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In the study by Odejide et al, ³ it was found that many students reported that they had their first drink of alcohol by the age of 8 years during family festivals, while the study by Obot et al, ⁵ found the average age of drinking onset to be 13.2 years. A study of 2660 pupils in secondary schools in Lagos revealed that the average age of first alcohol or cigarette use was on or before the age of 11, ⁸ while average age for onset of the use of illicit psychoactive drugs such a cannabis, heroin and cocaine, was 16 years and above.

Research indicates that the majority of drug use starts during the period of adolescence ². This is especially so for the ‘gateway’ drugs, alcohol and cigarettes.⁹ They are described as ‘gateway’ because they are usually the first drugs that are used before other drugs are tried out.⁹ Research also indicates that if the adolescent can be kept free of drugs, most will never use or abuse drugs during their lifetime.¹⁰ Therefore there is no better place and timing for the prevention and early detection of drug abuse than during the pre-adolescent and adolescent period.

In developing drug prevention programmes for Nigeria, it is important to understand the dynamics of drug use and abuse. Understanding the dynamics of drug use requires a combination of quantitative and qualitative research complementing each other. Quantitative research provides epidemiological information on the use of drugs,¹¹ while qualitative research methods are helpful for exploring complex issues in-depth and are particularly useful for providing a more thorough understanding of drug using behaviour.¹²

In-depth interviews were carried out on two adolescents and their parents to identify emerging themes and patterns for drug use.

Summaries of in-depth interviews illustrating the psychological and social dynamics of drug use in adolescents

Patient One

An 18-year old lorry driver’s assistant was brought by his mother to the emergency unit of the hospital. He presented with a four day history of irrational speech, disruptive behaviour, verbal and physical aggression and insomnia. His father is a brick layer and his mother is a cleaner. They all live together in four adjoining rooms in a ‘face-me-I-face-you’ rented house. His father had had 4 wives who had each left him. His mother who is the fifth wife is the only one still living with his father. TS described the relationship between his parents as not good because there were frequent verbal and physical fights between his parents, with threats of separation.

He had his first taste of alcohol at the age of 12 during his second year in secondary school, when on holidays in his village with his grandfather. During festivals he and other children were given palm-wine. He claimed he loved the taste and the ‘calming effect’ it produced and subsequently returned alone to the farms to steal palm-wine from gourds on the palm-trees. When he returned to school in Ibadan he began buying palm-wine regularly and would buy up to a 5-litre keg of palm-wine about once a week. Older men in the neighbourhood told him that palm-wine was good for preventing fever and he was encouraged to drink it regularly.

About four years after he started drinking palm-wine and at the age of 16, he had his first taste of cigarettes. He had gone out with a group of older boys against school rules. Initially palm-wine was ordered for all members of the group. Then one of the boys introduced cigarettes and passed this around. He said he saw the other boys as ‘big brothers’ and decided to smoke to impress them. He said he continued to smoke to live up to the expectations of his senior friends. He started by smoking an average of 3 sticks a day and he funded his smoking habit with his pocket money as well as money stolen from his parents. His friends also provided him with cigarettes or money to sustain his habit.

After smoking cigarettes for a year, a friend introduced him to smoking cannabis. His friend told him that cannabis aided academic performance. When he first tried smoking cannabis he felt increased strength and wanted to get into a fight to try out his new strength. He also experienced increased appetite and libido and invited his girlfriend over to have sexual intercourse.

His academic performance was said to have declined sharply in his second year in secondary school. It worsened over subsequent years with increasing reports of truancy. He was expelled from school in his fifth year after getting involved in a fight in which some of his colleagues sustained serious injuries. Subsequently he began to experience an increased desire for cannabis and would steal money from his parents to obtain this. He said that whenever he could not get cannabis he became irritable and would beat up his siblings. He had smoked 3 wraps of cannabis daily for the last 2 ½ years and he also smoked about 4 sticks of cigarette each day until he presented in hospital.

Patient two

A 16-year-old senior secondary school male student presented to the child and adolescent psychiatric clinic with a month’s history of insomnia and auditory hallucinations.

He had his first drink of alcohol at his grandmother’s funeral at the age of 10 years. His 16-year-old brother gave him a drink of palm wine to try out. They were in a group of about thirteen other teenagers. After he drank the palm-wine, everything around him appeared double and eventually he slept off. When he awoke he found that he had slept off on the place where cows had been slaughtered for the ceremony.

When he entered secondary school in 1998 at the age of 12, he received very little supervision from his parents because they both had very busy jobs, which involved their leaving home very early in the morning and returning late at night. Food was hardly ever cooked at home, therefore he was given money each day to buy breakfast and lunch.

By his third year in secondary school, he was playing truant. He would go to school just to sign the register and then leave to go to the local television station with his older brother to participate in what he called ‘interesting programmes for young people during the morning hours’. When he was 14 years old, his brother took him to a ‘joint’ for the first time and bought him a cup of ‘ogogoro’ native gin. This made him feel strong. His brother also gave him a cigarette and showed him how to take a puff. However after one puff he started to cough and refused to take any more cigarettes. He however continued with native gin as he says this made him strong and lively. On a certain evening his brother took him to a secondary school in Ibadan and bought some Indian hemp. His brother took a few puffs to demonstrate how to use it. He felt very good after this experience and he continued to take Indian hemp on a regular basis.

His parents soon discovered he was playing truant and moved him to a boarding school in another city. Soon after arrival in the new school, he was able to find a place where he could purchase Indian hemp on a regular basis and continued with the regular use of Indian hemp.

During the holiday period his brother also introduced him to gambling. At this time he was helping out in his father’s cement shop and started stealing money to use for gambling. His brother also introduced him to having sex, getting him a girl and teaching him how to have sexual intercourse. Since then he has kept two girlfriends and has unprotected sex with them on a regular basis. He continued to use Indian hemp until he started having insomnia and auditory hallucinations.

DISCUSSION

The two interview summaries illustrate the very important “gateway theory” of drug use progression and some of the social and psychological dynamics of substance misuse among adolescents in this country. The psychological dynamics identified in these two adolescents include peer pressure, a need to conform, experimentation, conduct problems, poor academic performance, a need to feel strong and the relationship between psychoactive drug use and sexual activity.

Social dynamics identified include poverty and overcrowding, poor parental relationship/family strife, lack of adequate parental supervision, cultural practice of giving children and adolescents palm-wine, social acceptability of palm-wine, misguided on use of palm-wine by elders, misguided on use of cannabis by older friend, overcrowded unsupervised schools, distracting influences during school time such as school programmes attractive to youths during school hours, available, accessible, affordable places for the purchase and use of psychoactive substances

Gateway theory

Gateway drugs are a term for drugs that apparently lead to the abuse of other substances. ¹³ Gateway drugs are drugs that serve as the “gate” or path that almost precedes the use of illicit drugs such as cannabis, heroin and cocaine. ⁹ These drugs serve to initiate a novice to the drug using world. Studies indicate that while not all users of gateway drugs progress to illicit drugs such as cannabis, heroin or cocaine, many do and it is not possible to predict which users will progress or not. ¹³ Common gateway drugs are tobacco, alcohol and inhalants. In explaining the dynamics on this gateway effect, ⁹ evidence indicates that the link is not biochemical but psychological and social. This link has been explained by social psychologists as ‘developmental progression’ whereby decisions to use gateway drugs set up patterns of behaviour that make it easier for a user to go on to use other drugs.

In these two patients, the drug first used is palm wine, a readily available and commonly consumed drink in this environment. Some of the social dynamics in these individuals identify the cultural practice of giving children and adolescents’ palm-wine and its social acceptability. Palm-wine is an alcoholic drink, which may be acting as a major ‘gateway drug’ in this environment. Studies indicate a statistical link between alcohol use and the use of illicit drugs that is age and dose related. Children and adolescents who begin using alcohol at a very early age are more likely to progress to illicit drugs in the future as opposed to first alcohol use after the age of 16. ^{9, 14} Also, children who drank alcohol heavily to the point of intoxication at least once in two weeks were at increased risk of progressing to illicit drugs. ¹⁴

In these two adolescents, the first use of alcohol was at age 10 and 12 respectively, with reports of intoxication occurring in both of them. This has far reaching implications for drug prevention programmes in this environment and requires further study, using quantitative techniques, to unravel its full extent in the community. Apart from the “gateway effect” of palm wine, the other psychological and social dynamics interplaying with each other as observed in these two adolescents cannot be ignored in drug prevention programmes.

Psychological dynamics

The need to conform and impress their peers was quite obvious in both adolescents. As the adolescents’ body matures several changes occur. Parental influence in issues of lifestyle reduces the influence of peers increases and the need to conform to their peer group becomes more dominant.¹⁰ A child may take up smoking or drinking alcohol so that they are drawn closer to a group where this is the norm.² In a study of drug use among junior high school children in Japan, peer pressure measured by ‘been tempted to use’ demonstrated the highest risk factor with adjusted odd ratio of 9.53,¹⁵ this was followed by problems at school (OR=2.56) and family issues (OR=2.15). Similarly in an attempt to find out the influence of drinking on smoking and smoking on drinking among high school students in the USA, rather than the effect of one of these drugs on each other, the strongest influence on being a drinker was approval of drinking by ones peers.¹⁶ Other factors include having friends who drink, peer pressure to drink, poor performance at school, being male, and family problems. In another study of public school students in the USA, statistically significant factors that affect the probability of alcohol use by adolescents, include the fact that their friends drink, awareness of risks involved with alcohol use and the ease of obtaining alcohol.¹⁷

Both adolescents also had conduct problems such a truancy, stealing, and frequent fighting. It is not clear whether this behaviour would have occurred in the absent of drug misuse, however studies reveal that many adolescents who abuse drugs have emotional problems such as low self esteem, dissatisfaction with life, less social confidence, need for approval, anxiety, restlessness, promiscuity, antisocial and conduct symptoms.¹⁰ Drugs are used for coping with the stress caused by these emotional states.¹⁰ In a study to identify the relationship between preadolescent psychiatric problems and substance use, it was found that presence of disruptive behaviour disorders such as conduct disorder predicted preadolescent drug use and a combination of preadolescent conduct disorder and early adolescent regular alcohol use, were highly predictive of early adolescent cannabis use.¹¹

Drug abuse may also be the adolescents’ way of coping with stress which may be unbearable such as poor school performance or a dysfunctional family or social phobia. ¹⁰

Drug use and sexual activity

Adolescents are also typically preoccupied with sex and sexual performance. This was observed in one of the adolescents who experienced increased libido following the use of drugs. Drugs such as sedatives, alcohol and cannabis can alleviate anxiety, lower the inhibitions surrounding sexual behaviour and improve performance when used in small amounts.¹⁰ An adolescent who discovers this may start to use it regularly. Closely linked to this is the need to feel strong, which was observed in both adolescents.

Social factors

Palm wine is an important alcoholic beverage in West Africa obtained from the juices of the oil palm and raffia palm plants. The fresh palm juice is a sweet, clear, neutral colourless nutritious juice containing sugars. However fermentation starts almost immediately after the sap is collected and within an hour or two its alcohol content is about 4%. Palm wine is the most common traditional beverage used widely especially in the Southern part of Nigeria at weddings and funeral ceremonies. Palm wine is given widely to children possibly as a result of its nutritional value and the general belief about the absence or negligible alcohol content.¹⁹ Both adolescents interviewed were offered palm wine as children at family festivities and the effect on both of them was negative. The public health implications of this cultural practice may be far reaching. Other factors associated with drug misuse in adolescence are availability and accessibility. Both adolescents’ had easy and ready access to alcohol, cigarettes and cannabis. Alcohol is readily available especially in the southern region of Nigeria in shops, bars and hotels. This is sold to underage children although licence granted for sale requires only to adults but no one obeys the rule. This situation is however different in some of the Northern states where religious (Islamic) laws have been enacted to ban the sale of alcohol.

Family influence

Adolescents’ raised in families where a family member such as a parent or sibling abuses drugs is more likely to also do the same.¹⁰ Similarly parental attitudes or the adolescents’ perceived parental attitude has a strong influence on the adolescents’ perceived decision making. In both cases alcohol was introduced by close respected family members, grandfather and older brother respectively. When parents or other adults in the environment use drugs the adolescents around are more likely to and where there are models for deviant behaviour around like older siblings on drugs there is increased risk. Other family factors associated with drug use with subsequent progression to misuse include family instability. Where there is family instability, divorce and parental rejection the adolescent is more vulnerable. ¹⁰

The two adolescents interviewed had established the use of three substances namely alcohol, nicotine and cannabis by late adolescence. Collins et al,²⁰ has illustrated factors that are associated with simultaneous poly drug use (SPU) being established by late adolescence and found that the best predictors of alcohol/cannabis SPU were a pro-drug environment, pro-drug beliefs, social deviance and family disruption.

Role of the media, poverty, unemployment and lack of recreational activities for youth

Although not identified as a factor in these patients, another important factor is the role of the media. There is no restriction on alcohol advertising in Nigeria. In the advertisements for cigarettes and alcohol, people who drink and smoke are portrayed as sexy, manly and sophisticated. Advertising of alcohol in Africa focuses on the youth, strength and nutritional values.²¹ This has a facilitating role for adolescents who are still trying to find their identity

According to Jokinen, Pitkanen and Hirvonen, ²¹a popular advertisement in Cote D’vorie showed a young person on a motorbike who was very exhausted but was revived after drinking a bottle of beer. Also even though Indian hemp (cannabis) is not advertised, it is glamorised and sensationalised in movies. All these make impressions on the developing adolescent mind.¹⁰

The world-wide observed ‘gateway’ phenomenon is clearly illustrated in the two patients interviewed. The interplay of the identified psychological factors of peer pressure, experimentation, conduct problems, academic failure with the social factors of availability, accessibility, affordability and acceptability of psychoactive substances need further study. This is especially so for the public health implication of the acceptability of palm- wine. In the interim, factors that have been identified must not be ignored in developing drug prevention programmes.

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