Journal of Prescribing Practice - A–Z of prescribing for children (14)

Abstract

This series focuses on aspects of prescribing for neonates, children and young people, from A–Z. Aspects of pharmacokinetics will be considered, alongside legal considerations, consent and medications in schools

R – Recreational drug use

The Misuse of Drugs Act (1971) aims to prevent the misuse of controlled drugs by banning their possession, supply, manufacture, importation and exportation, unless with a particular licence. Often, it is presented as a list of prohibited drugs between three ‘classes’ (A, B and C), alongside the range of penalties according to the particular offence. Having a knowledge of current classifications and ‘street’ names of illicit drugs is vital, and an understanding of such drugs is needed during history-taking.

A recent survey in secondary school pupils (NHS, 2024) demonstrated that 13% of pupils had taken illicit drugs, a fall in prevalence since 2021 when it was 18%. The survey also explored aspects of young people's wellbeing, focusing on loneliness: 10% of students reported that they have felt lonely, with 18% feeling they had no-one to talk to, and 15% of students feeling ‘left out’. Whether or not there is a link between feelings of loneliness and illicit drug use has not been explored clearly. However, recreational drug use can be a significant source of status among young people, facilitating a shared sense of belonging and confirmation of group identity (Fletcher et al, 2010).

Different illicit drugs are consumed for other reasons: cannabis and alcohol have been reported to be for relaxation, whereas amphetamines, ecstasy and cocaine are for enhancing an activity (such as ‘clubbing’) or keeping awake at night, alongside the use of LSD or hallucinogenic mushrooms for other activity enhancements, such as listening to music (Boys et al, 2001). Thorough history-taking with a young person in mind needs to explore aspects of socialisation and the potential for drug use in young people, and the SSHADESS screening tool (Ginsburg, 2014) can identify at-risk behaviours (see Table 1).

Table 1. SSHADESS screening tool

S	Strengths	What do you like doing? How would you describe yourself? Tell me what you're most proud of How would your best friends describe you?
S	School	What do you enjoy most about school? Least? How many days have you missed or had to be excused early or arrived late to school? How are your grades? Do you feel like you are doing your best at school? (If no) Why not? What's getting in the way? Do you feel safe on the way to school and in school? What would you like to do when you get older?
H	Home	Who do you live with? Any changes in your family? Could you talk with anyone in your family if you were stressed? Who would you go to first?
A	Activities	Are your friends treating you well? Do you have a best friend or adult you can trust outside your family? Are you still involved in the activities you were doing last year? What kind of things do you do just for fun? Are you spending as much time with your friends as you used to?
D	Drugs/substance abuse	Do any of your friends talk about smoking cigarettes, vaping, taking drugs, or drinking alcohol? Do you smoke cigarettes? Drink alcohol? Have you tried sniffing glue, smoking weed, vaping, or using pills or other drugs? If and when you smoke, drink, or get high, how does it make you feel or what does it do for you?
E	Emotions/eating/depression	Have you been feeling stressed? Do people get on your nerves more than they used to? Are you feeling more bored than usual? Do you feel nervous a lot? Have you been having trouble sleeping lately? (If yes) What kind of trouble? Would you describe yourself as a healthy eater? Have you been trying to gain or lose weight? Have you been feeling down, sad, or depressed? Have you thought of hurting yourself or someone else? Have you ever tried to hurt yourself?
S	Sexuality	Are you attracted to anyone? (using gender-neutral language) Are you comfortable with your sexual feelings? Are you attracted to guys, girls, both, or neither? Have you ever had sexual intercourse? What kind of steps do you take to protect yourself? Have you ever been worried that you could be pregnant? Have you ever been worried about or had a sexually transmitted infection?
S	Safety	Are there a lot of fights at your school? Do you feel safe at school? Is there bullying? Have you been bullied? Do you carry weapons? Does anyone at your school? What kind of things makes you mad enough to fight? Has anyone ever touched you physically or sexually when you didn't want them to? Does your boyfriend, girlfriend, or partner get jealous? Do you ever get into fights with your boyfriend, girlfriend, or partner? Physical fights? Have you ever seen people in your family or home hurt each other? Say mean things? Throw things or hit each other?

(Ginsburg, 2014)

“Several routine psychiatric medications can cause severe reactions if taken with illicit drugs; for example, antipsychotics for schizophrenia, bipolar disorders, personality disorders, or severe depression taken with amphetamines can reduce the effects of both drugs”

However, misuse of prescription drugs can also be classified under the ‘drug misuse’ umbrella, which is why prescribers should ask if their patient has sourced any of their medication online or from friends or family. This can be linked to illicit drug use, where it has been identified that up to 90% of prescription drug misusers have also consumed illicit drugs in a sample of nightclubbers (Kelly et al, 2014). Further positive correlations have been made comparing the use of prescription painkillers, analgesics and sedatives, as well as non-prescription and over-the-counter sleeping pills, to the use of marijuana, or crack cocaine use (Fleary et al, 2013).

Finally, consideration needs to be given to the potential contraindications and side effects of illicit drugs and prescribed drugs. Interactions between these two classes of drugs may have the ability to increase the power, or reduce the effect of either the illicit drug, the prescribed drug, or even both (Lindsey et al, 2012), which can result in unwanted toxic effects or not achieving the desired therapeutic activity. This is due to changes in the particular expression and/or activity of drug metabolising enzymes and drug transporters, particularly in cannabis, cocaine or methylenedioxymethamphetamine (MDMA – such as ecstasy) (Abbott et al, 2020). In particular, several routine psychiatric medications can cause severe reactions if taken with illicit drugs; for example, antipsychotics for schizophrenia, bipolar disorders, personality disorders, or severe depression, taken with amphetamines can reduce the effects of both drugs. Lithium used as a mood stabiliser, taken with ecstasy or alcohol, can cause dehydration, resulting in toxic lithium levels. Citalopram, a selective serotonin reuptake inhibitor (SSRI), taken with cocaine, can cause hypertension and increase the risk of haemorrhage, particularly in the brain (MIND, 2022).

It is clear that illicit drug use harbours dangers for any individual, but particularly in young people, who may not even be physiologically mature, with an impact on pharmacokinetic properties. They are also less risk adverse, with little regard for potentially damaging consequences. Thorough history-taking is vital and must include all aspects of medications, as well as considerations of psychosocial aspects.

Next in the series will be: S – School.