alcohol or drugs?
- Have you ever got into Trouble while you were using alcohol or drugs?
Answering “yes” to two or more questions indicates that substance misuse may be a problem. Red flags for
a more serious problem are:
- Substance use when the adolescent is alone
- Friends expressing concern about usage
Co-existing mental illness
It is estimated that 60-75% of adolescents with a substance misuse disorder also have some other form of mental illness.19 The
most common mental disorders amongst adolescents in New Zealand are anxiety, depression and conduct disorders.18 All
people identified with a substance misuse disorder should be also screened for mental health disorders and treated appropriately.
For further information see: “Depression
in young people”, BPJ special edition (Jan, 2010).
Treating adolescents for substance misuse in primary care
Goals of treatment
The overall objective of treatment for substance misuse is to return the patient to a state of medical and social wellbeing.
The combination of education and harm reduction strategies has been shown to reduce substance misuse in adolescents.21
Psychological treatments are recommended first-line in adolescents. There is little evidence supporting the use of pharmacological
treatments (e.g. benzodiazepines) for adolescents with substance misuse problems. Substitution medication (e.g. methadone)
is also not recommended for young people.21
It is important that adequate follow-up and support is provided. The aim is for the general practice team to be viewed
as helpful, accessible and safe. Text messages are a non-confrontational way of maintaining contact with adolescents and
reminding them of future appointments. Phone calls and face-to-face contact with practice nurses can also promote accessibility
to the general practice team. A multidisciplinary approach involving social agencies, school counsellors and other health
professionals is often required.
Self-management involves reducing drug and alcohol consumption and avoiding triggers which may cause a relapse, by encouraging
positive daily routines. Examples of this include; exercise, sleep hygiene, scheduling of activities, keeping a diary
and stress management.18 For further information about self-management see “Treatment resources” (see
Brief interventions of five to ten minutes, where the adolescent is given advice on the harms of excessive consumption,
can be effective in reducing alcohol and other drug use.21 Practitioners should discuss the health consequences
of the substance misuse and ask if the adolescent is willing to try to change their behaviour. Those who are willing should
be encouraged to set a goal (e.g. not using cannabis for a week) and be provided with supportive educational material.
Motivational interviewing is a form of brief intervention which can help a person to make the decision to stop misusing
a substance by highlighting and resolving factors such as denial and ambivalence.22 The aim is to encourage
people to recognise that there is a problem, to make a change and to stick with it. Motivational interviewing is of particular
benefit in encouraging engagement with more intensive treatment for substance misuse for those who require it.23
For further information see “Motivational
interviewing”, BPJ 17 (Oct, 2008)
Cognitive behavioural therapy (CBT) is a technique used to help the patient identify their thoughts, beliefs and feelings
which may be contributing to their behaviour. With the assistance of the therapist over a series of sessions, the patient
develops coping strategies for events that may trigger substance use. CBT should only be performed by a health professional
trained in the technique.
Best Practice Tip: “Become a coach”
Negative health behaviours such as substance misuse are often the “tip of the iceberg” in adolescents. Psychosocial
issues that underpin behaviours will influence any health intervention that occurs. For example, an adolescent will smoke
marijuana to cope with chronic stress (e.g. financial problems, abusive parents, relationship problems), and they are
unlikely to successfully address the substance misuse problem without also making a positive change in their circumstances
(e.g. finding employment). Merely supplying information on the harms of cannabis by itself would be ineffective. Primary
care clinicians have an important role in coaching adolescents so that they can make positive changes in their social
circumstances and learn coping skills to manage their reactions to adversity. An example of coaching may be: “You
can’t change the situation, but you can change how you deal with it”.
Substance misuse amongst adolescents is associated with increased numbers of sexual partners and unprotected sex, leading
to higher rates of sexually transmitted infections, pregnancy and abortion.2 In some cases sexual abuse may
be a causative factor in substance misuse. Adolescents may find it difficult to confide in someone about their sexual
behaviour - particularly if they do not identify as being heterosexual. A confidential and non-judgemental approach is
required to build trust and communication.
Adolescents should be instructed and encouraged in the consistent and correct use of condoms. Condoms can be obtained
under “Practitioner’s Supply Order” or prescribed fully subsidised on the Pharmaceutical Schedule.
Sexually active adolescent females should be encouraged to use condoms and one other form of contraceptive. Long-acting
forms of contraception may be considered for adolescent females who may have difficulty with daily contraceptive compliance.
A Public Health Officer or Child, Youth and Family Services (CYF) should be contacted where a person aged under 16
years is having consensual sex with a person significantly older than them, or where there are issues that may place
the young person in danger. Where non-consensual sex or any other form of abuse is involved, the police or CYF should
be contacted and, if necessary, a paediatrician consulted. If local resources are limited, it is essential for the practitioner
to give advice on how the adolescent can remove themself from harm. In all cases the safety of the adolescent is the
For further information see “Treatment resources” (below)
and “Let’s talk about sex”, BPJ 20 (Apr, 2009).
A searchable directory of addiction treatment and advice services (including Kaupapa Māori) in New Zealand is available
The alcohol drug helpline is available from 10 am - 10 pm, Ph: 0800 787 797 or visit: www.alcoholdrughelp.org.nz
Education material is available from: the Alcohol Advisory Council of New Zealand (ALAC) at: www.alac.org.nz ,
the Alcohol and Drug Association of New Zealand (ADANZ) at: www.adanz.org.nz and
the Foundation for Alcohol and Drug Education (FADE) at: www.fade.org.nz
The Low Down is a Ministry of Health sponsored website focused on self-management of adolescent problem solving, and
is available from: www.thelowdown.co.nz
Family planning provide resources for promoting sexual health. Clinics are available around the country or visit: www.familyplanning.org.nz
Rainbow Youth is an organisation for gay, lesbian and bisexual youth, run by youth. Visit: www.rainbowyouth.org.nz
Training in cognitive behavioural therapy is available from The Werry Centre in Auckland, which has occasional seminars
on CBT and has strong links with Auckland University which offers several papers in CBT, for further information visit: www.werrycentre.org.nz
|Performing a HEEADSSS assessment with an adolescent
Step 1 - Discuss confidentiality: The patient should be told that their personal
information will not be disclosed without their permission, unless the information reveals that someone might harm
them or they might harm themselves or someone else.18 Parents or caregivers should not be present during
Step 2 - Begin the interview: The interviewer creates their own questions which relate to the subjects
which make up the HEEADSSS acronym. The interview itself, including the order of questioning should not be treated
rigidly and should evolve naturally, based on the direction of conversation. More specific questions can be asked
at the interviewer’s discretion. Questions should cover:
Questions should be open-ended and non-judgemental. It is important not to make any assumptions about the adolescent’s
personal, family or social circumstances. In some cases it may be appropriate to discuss issues of culture and spirituality.
Questions that require a description, rather than an opinion, help to avoid a “dunno” type of response.
Some examples of questions are shown in Table 2.
It is recommended that the adolescent is asked if they have a trusted adult they can discuss
personal matters with.24 A connection to supportive parents or other adults has been shown to be protective
against a range of negative behaviours, including substance misuse.25
Step 3 - Wrapping up: By the end of the session, the interviewer should have a clear
idea about how the adolescent feels about their home-life, schooling or employment, interactions with peers and sexuality.
The interviewer should also have identified any factors such as peer pressure, bullying or substance misuse which
may be placing the adolescent at risk. The adolescent also needs to be given the opportunity to raise any concerns,
or request further information on specific topics.
It is important that the interview should also highlight the successful elements of an adolescent’s life.
Commenting on things that are going well provides a positive aspect to the interview and a source of encouragement
for the adolescent.
Best Practice Tip: For a useful and detailed account of
how to perform an effective HEEADSSS assessment see: Goldenring J, Rosen D. Getting into adolescent heads: An essential
update. Contemporary Pediatrics 2004;21(1):64-89.
|Table 2: Examples of positive questions that may be asked and negative questions that
are discouraged during a HEEADSSS assessment
||Ask questions more like
||Ask questions less like
||Where do you live and who lives there with you?
||Tell me about your mother and father?
||If the person’s situation does not conform to the question then they may be defensive
|Education or employment
||What are your favourite subjects at school?
||What marks are you getting at high school?
||Open-ended questions allow adolescents to present their own views
||What do you like and not like about your body?
||Do you think you are overweight?
||Issues of body image are often complex
||What do you and your friends enjoy doing?
||What sports do you play?
||Try not to restrict self-expression with narrow questions
||Have any of your friends experimented with tobacco, alcohol or other drugs?
||Do you take drugs?
||Asking about friends allows the adolescent to reveal information without implicating themselves
||Have you ever been involved in a romantic relationship? Describe the people that you have been “seeing”.
Have you ever had any unpleasant sexual experiences?
||Have you ever had sex?
||Asking about “having sex” is an ambiguous question and avoids wider issues such as
||Have you ever felt sad or down?
||Have you ever tried to kill yourself?
||These questions should focus on identifying thoughts or feelings that may lead to suicidal ideation
||Are there any people or situations which make you feel unsafe?
||Are you being bullied at school?
||Open-ended questions are more likely to uncover issues of concern
Thank you to Dr Sue Bagshaw, General Practitioner, President of the International Association of Adolescent
Health, Christchurch for expert guidance in developing this article.
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