Young people who attend specialist alcohol treatment: who are they and do they need special treatment?
Ms Devon Indig, National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052. Fax: (02) 9385 0222; e-mail: firstname.lastname@example.org
Objective: Patterns of drinking in adolescence and young adulthood may have major short term impacts and influences on later drinking, yet little is known about the characteristics of young people who seek help for alcohol problems. Here we examine the characteristics of treatment episodes for adolescents and young adults who present to specialist alcohol treatment in New South Wales (NSW).
Methods: The NSW Minimum Data Set for Alcohol and Other Drug Treatment Services was examined for all alcohol-related treatment episodes (N=21,012) reported between July 2004 and June 2005. We compared treatment episodes for adolescents aged 12-19 years, young adults aged 20-29 years and clients aged 30 years or more for their demographics, drug use and service delivery characteristics.
Results: Clients aged under 30 years were significantly more likely to be referred into specialist treatment by a police, court or criminal justice diversion program compared with older clients (adolescent: OR=3.7, 95%CI: 3.1-4.4; young adult: OR=2.2, 95%CI: 1.9-2.4). Concern about cannabis use was significantly higher among younger clients (adolescents: OR=2.8 95%CI: 2.3-3.3; young adults: OR=2.1, 95%CI: 2.0-2.4) than those aged 30 years or more. Younger clients were also more likely to be of Indigenous origin or seen in a rural setting.
Conclusions: Adolescent and young adult alcohol treatment clients include a higher proportion of clients who are Indigenous, legally coerced, and who have concerns with polydrug use. Service providers should seek to tailor their treatment programs to better meet these unique needs and to better attract young people into voluntary treatment.
Problem alcohol use among adolescents and young adults has been associated with a wide variety of mental health problems,1,2 injury,3 and sexual risk-taking.4 Early onset of problem drinking increases the risk of developing alcohol and other drug dependence.5–7
Previous studies have documented that adolescents and young adults rarely seek treatment for their alcohol use disorders.5,8,9 McLennan (1998) studied a large sample (N=3,395) of adolescents in order to determine the factors associated with their recognition that their alcohol consumption may be problematic.10 Most adolescents in the study who met the threshold for heavy drinking did not consider their alcohol use to be a problem. Of the 16% identified as heavy drinkers who did acknowledge a problem, the main factor in common was a higher rate of reporting of negative social consequences of drinking. Another possible reason for low treatment seeking among adolescents with alcohol problems is that they may not be sure where to turn for help.11
Alcohol treatment seeking populations are typically in their 40s and most research into treatment utilisation is focused on adults,12 with an occasional focus on ethnic13 or gender differences.14 Patterns of drinking in adolescence and young adulthood may have a major influence on later drinking, yet little is known about the characteristics of young people who seek help for alcohol problems or about their potentially differential treatment needs and concerns. In this study, we describe the client and service delivery characteristics of adolescent (12—19 years) and young adult (20—29 years) clients who present to specialist treatment for alcohol-related problems. Where appropriate, comparisons will be made with clients in treatment for alcohol problems who were aged over 30 years. The study hopes to better inform the development of age appropriate alcohol treatment services.
Sample and data collection
We examined the New South Wales (NSW) Minimum Data Set for Alcohol and Other Drug Treatment Services for closed treatment episodes reported between July 2004 and June 2005. This captures data on all clients who received publicly funded drug and alcohol treatment in New South Wales, Australia. The collection uses a closed treatment episode (rather than client) basis for enumeration. A closed treatment episode is defined as a period of contact, with a confirmed commencement and cessation date, between a client and a service provider. A treatment episode has the following key elements: it is delivered in one setting (e.g. inpatient or outpatient); it consists of only one main service provided (e.g. counseling); and it consists of only one principal drug of concern. Hence, a client may have more than one treatment episode (e.g. one for counseling and one for pharmacotherapy for alcohol dependence) open at the same time.
This study reviewed all closed treatment episodes (N=21,012) where clients nominated alcohol as their principal drug of concern. Among these episodes, N=4,613 (22%) were for clients aged 12 to 29 years, including N=747 for adolescents aged 12 to 19 years and N=3,866 for young adults aged 20 to 29 years. These treatment episodes represent N=4,126 unique clients aged 12 to 29 years, indicating just over 10% (N=4,126/4,613) of clients in this age group had more than one treatment episode at the same agency. A unique client was estimated based on a unique identifier at the agency level, which is certain to be an underestimation of the actual number of unique clients across NSW as a whole.
The collection includes measures of client demographics (age, sex, Indigenous status, country of birth, preferred language, living arrangement, source of income, usual accommodation), drug use (principal drug of concern, other drugs of concern, method of use for principal drug, injecting drug use) and service delivery (source of referral, main service provided, other services provided, number of service contacts, start date, end date, reason for cessation of treatment episode). The geographic location of the treatment provided was defined as metropolitan, regional and rural, based on the Area Health Service of the treatment agency. This may not always reflect where the client actually resides.
Statistical analysis was performed using SAS version 8.02.15 Descriptive analyses were conducted for alcohol-related treatment episodes for clients aged 12 to 19 years, 20 to 29 years, and 30 years or more. Statistical significance of differences were examined using t-tests for normally distributed continuous data and odds ratios with corresponding 95% confidence intervals for categorical data. Multivariate logistic regression was used to identify independent associations between demographic variables (age under 30, sex, Indigenous status), geographic location and dependent variables of interest (e.g. alcohol treatment episode, diversion into treatment, concerned about cannabis use).
The mean age for all alcohol treatment episodes was just over 40 years (mean=40.3 years, SD=12.8 years). Persons aged 12 to 29 years comprised 22% of the total number of alcohol treatment episodes, of which the majority (84%) were aged 20 to 29 years. Alcohol treatment episodes from adolescents and young adults were more likely to be male and of Indigenous origin than alcohol treatment episodes for people aged 30 years or more (Table 1).
Table 1. Characteristics of alcohol closed treatment episodes by age group, NSW 2004/2005.
|Country of birth: Australia||93.6||92.0||82.2|
|Partner and/or children||6.4||25.7||36.4|
|Other drugs of concern|
|No other drugs of concern||45.3||47.2||61.6|
|Source of referral|
|Previous treatment: Yes||39.2||54.5||64.5|
|Main service provided|
|Reason for cessation|
The majority of alcohol treatment episodes took place in regional or rural areas, with the highest proportion of regional or rural attendees among those aged 12 to 19 years (78%), followed by those aged 20 to 29 years (74%) and those aged 30 years or more (64%). In rural areas, one in four people with an alcohol treatment episode were of Indigenous origin, while in metropolitan areas, only one in twenty was Indigenous. Alcohol treatment episodes for Indigenous clients were significantly younger (mean age 34.2 years versus 40.8 years, p<0.001) than non-Indigenous clients.
Other drug use
Concern about cannabis use was significantly higher among alcohol treatment episodes for younger clients (both adolescents and young adults) than for those aged 30 years or more (see Table 2). This concern with cannabis use among alcohol treatment episodes was significantly higher among males and among Indigenous young adults than for treatment episodes with females or non-Indigenous alcohol clients in these age groups. Multivariate logistic regression confirmed that being younger, male, of Indigenous origin and living in a rural area were independently associated with being concerned with cannabis use.
Table 2. Characteristics of alcohol closed treatment episodes for clients aged <30 years compared with those aged 30+ years, NSW 2004/2005.
|Male||NS||NS||1.3 (1.2-1.4)||1.2 (1.1-1.3)|
|Indigenous||2.2 (1.8-2.7)||NS||2.0 (1.3-2.2)||1.4 (1.2-1.5)|
|Born in Australia||3.2 (2.4-4.3)||2.8 (2.0-3.8)||2.5 (2.2-2.8)||2.4 (2.1-2.8)|
|Rural||2.4 (2.1-2.8)||1.5 (1.3-1.8)||1.8 (1.7-1.9)||1.3 (1.2-1.4)|
|Concern with cannabis use||3.1 (2.7-3.7)||2.8 (2.3-3.3)||2.4 (2.2-2.6)||2.1 (2.0-2.4)|
|Diverted into treatment||4.9 (4.2-5.8)||3.7 (3.1-4.4)||2.8 (2.5-3.0)||2.2 (1.9-2.4)|
|Main service: counseling||1.4 (1.2-1.6)||1.4 (1.2-1.7)||1.3 (1.2-1.4)||1.3 (1.2-1.5)|
|Main service: assessment only||1.7 (1.4-2.0)||1.8 (1.4-2.2)||1.5 (1.3-1.6)||1.5 (1.4-1.7)|
|Left treatment||1.3 (1.1-1.5)||1.3 (1.1-1.6)||1.3 (1.2-1.4)||1.3 (1.2-1.5)|
Source of referral
Alcohol treatment episodes for clients aged under 30 years were significantly more likely to be referred into specialist treatment by a police, court or criminal justice diversion program compared with those aged 30 years or more. Diversion into alcohol treatment was significantly more common among males (adolescent: OR=5.4, 95% CI: 3.3-8.8; young adult: OR=3.0, 95% CI: P2.4-3.8) and clients of Indigenous origin (adolescent: OR=3.4, 95% CI: 2.3-5.1; young adult: OR=2.3, 95% CI: 1.9-2.8). Further, the proportion of alcohol treatment episodes who were referred into treatment by a diversion scheme increased nearly three-fold from metropolitan areas (10.9%) to rural areas (30.8%). When all of these variables (age under 30 years, male sex, Indigenous status and living in a rural area) are included in a logistic regression model, each remained an independently significant predictor of a higher likelihood of being referred via a diversion program.
Once in treatment, the most common service provided was counseling. Treatment episodes for young adult alcohol clients had a significantly shorter (88.6 versus 101.5 days, p<0.008) average duration in counseling and significantly fewer counseling service contacts (4.7 versus 5.7 contacts, p<0.001) than treatment episodes for alcohol clients aged 30 years or more. Treatment episodes for adolescent and young adult alcohol clients were significantly more likely to receive an assessment-only than were alcohol clients aged 30 years or more (adolescent: OR=1.7, 95% CI: 1.4-2.0; young adult: OR=1.5, 95% CI: 1.3-1.6). Among treatment episodes for young adult alcohol clients, having received only an assessment was more common among those who attended through a diversion program (OR=1.9, 95% CI: 1.6-2.3) or who were of Indigenous origin (OR=1.6, 95% CI: 1.3-2.0). The provision of pharmacotherapies for alcohol dependence such as naltrexone and acamprosate was very uncommon among treatment episodes, recorded in only 0.4% of all alcohol treatment episodes and largely (90%) provided to clients aged 30 years or more.
Regardless of main service provided, treatment episodes for female clients had, on average, at least one more service contact than male clients (adolescent: 5.2 versus 2.9 contacts, p<0.009; young adult: 4.0 versus 3.0 contacts, p<0.001) and had significantly longer treatment duration than males in the same age group (young adult: 56.1 versus 46.4 days, p<0.008). Treatment episodes for Indigenous and non-Indigenous clients under age 30 years had identical completion (60.5%) and subsequent referral rates (46%). Completion of the treatment episode among young adult alcohol clients was higher in regional and rural areas (63%), than in metropolitan areas (55%), independent of their participation in a diversion program. Treatment episodes for alcohol clients under age 30 years from rural areas also reported the best retention in treatment, with nearly 40% engaged in treatment longer than one month. By comparison, only 25% of treatment episodes for metropolitan alcohol clients remained in treatment for this length of time.
Nearly one quarter (24.6%) of treatment episodes for both adolescent and young adult alcohol clients left treatment before it was completed, compared with one-fifth (20.1%) of those aged over 30 years. This difference was statistically significant (adolescents: OR=1.3, 95% CI: 1.1-1.5; young adults: OR=1.3, 95% CI: 1.2-1.4). There were no significant differences in treatment completion rates by sex or Indigenous status.
Alcohol problems are far more common than other drug problems among young Australians, and across all age groups, treatment for alcohol-related concerns is more common than treatment for other drugs in Australia.16–18 Despite the significantly higher burden of alcohol-related morbidity and mortality, only 25% of treatment episodes for clients under 30 years of age who attended specialist drug and alcohol treatment presented with alcohol as their principal drug of concern. Many young at-risk drinkers do not perceive a need for treatment.11,19 In this sample over one-fifth of treatment episodes for young adult clients were referred into alcohol treatment by the police, courts or other criminal justice services, rather than seeking help. More training is needed for healthcare providers to better identify alcohol problems and provide appropriate referrals to adolescent and young adult at-risk drinkers and also to support clinicians in managing legally-coerced clients. Ongoing liaison is needed with the criminal justice system to ensure those clients ordered to receive compulsory treatment are being referred to the most appropriate service. Further, there is a need to inform young people in Australia about available alcohol treatment options.
Proportionally, participation in alcohol-related treatment by clients aged under 30 years is highest in rural areas. This has significant resource implications for the distribution of services across the state. Further, treatment episodes for alcohol clients under 30 years from rural areas reported the longest duration in treatment, with nearly 40% engaged in treatment longer than one month compared to only 25% in metropolitan areas. This result contrasts with other reports of greater barriers to treatment for rural at-risk drinkers.20–22 Some possible explanations for this higher retention may be that clients in rural areas have more severe problems or that they are better able to develop a relationship with service providers in their community. More research needs to be undertaken to explore why retention in treatment for young adult alcohol clients is greater in rural areas in order to potentially improve services across the state.
Indigenous Australians are over-represented (16%) among adolescents and young adult alcohol clients. By comparison, the 2001 Australian Bureau of Statistics Census reports that 2.6% of the NSW population aged 10 to 29 years is of Indigenous origin.23 Previous research has shown that while Indigenous Australians are less likely than non-Indigenous Australians to consume alcohol, those who do are more likely to drink at high risk levels.24 Indigenous clients represent nearly one in four alcohol treatment episodes for clients aged under 30 years in mainstream services in rural areas. Young Indigenous people are more than twice as likely to be diverted into alcohol treatment from the criminal justices system as are non-Indigenous persons, yet completion rates and treatment duration are not significantly different. This higher rate of treatment participation may reflect different patterns of arrest, sentencing and referral in the community. These figures do not include Indigenous clients who may seek treatment for their alcohol problems through Aboriginal controlled health services or other services.25 However, as the majority of the specialist alcohol treatment services in rural areas are run by the government, efforts need to be made to ensure services are appropriate for young Indigenous clients and to encourage early and voluntary entry into treatment.
The most common services provided to clients concerned about their alcohol use are counselling or assessment-only. The finding of significantly more assessment-only treatment episodes among young clients, particularly Indigenous and diverted clients, is concerning. Having an assessment-only may indicate no further treatment was accepted or needed, or it may indicate that a new treatment episode was created at a different agency (e.g. a detoxification unit) after the client was assessed. However, it may also reflect a difficulty engaging a client into treatment. Further research is needed to understand the reasons for these assessment-only episodes, including whether these young alcohol clients are being appropriately diverted or referred into treatment.
This study suggests that the use of pharmacotherapies such as naltrexone or acamprosate for alcohol dependence is rare across all age groups, as documented in previous studies.26 While these figures may be influenced by incomplete recording of pharmacotherapy use, the likely under-utilisation of these pharmacotherapies, and the reason for this, needs further exploration.
Many clients aged under 30 years who identify alcohol as their principal drug of concern indicate they were also concerned with their cannabis use, particularly males and clients of Indigenous origin. It is important that treatment providers ensure that treatment can deal with the client's health concerns holistically. Therefore, integrating smoking cessation programs for both tobacco and cannabis would be likely to be beneficial for younger adult clients who present to treatment for their alcohol use.
There were a number of limitations to this study. First, the data collection is based on treatment episodes, not individual clients. The only client-unique identifier is kept at the agency level, so it is only possible to determine individual client characteristics at this local level. As only 10% of treatment episodes for alcohol clients at the agency level were for repeat attendances, it is reasonable to present these statewide figures using treatment episodes to describe the population. Second, there were no treatment outcome measures in the data collection. Third, the collection is based on the substance that the client identifies as his or her principal drug of concern and may not accurately reflect the prevalence of alcohol problems in the context of polydrug use in this sample. Fourth, as the data recording is done by clinicians, it is possible that some episodes of treatment are not documented when their clinical load is high. Finally, this data collection does not include individuals who seek support for their alcohol-related problems from their general practitioner, hospital or community-based agencies,27 so may be an underestimate of all alcohol-related treatment. Despite these limitations, the NSW Minimum Dataset for Alcohol and Other Drug Treatment Services is a valuable data collection to identify client and service delivery characteristics of people presenting to specialist drug and alcohol treatment.
This study has identified that treatment episodes for alcohol clients under 30 years of age were disproportionately diverted into treatment by the criminal justice system. They were also more likely to be seen in a rural setting, be of Indigenous origin and to also be concerned with their cannabis use. Service providers should seek to tailor their treatment programs to better meet these unique client needs and to be better able to attract young people to voluntary treatment.
This study was funded by the Centre for Drug and Alcohol, NSW Department of Health.