Understanding changes in substance use in the adolescent and young adult cancer population: a literature review
Intended for healthcare professionals
Evidence and practice    

Understanding changes in substance use in the adolescent and young adult cancer population: a literature review

Gerard Kenny Teenage and young adult cancer research nurse, University Hospitals Bristol and Weston NHS Foundation Trust (UHBW) specialised services, Bristol, England
Jamie Cargill Consultant nurse lead for teenage and young adult cancer team, UHBW, Bristol, England
Rachel Dommett Consultant oncologist and lead for teenage and young adult cancer, UHBW, Bristol, England
Divya Bassi Late effects lead, UHBW, Bristol, England
Megan Willsher Specialist nurse teenage and young adult cancer, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, England
Laura Baker Clinical psychologist, UHBW, Bristol, England
Elizabeth Allison Clinical nurse specialist germ cell and sarcoma, UHBW, Bristol, England

Why you should read this article:
  • To understand why adolescents and young adults with cancer engage in risk-taking behaviours involving substance use

  • To be aware of the evolution of substance use, driven by new psychoactive substances and nitrous oxide

  • To identify that nurses require support to address the risk of substance use among adolescents and young adults with cancer

The nature of the risks involved in adolescents and young adults’ substance use has evolved considerably in the 21st century. While there has been a decline in the use of some substances such as alcohol, and changes in how substances such as nicotine and cannabis are consumed, the overall increase in substance use in this population has been driven by new psychoactive substances and nitrous oxide (laughing gas). However, adolescents and young adults with cancer are often reluctant to discuss their substance use with healthcare professionals, who often lack the knowledge, skills and time to engage with this complex and continually changing area.

The authors undertook a narrative literature review on risk-taking behaviour involving substance use in adolescents and young adults, contextualising the main themes to adolescents and young adults with cancer. Healthcare professionals working with adolescents and young adults with cancer require improved evidence to understand the effect of substance use on treatment regimens, adherence to cancer therapy and the consequences for late effects. There is also a need for a wider appreciation of the effect that family, peers and social setting have on the nature and expression of substance use in this population.

Cancer Nursing Practice. doi: 10.7748/cnp.2021.e1787

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

Gerard.Kenny@uhbw.nhs.uk

Conflict of interest

None declared

Kenny G, Cargill J, Dommett R et al (2021) Understanding changes in substance use in the adolescent and young adult cancer population: a literature review. Cancer Nursing Practice. doi: 10.7748/cnp.2021.e1787

Acknowledgements

The authors would like to acknowledge the support of David Rea and the South West Clinical Research Network in supporting the teenage cancer research nurse role, and in the development of this article

Published online: 21 September 2021

All health disciplines agree that adolescence is a phase of significant physical, emotional and social change, but there remains contention about how to define this period of growth and development between childhood and adulthood and the terms that best describe this phase. Sawyer et al (2018) recommend a definition of adolescence as being between the ages of 10 and 24 years.

The adolescent and young adult developmental phase is characterised by an increase in exploration, spontaneity and risk-taking behaviours, including substance use. This period is when risk-taking behaviours are likely to have a significant effect on physical development and long-term psychosocial and economic outcomes (Lisdahl et al 2018). The nature of risk has shifted considerably in the 21st century with the advent of social media and greater exposure to illicit substances. The relationship between old risk-taking behaviours, for example smoking and drinking, and new risk-taking behaviours, for example vaping using illicit substances, and using new psychoactive substances and nitrous oxide (laughing gas), is unclear. The consequences of these risk-taking behaviours increase exponentially. Healthcare professionals working with adolescents and young adults with cancer should understand how the confluence of these risks and behaviours affects the experience of cancer (Walsh et al 2020).

Key points

  • Adolescents and young adults with cancer engage in risk-taking behaviours involving illegal substances

  • Healthcare professionals’ understanding of these health behaviours has been outstripped by trends in substance use

  • Healthcare professionals have a statutory duty to engage with adolescents and young adults with cancer about substance use and ensure they are safeguarded

Increased risk in adolescence

Neurological brain development is important when considering risk-taking behaviour in adolescents and young adults. The prefrontal cortex plays an important role in self-regulation and decision-making, but it is still developing in the adolescent brain, resulting in an increased likelihood that adolescents will engage in risk-taking behaviours and will do so in part to avoid peer exclusion (Blakemore 2018).

The increased likelihood of engaging in risk-taking behaviours also applies to adolescents and young adults with cancer. For example, in a sub-analysis that described rates of sexual behaviour and substance use in a sample of adolescents and young adults with cancer, Fladeboe et al (2020) found a baseline of 22% reporting alcohol use, 31% prescription drug use, 19% illicit drug use and 9% tobacco use.

Aim

To review the literature on risk-taking behaviour involving substance use in adolescents and young adults and to contextualise the main themes to adolescents and young adults with cancer.

Method

Between April and May 2020, a database search was conducted of AMED, PubMed, CINAHL, MEDLINE, PsycARTICLES, WorldWideScience and the Cochrane Library, including Cochrane Reviews. Searches were also conducted of Google Scholar and System for Information on Grey Literature in Europe (SIGLE). Search terms used were adolescent, young adult, teenager, risk behaviour and cancer. The approach adopted was iterative searching of literature, selective, judicious sampling and cascading of relevant literature alongside the systematic searching techniques. International literature was included on the understanding that adolescence and risk behaviour are universal experiences and that the experience of a cancer diagnosis will be shared across cultural and social boundaries. More than 200 pieces of work were identified and reviewed by a clinical team that included cancer nurse specialists, a consultant physician and nurse, a public health expert and a psychologist. Articles were selected based on their usefulness to inform and guide clinical practice. In total, 40 articles were included in the final review and synthesised to elicit a meaningful narrative that combined the themes of risk in adolescents and young adults and cancer.

Results

Alcohol

Context

Historically, alcohol has been the most commonly used substance by adolescents (Johnston et al 2017). In England, the chief medical officer’s guidance is that the healthiest and safest option is for children to remain alcohol-free until the age of 18. Alcohol should not be consumed before the age of 15 years, and for young people aged 15 to 17 years, it is suggested they drink only once a week in a supervised environment such as with parents (Donaldson 2009). Drinking alcohol at a young age is positively associated with suboptimal academic performance at school and antisocial activity, including being a victim of and contributing to physical violence and unsafe sexual behaviour (Lisdahl et al 2018).

Although overall alcohol consumption by adolescents and young adults is declining, the prevalence is that nearly half of those aged under 14 years have tried alcohol at least once. In 2018, 44% of pupils in England said they had ever had an alcoholic drink, the same as in 2016 (NHS Digital 2019). A national and international trend that distinguishes drinking behaviour in adolescents and young adults from older groups is that underage drinkers (those aged 12 to 20 years) typically consume four to five drinks per drinking episode, which is nearly double the average consumed by adults aged 25 years and over (Chung et al 2018). European data identify that one in three young people had engaged in heavy episodic drinking (defined as drinking a minimum of five alcoholic drinks on one occasion at least once) in the last 30 days (European School Survey Project on Alcohol and Other Drugs 2020).

Alcohol and adolescents and young adults with chronic illness

Across the adolescent and young adult chronic illness group, addressing alcohol use in specialty care settings remains rare (Levy et al 2016). Those with malignant disease share common experiences with their peers with chronic illness. Globally, the overall prevalence of chronic illness in children and adolescents is estimated to be 15-20% (Jin et al 2017). The adolescent and young adult cancer population falls into the general category of young people with a chronic illness: a health issue lasting more than three months, affecting normal activities, requiring frequent hospitalisations and extensive medical care. Clinical features that characterise chronic illness are unresolved prolonged symptoms that are rarely cured (Barr et al 2016).

Adolescents and young adults with chronic illness experience similar risks from alcohol consumption as their healthy peers: injury and violence, unsafe sexual practices and mental health issues (Centers for Disease Control and Prevention 2018). Alcohol use is also associated with treatment non-adherence and interaction with medicines and laboratory tests for the adolescent and young adult chronic illness population (Weitzman et al 2015).

Evidence relating to treatment adherence in adolescents and young adults with cancer is limited due to small samples and issues with self-reporting. The evidence that does exist, on oral medicines, has suggested that adherence is suboptimal. Studies in children and adolescents with acute lymphoblastic leukaemia (ALL) report non-adherence to maintenance therapy in 17-46% of cases, although factors affecting adherence were not identified (Alsous et al 2017). The consequences of suboptimal treatment adherence in ALL are well known, including increased clinic visits, an extended course of illness, inadequate symptom control and unnecessary hospital admissions (Alsous et al 2017).

Nicotine and tobacco products

Context

In common with other European countries, smoking among the general adolescent and young adult population in England has declined in recent decades (NHS Digital 2019). Over time, the largest reduction in smoking prevalence in the UK has been among those aged 18-24 years: 26% of this group smoked in 2011 compared with 16% in 2019 (Office for National Statistics (ONS) 2020a).

Smoking and adolescents and young adults with cancer

For adolescents and young adults with cancer, smoking may exacerbate treatment side effects and interfere with the three most common cancer treatments: surgery, chemotherapy and radiotherapy (Warren et al 2014). Specifically, smoking increases infection risks for surgery, slows wound healing, decreases responses to radiotherapy and reduces the effectiveness of chemotherapy. Smoking after a cancer diagnosis is associated with cancer recurrence, second primary cancer and all-cause mortality (Burke et al 2009).

There is little evidence concerning the use of cigarettes by adolescents and young adults with cancer before or during cancer treatment, and most data relate to survivorship. US figures for 2019 suggest smoking rates of 24% in cancer survivors aged 18-44 years (National Cancer Institute 2021). A study by Salloum et al (2019) identified that young adult cancer survivors aged 18-44 years in the US had the highest rates of current cigarette smoking at 28%. Kasteler et al (2019) found that adolescent Swiss childhood cancer survivors smoked as often as their siblings. The study identified that peer smoking was an important reason for survivors smoking compared with the general population. This finding correlates with English figures that show smoking in the general population of those aged 11-15 years is significantly associated with having friends who smoke (NHS Digital 2019).

Vaping and adolescents and young adults with cancer

The nicotine context has changed significantly with the introduction of vaping, the inhaling of a vapour through an electronic cigarette (e-cigarette) or other vaping device. Patterns of e-cigarette consumption in adolescents and young adults with cancer are unknown, and the evidence that exists suggests the need for caution when drawing parallels with the non-cancer population. Fahey et al (2019) suggest that using more than one tobacco product is common among cancer survivors. The study found that the young adult cancer population had the highest cigarette and e-cigarette use at 28% and 12%, respectively. Therefore, it may be inaccurate to assume that the adolescent and young adult cancer population is using e-cigarettes only as a smoking cessation tool (Salloum et al 2019).

Cannabis

Context

After alcohol, cannabis remains the most widely used illicit drug globally, with 188 million users in 2017 (United Nations Office on Drugs and Crime 2019). In Europe nearly 20% of those aged 15-24 years reported having used cannabis in the last year (European Monitoring Centre for Drugs and Drug Addiction 2019). A Spanish study by Rial et al (2019) found that the percentage of adolescents using tobacco and cannabis was higher than those using tobacco alone. Regular use of cannabis during adolescence is concerning. Data suggest that weekly cannabis use during adolescence is associated with neurocognitive abnormalities, lower IQ, suboptimal sustained attention and verbal memory (Lisdahl et al 2018).

Cannabis and adolescents and young adults with cancer

While cannabis use by adolescents with cancer is a topic regularly discussed in our local multidisciplinary team meetings, actual patterns of consumption and prevalence are less well understood. The studies that do exist tend to focus on adult use. In a Canadian survey of cannabis use in cancer, Hawley and Gobbo (2019) found that 23% of adult respondents were currently using cannabis-based products for pain, insomnia, nausea and anxiety, and many were also hoping for anti-cancer effects. Pergam et al (2017) found that 66% of adult US cancer patients had previously used cannabis. These figures identify that cannabis use among adults with cancer in the US was at much higher levels than among the general adult population where it was 3% (Han and Palamar 2020).

New psychoactive substances and nitrous oxide

UK context

There has been a decline in some substance use such as alcohol and an evolution in how some substances are consumed, for example nicotine and cannabis. However, the overall increase in substance use in the adolescent and young adult population has been driven by new psychoactive substances and nitrous oxide (NHS Digital 2019).

New psychoactive substances are designed to replicate the effects of illegal substances like cannabis, cocaine and ecstasy while remaining legal – hence their previous name ‘legal highs’. They include mephedrone and methoxetamine. Nitrous oxide – which is normally used as a propellant for canned whipped cream – has become a significant drug of abuse among adolescents (ONS 2020b). Users inhale the nitrous oxide through a balloon inflated with the gas. Intoxication is characterised by euphoria, incoordination, dissociation and hallucinatory experiences. New psychoactive substances and nitrous oxide are covered by the Psychoactive Substances Act 2016, which restricts the production and sale and supply of such substances.

Figures for England and Wales identify that around 82,000 people aged 16-24 years had used new psychoactive substances in the year ending March 2020. Young adults therefore account for a disproportionately large proportion of new psychoactive substance users, at around 71% (ONS 2020b).

Polysubstance use

Context

Adolescents and young adults will use new psychoactive substances and nitrous oxide simultaneously with other substances, meaning the effects and consequences can be unpredictable (Johnston et al 2017). Research on the co-use of substances is rare. In an Australian study, polysubstance use in adolescence was linked with multiple adverse outcomes, including escalating use, depressive symptoms, psychological distress, ‘dropping out’ of school and interpersonal violence (Kelly et al 2015).

In a nationally representative sample of US adolescents, Moss et al (2014) reported polysubstance use of 34%, with common combinations being alcohol and marijuana, or alcohol, marijuana and cigarettes. Schuster et al (2016) identified that the combination of cannabis and alcohol had an adverse effect on working memory in young adults. It is challenging to disentangle the complex interrelationships that exist around polysubstance use; for example, the personal choice characteristics, cultural contexts and the economic market in which these behaviours occur (Elliott et al 2019). What is clear is that polysubstance use will have an increased adverse effect on the health of users.

Polysubstance use and adolescents and young adults with cancer

In a US survey of young adult cancer survivors, Lowe et al (2016) explored the effect of cancer on health-related behaviours. The themes identified were that cancer legitimised the use of cannabis; a sense of ‘making up for lost time’ justified an increased alcohol intake; and managing psychological distress was a rationale for smoking. Milam et al (2016) examined polysubstance use in a cohort of Hispanic childhood cancer survivors and found that the prevalence of using at least two substances was 16%. The most common polysubstance interrelationships were smoking and marijuana use, binge drinking and smoking, and binge drinking and marijuana use.

Polysubstance users also had higher levels of depressive symptoms. However, the link between polysubstance use and depressive symptoms in adolescents and young adults generally is complex. Felton et al (2015) identified that traditional understanding focuses on a relationship where issues with substance use result from attempts to use substances to relieve depressive symptoms.

Conversely, healthcare professionals also appreciate that substance use may increase the risk of depressive symptoms (Felton et al 2015). Given the complexity of this developmental stage combined with a cancer diagnosis, it may be more beneficial to understand the relationship between depression and substance use as reciprocal, where each can exacerbate the other. One example of this heightened relationship is that adolescents and young adults with cancer are at substantially increased risk of suicidal behaviour, particularly during the first year after diagnosis (Lu et al 2013).

Discussion

The results of this literature review show that adolescents and young adults with cancer engage in ‘typical’ risk behaviours at the same rate or more than their peers who do not have cancer, despite the negative health consequences. There is evidence that adolescents and young adults with cancer do not see the need to discuss their substance use with healthcare staff (Pugh et al 2020), and underestimate the effect that such behaviour may have on their treatment and recovery.

In the US, the Children’s Oncology Group (2018) has advocated that clinicians caring for survivors of childhood, adolescent and young adult cancers should assess risk behaviours and provide health education during follow-up visits. Lowe et al (2016) identified that young adult survivors of childhood cancers had suboptimal recollection of having been asked about their substance use.

A lack of recall is significant. Possibly, clinicians were raising these issues, but not in a manner that survivors recognised. The phenomenon of patients being unable to recall or recognise being asked by healthcare professionals about a specific topic has been identified in other areas; for example, in a report exploring the perinatal mental health experiences of women and healthcare professionals, the women could often not remember being asked about their emotional well-being (Boots Family Trust 2013). In the authors’ clinical experience, there is a danger that asking about complex issues in a time-limited context can be reduced to a tick-box exercise with no meaningful effect on actual health behaviours. Healthcare professionals working with adolescents and young adults with cancer require support and time to be able to engage with these topics in a way that this group not only understands but also feels comfortable with. However, engaging with these topics is beset with challenges because there is a paucity of data to guide clinicians about substance use in adolescents and young adults with cancer.

This lack of data is a particular factor when the use of class A drugs (class of controlled drugs considered the most harmful by the UK parliament) are considered. While no direct data exist in relation to class A drugs and adolescents and young adults with cancer, data from England and Wales identified that the 20-24-year age group had the highest level of class A drug use in 2018-19 (Home Office 2019).

In the authors’ opinion, there is a danger of a ‘don’t ask, don’t tell’ culture where healthcare professionals prioritise relationship-building and avoid ‘policing’ (literally and figuratively) potential illegal behaviour by adolescents and young adults. This is despite National Institute for Health and Care Excellence (2017) guidance recommending that health and social care professionals use routine appointments and opportunistic contacts to assess if someone is vulnerable to drug misuse. Healthcare professionals require significant safeguarding support when previously hidden or unknown substance use is discovered or disclosed in an outpatient context (Strike et al 2020).

While cancer professionals tend to work with individual adolescents and young adults and their families, it is important to recognise that the young person is part of a wider social network. As already noted, sibling behaviour is a significant predictor of substance use (Kasteler et al 2019). Branstetter et al (2011) identified that any effective assessment, support and subsequent substance use interventions should include parents and peers simultaneously so that the nature and expression of substance use by adolescents and young adults with cancer can be fully understood.

This complex area requires innovative mixed-methods research that seeks to elicit the data that, by its nature, adolescents and young adults would rather not discuss with healthcare professionals. Quantitative approaches can support knowledge about new substances, how these substances are combined and what effect the combination has on treatment and adherence to therapy. However, qualitative approaches are required to understand the psychosocial implications of substance use and how family settings, siblings and peers influence the nature and expression of substance use by adolescents and young adults with cancer.

Limitations

One consequence of undertaking a wide-ranging literature review is that in seeking to demonstrate how illicit substances are blended and co-used in an adolescent cancer context, the authors have sacrificed the depth and complexity of discussion around individual substances. However, the aim of this review was to begin an exploration of an important aspect of the cancer experience for adolescents and young adults.

Conclusion

In the field of risk, assessing adolescents and young adults with cancer needs to move away from individual health behaviours to overall risk behaviour. Polysubstance use raises an essential issue in the process of treatment and survivorship and a focus on individual substances can leave adolescents and young adults with cancer experiencing a mismatch between what healthcare professionals ask and their experience. There is also the danger of enquiring about challenging issues in a time-limited context with no meaningful effect on actual health behaviours. Service development and future research will need to pay attention to new substances and how they blend with the traditional triad of alcohol, cigarettes and cannabis and, in turn, how familial and social settings influence this blending.

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