This book is my way of sharing two decades of experience in helping people with drug problems. Using the latest science on how drugs work in the brain, I have tried to show their attraction as well as the problems they cause. Drug use peaks in adolescence, just at the time when the developing brain is uniquely vulnerable to their harmful effects.
For parents with children who are not using drugs, I hope the advice in this book will help stop problems developing. Having the drug conversation with your child before they are exposed to drugs will allow you to return to the topic if needed, without your child fearing that you are unable or unwilling to discuss it. They may then come to you earlier and be more honest about drugs, giving you a better chance of helping.
For parents with children who are experiencing drug problems, I hope this book has provided useful advice and either reassured you that you are doing the right things or helped you see a new path. There are no easy solutions and no simple right or wrong approaches. Much will depend on your relationship with your child and working as a team with family and friends.
I will finish with the key messages that, in my experience, parents have found helpful.
Preventing drug use
Try to have a knowledgeable, open conversation about drugs before your child is exposed to them or people using them.
Provide accurate information
Make sure your child knows where to get reliable information and is aware of any specific vulnerabilities they have to drugs, such as family history.
Your child will almost certainly be offered drugs at some point and may or may not try them. Adolescence is a difficult period, during which huge physical, psychological and social changes take place. Be vigilant for changes that might suggest that your child is coming into contact with drugs, for example changes in peer groups or academic performance.
Managing drug use
Is there a problem?
If you think your child is using drugs, try to establish what is really going on. This will almost certainly involve you speaking to them and perhaps others.
Do you remember your adolescence? Was it a period of gentle, steady maturing or a storm of intense, confusing emotions? For many people it will have been a mixture. What about your own children? Most parents notice changes as their children progress through adolescence. They might become uncharacteristically irritable, over-sleep or break previously accepted rules of behaviour. Out go cuddles, ‘please’ and ‘thank you’, replaced by complaints and criticism. This dramatic change is less surprising when we understand that adolescence is a period of massive physical and mental change.
Imagine how it feels for the adolescent. They suddenly find themselves having to cope with intense new emotions, a rapidly changing body and impulses and drives that are confusing and often contradictory. Without a guidebook or instruction manual, they manage by relying on trial and error. Just when they most need the stability and guidance of those around them, their peers are going through the same thing and their parents are missing their sweet, obedient pre-adolescent child. It is perhaps unsurprising, in this roller coaster of change, when the adolescent angrily tells their parents ‘you just don't understand!’
In this chapter, we will focus on the impact of drug use during adolescence. As we will see later, the adolescent brain is especially vulnerable to the harmful effects of drugs, just at the time when drug use is most likely. But why are adolescents at such a high risk of experimenting with drugs and so susceptible to their harmful effects? Before we answer these questions, let's first try to understand what is going on in the young brain.
What is adolescence?
Some have argued that adolescence is not a specific developmental stage but instead an invention of marketing executives looking to sell their products and extract money from parents. Music, fashion, literature and food have all been aimed with increasing precision at the teen market. Most parents will recognise the plea for the latest must-have electronic device or branded clothing, without which social exclusion and humiliation are certain.
When it comes to drugs, the marketing strategies are surprisingly similar. In the legal market, alcopops (alcoholic drinks with added flavours and packaging to appeal to younger drinkers) have been heavily marketed to young people. This strategy is mimicked by ‘head shops’ and online sites, which market so-called ‘legal highs’ using brightly coloured labels and cartoons to attract younger users.
To have a meaningful conversation with your child about drugs, you need to be confident that you have enough information about the different drugs, how they're used, what effects they cause and the risks they carry. This chapter will focus on the key knowledge you need in order to plan the drug conversation.
Psychoactive drugs cause their dramatic effects by influencing the messaging between nerves in the brain. Different drugs work through different receptors to cause particular effects on feelings and behaviours. A strong cup of coffee makes us feel alert and energised, whereas too much alcohol makes us feel sleepy and tired. This is because caffeine works by stimulating the brain, whereas alcohol causes sedation. Knowing the types of drugs is important, because it helps us understand the risks associated with them.
You will have heard of some drugs, for example heroin, cocaine or cannabis. But in addition to these well-known drugs, there are hundreds of more obscure drugs available, sometimes better known by their brand names.
Psychoactive drugs can be broadly classified into four groups according to their primary effect:
In most cases, the name of a drug gives away little about its probable effects when consumed. Some drugs have more than one effect (Fig. 5.1) or different effects at certain doses. For example, ecstasy (MDMA) has both stimulant and hallucinogenic properties, while ketamine can cause euphoria at lower doses but is sedating at higher doses. Box 5.1 shows the most common drugs within each group.
• Psychoactive drugs can be divided into four broad groups according to their effect.
• Stimulants, such as cocaine, cause euphoria and alertness.
• Sedatives, such as cannabis, cause relaxation and calm.
• Hallucinogens, such as LSD, cause hallucinations.
• Dissociatives, such as ketamine, cause ‘out-of-body’ experiences.
What are stimulant drugs?
As the name suggests, stimulant drugs cause a person to feel alert and energetic, increase concentration and reduce fatigue. Stimulants can also produce powerful feelings of euphoria and well-being. As well as their psychoactive effects, stimulants can produce powerful physical effects, such as a racing heart rate, increased blood pressure and a reduced need to sleep and eat.
So far, this book has focused on the problems different drugs cause. It is now time to look at how to tackle these problems. This chapter will look at what treatments are available, how well they work and what you and your child can expect from your treating team.
A challenging fact about drug problems is that, unlike most other health problems, not everyone who needs help, wants it. Knowing that you have a problem and wanting to recover is sometimes called having insight into the condition. People with drug problems sometimes have poor insight into their problems and need for help. This can make things very difficult for worried relatives and concerned clinicians.
Some people want treatment, others don't
Many people who come to my clinic are suffering terribly from the effects of using drugs and are desperate to stop, but struggling to do this. They ask for my help to stop the drug use and get their lives back on track. Motivated to change, they work hard to get better and tend to do well in treatment.
But not everyone wants treatment, or even accepts there is anything wrong. Young people are sometimes dragged to see me by their worried parents. They don't think they have a problem, don't want to make any changes to their drug use and are usually very clear that I'm wasting my time.
In my experience, it is very difficult to help someone who does not wish to change. The treatment of drug problems is very much a collaborative effort between the patient and their treating team, with relatives often very involved. If there is no cooperation, helping someone can be tough, and I find it particularly upsetting to see people deteriorate when treatment could help. However, there is usually little point in trying to strong-arm into treatment someone who doesn't want help at that moment. A better approach is often to help them reduce their current risks as much as possible and keep gently explaining that treatment might help – if only they would agree to try it. Circumstances can change rapidly and as harms develop, so can the realisation that things can't go on as they are. Sometimes, keeping the door open and waiting is a better option than trying to push someone through it when they have dug in their heels.
To understand why people use psychoactive drugs, we need to understand how they cause their powerful effects. We will now turn our attention to how drugs work in the brain.
Drugs can change a person's mood (e.g. causing euphoria), cognition (ability to think logically), level of consciousness (from very alert to very drowsy) and behaviour (act out of character). These effects are usually the reason people take the drug in the first place. The experience of ‘getting high’, ‘getting stoned’ or ‘tripping’ is caused by changes in the chemical systems of the brain.
Psychoactive drugs can act in several ways.
• Stimulants make you feel excited and alert.
• Sedatives make you feel calm and relaxed.
• Hallucinogens distort how you see, hear and feel things.
• Dissociatives change your sense of yourself and your body.
Before we look at these effects, let's talk about how the brain works without drugs.
A quick tour of the brain
The brain is our most complex organ and is the body's command centre. It is divided into different sections, or lobes, which focus on particular activities.
The occipital lobes, at the rear of the brain, are involved with vision. Parts of the temporal lobes, which are at the sides of the brain, process sound, and the parietal lobes, at the top of the brain, are largely responsible for integrating sensory information relating to taste and touch. Perhaps the most important are the frontal lobes, which, as the name suggests, are located at the front of the brain directly above our eyeballs.
The frontal lobes are responsible for, among other things, decision-making. This is where we balance the pros and cons of a particular action and decide if it is a good idea or not. None of the lobes work alone. Instead, they are joined by a complex network of nerves that reaches across the brain. This network helps the brain communicate information at high speed, making it very efficient.
How the brain ‘thinks’
The building blocks of this network are nerve cells called neurons. The adult human brain is thought to have between 80 and 100 billion of them. Neurons consist of a main cell body and a long, slender extension known as an axon (Fig. 4.1).
Legal highs, club drugs, research chemicals and novel psychoactive substances
The past 40 years has seen the manufacture of a large number of synthetic drugs intended for recreational use. Labelled variously designer drugs, legal highs, club drugs, research chemicals and novel psychoactive substances, they have two things in common. First, they attempt to mimic the effects of ‘traditional’ drugs, such as cocaine and cannabis. Second, they are produced specifically for recreational purposes, with no intention on the part of the manufacturers to give any medical benefits. They are, essentially, drugs for fun.
Some of these synthetic drugs were developed by pharmaceutical companies, but discarded because their psychoactive effects were too powerful or other side-effects were considered too severe. In other cases, new synthetic psychoactive drugs are manufactured by modifying the chemical structure of existing drugs, in an attempt to make new and more powerful versions. For example, amphetamine, a stimulant drug, has been chemically modified to produce hundreds of similar drugs.
New synthetic drugs have been developed to mimic all the psychoactive drug effects a user could wish for, including synthetic stimulants, synthetic sedatives, synthetic hallucinogens and synthetic cannabis. There has never been a wider choice of drugs available to users. Many of these new variations fall outside existing drug control legislation and because of this are technically legal.
The rise of the synthetics
The past decade in particular has seen an extraordinary rise in the production and distribution of synthetic psychoactive drugs. Globally, 95 countries or territories have detected 541 new psychoactive substances since 2008 (United Nations Office on Drugs and Crime, 2013). There has been a huge increase in the number of new substances available for sale on European drug markets. Since 2008, that number has increased every year, with 101 new substances detected in 2014 alone (European Monitoring Centre for Drugs and Drug Addiction, 2015; Fig. 6.1).
One of the problems with the new synthetic drugs is that their effects can be much more powerful and unpredictable than the drugs they are trying to mimic. For example, some synthetic cannabinoids produce much stronger effects than natural cannabis. As the strength increases, so does the potential for harm, leading to problems such as rapid intoxication, abnormal heartbeat, psychosis and dependence syndrome.
What are psychoactive drugs?
A psychoactive drug is a chemical substance that alters the functioning of the brain, causing changes in the way we think, feel and behave. All drugs can be divided into those that have psychoactive effects and those that don't. Most drugs, for example medications like antibiotics, are not psychoactive. Antibiotics treat infections but they don't change our emotions.
Psychoactive drugs can be stimulating, sedating, cause hallucinations or produce an out-of-body state called dissociation. Some psychoactive drugs can cause more than one of these effects.
How much of a problem are psychoactive drugs?
Before we talk more about psychoactive drugs and the problems they can cause, let's look at how commonly they are used. The United Nations Office on Drugs and Crime (2014) estimates that around one person in twenty of the world's population between 15 and 64 years of age has used an illicit psychoactive drug in the past year. That's around 250 million people. Of these people, about one in ten experience problems with their drug use. The same report estimates that, globally, 183 000 people a year die from drug-related causes: about 40 people per million.
The UK government conducts an annual survey estimating drug misuse in England and Wales (Home Office, 2014). It shows that around one in three adults have taken an illicit drug at some point during their lives, and about one in twelve have used drugs in the past year. As with all surveys, some people will not tell the truth, inflating or reducing the estimates, but a yearly survey does give an indication of changes in patterns of drug use over time. The survey results suggest that the past decade has seen a gradual reduction in the number of people using drugs, and this seems to be true for all age groups.
While heroin use seems to be declining in the general population and in young people in particular, other drugs seem to be gaining popularity: cannabis and the so-called legal highs. Most newer drugs are not accurately recorded in surveys, so their use is likely to be underestimated. Chapter 6 discusses them in more detail.
Chapter 3 looked at how you might talk to your child about drugs before they come into contact with them. But what if you think your child is actually using drugs?
How parents react to finding out their child is using drugs depends on the situation. There is a big difference between a child who experiments once or twice with cannabis before deciding it is not for them and a child who uses cocaine heavily, leading to major health problems. What is the best approach to take? Should you gently engage or directly confront them?
There is very little research in this area to draw on. Situations and families are so different that there is no guaranteed ‘best’ approach. The following suggestions are based on what has worked for the families I've encountered over my years in clinical practice.
What is normal adolescent behaviour?
Adolescence is a time of huge physical and psychological change. Many of these changes can confuse and worry parents. In most cases, the things parents see are completely normal parts of the process of growing up. However, a complication is that many of the normal signs of adolescence can mimic the signs of harmful drug use. Telling the difference can be virtually impossible without further information. Table 7.1 shows some of the overlap between the changes typical for puberty and the signs of drug use.
Given this overlap, how can you tell what's normal and what isn't? If your previously delightful and obedient child turns into a moody, irritable and withdrawn adolescent, should you assume it's because of hormones, or should you wonder whether they are using drugs?
How to tell whether your child is using drugs
Most parents assume their children don't use drugs, and most children don't. However, UK statistics from 2013–2014 suggest that about a third of people between 16 and 24 years of age have taken an illicit drug at some point, equivalent to around 2.2 million young adults (Home Office, 2014).
If your child uses a drug once or twice at a party and then stops, you will probably never know, unless they decide to tell you or experience a bad reaction. If, on the other hand, your child starts to use regularly, you will probably start to notice changes in the way they look and behave.
National Institute for Health and Care Excellence
www.nice.org.uk Offers a range of guidance for medical professionalson drug and alcohol problems
Talk to Frank
www.talktofrank.com Government drug-information website for England and Wales
Know the Score
http://knowthescore.info Government drug-information website for Scotland
National Institute on Drug Abuse
www.drugabuse.gov Government drug-information website for the USA
www.drugscience.org.uk Independent drug-information website
www.crew2000.org.uk Independent drug-information website for Scotland
www.angelusfoundation.com Independent website about ‘legal highs’ for adolescents
www.alcoholconcern.org.uk Independent alcohol-information website for the UK
www.neptune-clinical-guidance.co.uk Independent website with guidance for clinicians on club drugs
Support for families
Royal College of Psychiatrists, Faculty of Addictions Psychiatry
British Psychological Society, DCP Faculty of Addictions
British Association of Social Workers, Alcohol and Other Drugs Special Interest Group
Good information is critical in decision-making. If you don't have the right information, how can you weigh up the risks and benefits of different choices? The challenge for parents is not just to provide the correct information, but to do so in a way that your child will pay attention to it.
For some parents, talking to their child about drugs is relatively easy, but for others it's awkward and embarrassing. It is a good idea to start talking to children about drugs before they come into contact with them or people who are using them. Having the right information early on will help them weigh up the risks and might stop them from even trying drugs. If they do choose to use drugs, good-quality information may help them reduce the risk.
Just as importantly, by talking with your child about drugs, you help them understand that this is a topic you know something about and you're happy to talk about, and that you might even be a source of good advice if problems arise.
Do I really need to talk to my child about drugs? Won't the school do it?
Many schools provide information to children about drugs, either from people within the school or by bringing in outside speakers. However, there are no specific requirements for UK schools to deliver a particular programme. Instead schools are given the flexibility to tailor their local personal, social, health and economic (PSHE) education programmes to reflect the needs of their students. Government guidance states that schools should ‘use their PSHE education programme to equip pupils with a sound understanding of risk and with the knowledge and skills necessary to make safe and informed decisions’ (Department for Education, 2013). Although the PSHE curriculum suggests covering the topic of drugs, schools do not have to. Drug education is a required part of the science curriculum, which begins in Year 6 (when students are 10 or 11 years of age).
Unfortunately, it is not clear which is the best way to teach children about drugs. Research suggests that teaching all children about drugs may not be the most effective approach (Faggiano et al, 2014).
‘Mind your own business. What I do is up to me. You always go on about drugs being bad, but what do you know? You told me you've never taken any, right? So how do you know what's what? You don't know anything!’ – a 15-year-old's response to being asked by his mother if he is taking drugs.
I'm sitting with Harry, a bright, articulate 15-year-old who attends a well-known school in London. Harry's parents are here too, looking anxious and frustrated. This is my second meeting with Harry and he is here because he uses drugs. He mostly uses cannabis but also occasionally ecstasy and, on one occasion, he has taken cocaine. To Harry's dismay, one of his friends told a teacher that they were worried about him. The head teacher called Harry and his parents to a meeting to discuss his progress and reported drug use.
Harry doesn't think his drug use is a problem, claiming that all of his friends smoke a joint (of cannabis) ‘now and then’ and that he uses less than some. Despite recently falling grades, Harry knows he is bright and wants to go to university to study journalism, something he has wanted to do for as long as he can remember. He seems relaxed, even confident, as he talks to me about how cannabis helps control his anxiety, improves his sleep and makes him feel relaxed and ‘part of the crowd’. He can't imagine a life without drugs.
Harry's parents, on the other hand, are horrified. They can hardly bring themselves to believe that Harry is using drugs and blame his friends for introducing him to them. They think he has fallen in with a ‘bad lot’ and is putting his promising future at risk. At today's meeting, they ask Harry to stop using drugs immediately, threaten to ban him from seeing his friends and insist that he is drug-tested every week. They become frustrated and angry when he says that they are overreacting and accuses them of being out of touch and ignorant about drugs.
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