Preventing substance-related harms among Canadian youth through action within school communities: A policy paper

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Public Health Agency of Canada

Date published: 2021-08-13

Cat.: HP10-38/2021F-PDF

ISBN: 978-0-660-40123-2

Pub.: 210272

August 2021

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Introduction

Recent years have seen unprecedented political and public attention on substance use among youthFootnote 1. In Canada, the legalization of non-medical cannabis use, rising numbers of opioid-related deaths and increases in the use of vaping products among youth are some of the factors that have led to the emergence of substance use as a priority concern.

Canada's Chief Public Health Officer (CPHO) put a spotlight on youth substance use through her 2018 report Preventing Problematic Substance Use in Youth. The report highlights why youth are a priority population for prevention efforts, and represents a call to action for new and better ways of addressing youth substance use, including by leveraging the strengths and reach of school communities.

Who this paper is for

The intended audience for this policy paper is Canadian school communities. This includes:

  • those working within the education system (for example, administrators, teachers, guidance counsellors, health professionals who work in schools, among others)
  • community organizations that support youth
  • planning and decision-makers within the education sector (for example, school boards and districts, school health organizations, government organizations)

Why and how this paper was developed

This policy paper describes issues related to youth substance use from a public health perspective and aims to inform action to prevent substance-related harms through school communities.

The need for clarity on topics related to youth substance use was raised during School Matters: Building a Blueprint for Action for School Communities to Help Prevent Substance Use Harms, a national forum that took place in February 2020. See Box 1 for more detail on the forum.

Box 1. A spotlight on the School Matters Forum

The School Matters Forum was hosted by the Public Health Agency of Canada (PHAC), in partnership with the Canadian Centre on Substance Use and Addiction, the Canadian Students for Sensible Drug Policy and the Joint Consortium for School Health. It brought together over 50 stakeholders from across Canada to inform the development of an evidence-based resource, Blueprint for Action: Preventing substance-related harms among youth through a Comprehensive School Health approach. Forum participants represented students and youth, teachers, administrators, public health organizations, people with lived and living experience of substance use, school health organizations, researchers, community organizations, Indigenous organizations, parents/families and government organizations.

The forum focused primarily on secondary school contexts, although many forum participants underscored the need for complementary interventionsFootnote 2 at other school levels. Participants also indicated that the objectives and principles identified in this paper are likely relevant to other audiences and sectors outside of education.

Participants described innovative initiatives underway within school communities across the country designed to promote students' health and well-being and prevent substance-related harms. However, they signalled the need for broader-scale change in how youth substance use is addressed within the education system. Participants emphasized that moving forward effectively towards this reform requires a shared understanding of goals and objectives related to youth substance use.

There are various perspectives on youth substance use, which has implications for how youth substance use is being addressed. Some individuals and institutions oppose any substance use among youth, while others take approaches that focus on reducing substance-related harms. The complexity of substance-related harms is not fully appreciated when we observe and measure substance use among youth and label these behaviours as good or bad. As one forum participant expressed, "we know that simplistic, binary thinking is damaging and inaccurate in many domains; the same is true for youth substance use."

This paper highlights some of these nuanced perspectives and suggests a path forward for the education sector.  It also provides context to inform research and interventions, and support greater alignment with public health objectives.

While this policy paper stems from discussions at the School Matters Forum, it also reflects PHAC's work related to youth substance use and key themes from the CPHO's 2018 report. School Matters Forum participants and other key stakeholders were invited to share their input on draft versions of the paper. Although the forum took place before COVID-19 reached Canada, consultations with forum participants took place virtually in early summer 2020, in the midst of the pandemic. Many participants indicated that the pandemic's significant impacts on both the education system and students' and families' health and well-being reinforce the timeliness and relevance of this paper. We are grateful to School Matters Forum participants for their contributions to this work.

Defining the problem

Substance use is associated with a range of potential harms. They range in severity and include:

  • mental health problems
  • family and interpersonal violence
  • fatal and non-fatal overdoses or drug poisonings
  • memory and learning impairments
  • substance use disorders
  • other health conditions (for example, heart disease, stroke, sexually transmitted and blood borne infections, liver disease, brain injury, cancer)
  • motor vehicle accidents
  • intentional and unintentional self-harm and suicide

Substance-related harms are associated with significant social and economic costs in Canada, as well as personal costs to youth and their families who lack supports to help prevent or mitigate these harms.

Relative to adults, youth are more vulnerable to substance-related harms for a variety of reasons. For example, youth are typically physically smaller than adults, which can impact the amount of substances that their bodies can handle. Further, substance use before or during sensitive periods in brain development can affect brain structure and volume, with negative effects on higher brain function and impulse control. This is in part why adolescence is a critical at-risk period for substance use disorders. In addition, adolescence and young adulthood is a time of major social and emotional development; regular substance use during these years can truncate this learning. The earlier and more frequent the exposure to substances, the greater the risk of these harms.

When confronted with substance-related harms, there is an inclination to attribute substance use itself as the central problem. This is particularly the case when these harms affect youth. However, as participants emphasized throughout the School Matters Forum, there are a number of issues with characterizing substance use itself as the core issue.

How risks posed by substance use can vary

Substance use among youth is often viewed as inherently problematic. While adolescents are developmentally at a heightened risk of harm if they engage in regular, ongoing substance use, many youth use substances without causing significant or long-lasting harm to their health or well-being or that of others. While completely avoiding substance use is the only way to fully prevent the potential social and health risks of substance use, there is evidence that substance-related harms vary.

Substance use experts assert that substance use exists along a spectrum, ranging from beneficial use to use that contributes to significant harms. School Matters Forum participants highlighted the importance of acknowledging the benefits that some youth attribute to their substance use (for example, therapeutic and social benefits). While the latter end of the substance use spectrum warrants close attention and action, there are efforts that can help prevent substance-related harms at every part of the spectrum.

Social and structural factors influence substance-related harms. For example, the "alcohol harm paradox" demonstrates that those with the lowest incomes report less heavy drinking but are more than twice as likely to be hospitalized for conditions entirely caused by alcohol, compared to those with the highest incomes. Researchers attribute these differences to greater stress, limited social support and poorer overall health among those living in poverty. This paradox illustrates that comparable substance use behaviour can produce varying degrees of harm across individuals. In addition to broader social and protective factors, a person's likelihood of experiencing substance-related harms is moderated by their access to and use of harm reduction supports and strategies.

Some of the discourse around youth substance use centres on individual-level deficits, portraying youth as reckless, unmotivated and in some cases, criminal. This narrow framing can fuel stigma targeting youth who use substances.

These perspectives fail to recognize that substance use and its associated harms are shaped by several biological, social, structural and environmental determinants that are largely beyond an individual's control. These determinants include experiences of trauma, violence or abuse; physical and mental health status; income and housing; social and community connectedness; and stigma and discrimination (including anti-Black and anti-Indigenous racism). Additionally, there is strong evidence that adverse childhood experiences can have long-lasting impacts on the human brain, and increase one's likelihood of mental illness and substance use disorder in later life.

School Matters Forum participants described the far-reaching impacts of these determinants. They also noted other relevant factors, such as ageism of youth by adults and society's failure to understand and celebrate aspects of youth development, such as adolescence as a natural stage for experimentation and risk-taking behaviours (reflecting the under-developed prefrontal cortex region of the adolescent brain). Forum participants underscored that substance-related harms among youth are symptoms of larger societal problems versus problems with youth themselves.

Public health objectives related to youth substance use

This section outlines two overarching public health objectives that individuals and institutions within the education sector can advance through a variety of intervention efforts.

Objective #1: To prevent harms related to substance use among youth

Youth differ tremendously with respect to their substance use. While many youth use substances to some extent, some youth completely refrain from use and others are managing a substance use disorder.

By focusing on preventing harms (versus preventing use), school communities can move forward with interventions that reflect these nuanced realities and aim to support all youth, including those who are not able or prepared to completely refrain from substance use. This objective supports interventions that are both inclusive and pragmatic.

Additionally, this focus provides school communities a broader range of goals they can pursue through interventions. These include delaying or reducing substance use, connecting youth to harm reduction and treatment supports and facilitating other strategies or conditions that reduce the potential for harms.

A focus on preventing substance-related harms also directs attention beyond individual behaviour and toward the broader contextual factors that create or exacerbate substance-related harms. By understanding and framing substance-related harms as a societal issue, versus a reflection of personal shortcomings, school communities can help to counter the associated stigma that negatively affects Canadians who use substances and their loved ones.

Objective #2: To promote health and well-being among youth, irrespective of their substance use

At the School Matters Forum, participants described the need for upstream strategies to address various determinants of substance-related harms among youth. For example, they described the importance of fostering community connectedness, celebrating and making space for youth voices, cultivating a trauma-informed learning environment and providing accessible mental health supports. Participants highlighted that the meaningful involvement of youth in planning and decision-making around issues that impact them, within their schools and greater communities, is critical to supporting solutions grounded in their lived realities.

Participants also noted the value of creating opportunities for skills development (including socio-emotional skills and applied skills for employment), and offering diverse athletics and recreation and cultural programming (for example, music, cooking, photography, dance). While none of these strategies are explicitly tied to substance use, they all centre on creating conditions that facilitate general health and well-being among youth and protect their human rights. These types of actions protect against substance-related harms among youth by reducing stress, and strengthening factors such as belonging, competence and autonomy. Proponents of this upstream approach often say, "the best prevention measures often have nothing to do with substance use at all."

By framing efforts to improve youth health and well-being as legitimate means of preventing substance-related harms, school communities can broaden the range of partners who can be engaged to support this work.

PHAC's youth resilience resource series provides additional guidance and evidence to school communities on strategies for preventing substance-related harms centred on enhancing well-being.

Key principles for action to address youth substance use

While the objectives stated above describe what school communities can strive for with respect to addressing youth substance use, the principles for action below describe how they can effectively fulfill these objectives. The principles apply to any intervention effort to prevent substance-related harms among youth, including those set within the context of school communities.

Principle #1: Health equity

Many sub-groups of youth are particularly vulnerable to substance-related harms, including:

  • youth experiencing homelessness
  • youth in the child welfare system
  • Black, Indigenous and People of Color (BIPOC) youth
  • youth with a parent/guardian who has a substance use disorder
  • LGBTQ2+ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning and Two-Spirit) youth
  • youth with learning disabilities

These groups are generally prone to earlier, more frequent, or higher risk patterns of substance use, and often experience greater social and health harms related to substance use relative to other youth. These disparities reflect intersecting forms of stigma, as well as inequitable social, economic and structural contexts related to education, employment, access to health and social services, and social inclusion. For example, many School Matters Forum participants noted that BIPOC youth are disproportionately impacted by punitive school substance use policies and other sanctions.

By applying a health equity lens to intervention planning and implementation, school communities can work to address these disparities. Supporting health equity simply means working to give everyone a fair chance at reaching their full health potential. At a high-level, this involves dismantling structural and socially determined barriers to health and well-being, particularly those that affect individuals and groups who experience oppression on account of race, gender, socio-economic status, ability, LGBTQ2+ identity and/or other identities. It also means purposefully centring the subgroup and jointly designing interventions that reflect an understanding of their unique needs and context.

Principle #2: Compassionate, non-judgemental and strength-based approaches

Youth substance use is subject to considerable stigma. As described earlier, youth who use substances are often assigned negative labels and deemed responsible for the substance-related harms they experience. Additionally, research demonstrates that many teachers and families avoid conversations with youth about substance use (for example, due to the adults' discomfort, lack of knowledge or disapproval of this behaviour). Both instances contribute to substance use stigma and limit youths' opportunities for quality support related to substance use and the likelihood of accessing available supports. At the same time, youth have largely been excluded from decision making about matters that influence their lives, including substance use-related initiatives.

Effective interventions designed to prevent substance-related harms among youth require meaningful engagement of a diversity of youth, including those with lived and living experience of substance use. Active youth leadership and participation is critical to the success of interventions. Youth can help by:

  • identifying priority areas
  • advising on how to best reach and resonate with their peers
  • drawing attention to "blind spots" that adults may hold

When done effectively, youth engagement can increase community connectedness, empower youth and result in many other positive social and health outcomes.

Interventions should strive to leverage youths' strengths and enhance their resilience, instead of fixing their shortcomings. They should also explicitly acknowledge and aim to reduce substance use stigma, including by framing substance use as a health issue. School Matters Forum participants emphasized that this kind of framing encourages action that supports, students and works toward retaining youth in educational settings, as opposed to approaches focused on punishment.

Principle #3: Harm reduction

As outlined above, substance-related harms are not fixed and can be reduced through harm reduction efforts. Harm reduction is a philosophy that can be expressed through policies, programs, practices and education initiatives that reach and impact youth. Harm reduction initiatives reduce the potential social, economic and health harms related to certain health behaviours, without prohibiting the behaviour. Central to harm reduction is the understanding that individuals vary in their experience with substance use, as well as their desire and readiness for change. Given these realities, harm reduction initiatives strive to meet individuals where they are at by taking into account their social location, interest and priorities and celebrating each step, however small, towards improved health and well-being.

Harm reduction is recognized as a practical, effective and equitable approach to youth substance use. Examples of youth-focused harm reduction initiatives include:

  • health messages around the benefits of delaying or reducing substance use, for example the recommendations for youth within Canada's Low-Risk Alcohol Drinking Guidelines and Lower-Risk Cannabis Use Guidelines
  • programs that provide access to nicotine replacement therapy for youth who want to reduce their tobacco smoking
  • creation of safe spaces and supports for open and honest dialogue where youth can discuss their substance use without fear of judgement or reprisal

School Matters Forum participants also noted that efforts to prevent substance-related harms among youth must include interventions directed at adults in youths' lives (including parents/guardians, teachers, coaches). Examples include training for school staff in trauma- and violence-informed care and teaching parents/guardians skills for effectively managing stress and anxiety within the family. As one participant remarked, "when you surround youth with healthy adults, they flourish". This underscores the value in supporting adults in order to facilitate youth health and well-being.

Principle #4: Multisectoral Partnerships

School Matters Forum participants emphasized that meaningful reductions in substance-related harms among youth requires a collective response. This means looking beyond public health and identifying meaningful roles for a broader range of individuals and organizations. These include partners from various sectors (including education, social service, housing, employment, academia, health care) and at various levels (including individuals, families, local communities and governments). School Matters Forum participants represented many of these diverse levels and sectors; they identified many specific actions that various stakeholders can take within their respective roles and responsibilities, to help prevent substance-related harms among youth. This collaboration is essential, as many of the factors that can either prevent or precipitate substance-related harms (and other complex public health concerns) extend well beyond the reach of public health. For example, public health lacks the levers to directly influence the competencies embedded in school curricula, housing policy, the accessibility and diversity of programming for youth within communities and the availability of social supports for new parents.

Partnerships between the health and education sectors in matters related to youth health (including substance use) are particularly important, since schools are a central social institution in the lives of most youth and their families and school communities have many levers for influencing youth health. Models of school health, notably the Comprehensive School Health framework, emphasize the need for action across various domains of school communities, including teaching and learning, social and built environment, policy and partnerships and services. PHAC's Blueprint for Action provides additional details on applying Comprehensive School Health to prevent substance-related harms within the context of school communities.

Principle #5: Evidence-based or show promise of working

Decades of research demonstrate that some of the traditional methods for addressing youth substance use within some school communities (such as zero tolerance policies, expulsion and suspension, calling the police) are ineffective and in some cases may exacerbate substance-related harms. This underscores the importance of taking new actions to get different results; not merely repeating the status quo with prevention efforts. Intervention planning and delivery and measurement of intervention outcomes need to be informed by the best available evidence and regularly re-evaluated. Ongoing evaluation can also help to identify possible unintended negative consequences of well-meaning interventions.

Conclusion

Youth substance use is a complex health issue with much relevance to school communities. School communities are key players to advance public health efforts to prevent substance-related harms. Youth overall health and wellbeing can be optimized by creating supportive environments for youth, leveraging youth voices and strengths applying a health equity lens, basing initiatives on evidence and engaging in cross-sectoral partnerships. It is through this public health approach that the education sector can move forward with more effective and wider-reaching intervention efforts to prevent substance-related harms among youth across the country.

Footnotes

Footnote 1

By youth, we are referring to individuals in the period of transition from the dependence of childhood to adulthood's independence. Given that this transition can take place at different points in time, depending on the individual, there are no specific age limits on who may be considered a "youth".

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Footnote 2

Interventions are the programs, policies, practices and other initiatives to address a specific social or health issue.

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