Quality of life among adolescents with substance use disorders

Background: Adolescents are vulnerable to substance use, which profoundly aﬀects their func�on, feelings and quality of life (QoL). This study aimed to assess the physical health, psychological, social rela�onships, and environmental domains of QoL among adolescents with substance use disorders (SUDs). Methods: A cross-seconal study was done from October 2020 to September 2021 among 44 adolescents selected purposively from Central Drug Addic�on Treatment Center (CDC), Dhaka and Ashok� Punorbashon Nibash (APON), Manikganj. Clinical diagnosis was assigned using The Diagnos�c and Sta�s�cal Manual of Mental Disorders, Fi�h Edi�on (DSM-5) by psychiatrists. Then, they were interviewed with a ques�onnaire and a Bengali Version of the World Health Organiza�on quality of life scale brief version (WHOQOL-BREF). Results: Among the 44 adolescents with SUD, 18 (40.9%) rated their QoL as poor, 14 (31.8%) as very poor, 8 (18.2%) as neither poor nor good, and only 4 (9.1%) as good. Nearly half of them (47.7%) reported that they were dissa�sﬁed, one third (29.5%) were very dissa�sﬁed with their health. Among the four domains, the psychological domain (9.8±2.3) had the lowest mean score, followed by physical health (10.5±2.7), social rela�onships (10.6±2.6), and environmental domain (11.5±2.2) of the WHOQOL-BREF. Mul�ple drug users had poorer scores of their QoL than single drug user. Conclusion: Our study demonstrated that all domains of QoL (physical, psychological, social, and environmental) are impaired in adolescents with SUDs.


INTRODUCTION
Substance use disorders (SUDs) are one of the alarming mental health issues in adolescents throughout the world, which lead to impairment and distress.There are substantial geographical variations in the prevalence of SUD among adolescents.A study done in the United States using data from the National Household Survey on Drug Use and Health (NSDUH) shows that 7-9% of adolescents in the US between the ages of 12-17 years met the criteria for an alcohol or illicit drug disorders. 1

ORIGINAL ARTICLE
and multiple hospitalizations and treatment episodes. 10study revealed that adolescents who met the criteria for SUDs had reduced scores across all domains of QoL, with the most observable effects on academic achievement and school adjustment. 11 Stevanovic et al.   found that adolescents who reported using substances had significantly lower scores in total, physical, emotional, social, and school functioning domains of the Pediatric Quality of Life Inventory (PedsQL) than those who did not report using any substance. 12On the other hand, a moderate reduction in the frequency of substance use among adolescents was associated with improvements in QoL. 13 The primary objective of our study was to assess the quality of life in relation to sociodemographic factors among adolescents with SUDs.Our secondary objective was to compare the quality of life among adolescents using single and multiple substances.

b. DSM-5 criteria for SUD
The DSM-5 criteria for substance use disorders were used to diagnose SUDs in adolescents.The DSM-5 recognizes SUDs resulting from the use of ten separate classes of drugs: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives-hypnotic-or anxiolytics, stimulants, tobacco, and other unknown substances. 14

c. World Health Organization quality of life scale, brief version (WHOQOL-BREF)
This study used WHOQOL-BREF to assess the quality of life of adolescents with SUD.The scale had 26 items, among which the first two items are used to measure an individual's overall perception of QoL and overall perception of their health.The remaining 24 items measured the following four domains: physical health, psychological, social relationships, and environment. 15e WHOQOL-BREF has been translated into Bangla and validated for Bangladeshi adolescents. 16

Data collection
Prior permission was taken from the authority of two institutions: CDC and APON.Participants and their parents were informed about the study's purpose, method, and outcome.Informed written assent/consent was taken from the patients and one of their parents before data collection, as appropriate, by face-to-face interviews.Qualified psychiatrists made clinical diagnoses by applying DSM-5 criteria of SUD.Then, socio-demographic information was documented using the semi-structured questionnaire.The Bangla version 2. Among the four domains of the WHOQOL-BREF scale, the psychological domain is affected most by adolescent substance usage.
3. Multiple substance use affect QoL more adversely than single substance use.
of the WHOQOL-BREF was applied to evaluate the QoL.One of the investigators (RK) read out the questions and recorded the answers given by the participants.

Data analysis
Descriptive statistics such as frequency (percent) or mean (standard deviation) were used as appropriate.
Student's t test was used to compare the mean score of four domains (physical health, psychological health, social relationship, and environment) of the WHOQOL-BREF categories.The analysis of variance was used to compare more than two categories (e.g., education).
P<0.05 was considered statistically significant.young adults. 17SUD impairs individuals' physical and psychological health and also jeopardizes general safety and social performance and, thereby, overall quality of life.Thus, the present study aimed to evaluate the quality of life among adolescents with SUD.

Forty
Our study's mean scores for four domains were from 9.8 to 11.5 According to the WHOQOL-BREF scale, the higher the mean scores, the better the quality of life.We found that the mean scores of physical health, psychological, social relationships, and environmental domains of WHOQOL-BREF were higher in the healthy male adolescent population of both slum and residential areas of Dhaka city than the mean scores of these four domains of our respondents who were substance users. 18This indicates that all four domains of the QoL of adolescents with SUD were low compared to the healthy adolescent male A study done in Etawah, India, on 145 street children 13 -18 years of age abusing substances revealed that mean scores of physical health, psychological, social relationships, and environmental domains were low. 19 international study involving 2393 adolescents from seven countries using the Pediatric Quality of Life Inventory (PedQL) showed adolescents using substances have a significantly lower score in PedsQL physical, emotional, social, and school functioning domains. 12st adolescents rated their QoL as poor or very poor.
Most of the substance-dependent adolescents were dissatisfied with their health, and only a few were satisfied.Though the QoL among adolescents with SUD is a major public health concern, QOL assessment using the WHOQOL-BREF among adolescents was minimal.
Therefore, comparing this study's results concerning the perception of quality of life and satisfaction with health with other studies was impossible.Among the four domains, the psychological domain was mostly affected in adolescents with SUD.Psychological distress is a common experience for patients with SUD, partly due to substance use and its consequences and partly due to psychiatric disorders that often coexist with SUDs, resulting in a double burden of symptoms and problems. 20Approximately 70-80 percent of youths presenting to treatment for SUD are duly diagnosed. 21A study in Bangladesh revealed that among the patients with first-episode psychosis, lifetime SUD was double that of control. 22The temporal relationship between substance use and psychological symptoms, such as depression, anxiety, or psychosis, should be considered.
Substance use may be a perpetuating factor for deteriorating mental health.On the other hand, impaired mental health may also have preexisted before the substance use, precipitated the substance use, and may have deteriorated further. 23 Clear male dominance was (88.6%) observed.
Throughout the world, the prevalence of substance use is higher in males than in females. 24Due to social restrictions and the society's attitude, male dominance is also observed in our country.The majority (79.6%) of the patients hailed from urban areas.As the sample was collected from two centres near Dhaka city, most attendants belonged to the metropolitan area.It may also refer that adolescents from urban areas have better access to services.
Education might have some link to adolescents' addiction behaviour.However, our participant's educational background is almost identical to the national data.Moreover, it is similar to other studies. 25oken family and history of substance use in the family increase the risk of adolescent substance use. 26 the present study, the average age of onset of substance use was 12 years, and the reasons for initiation were peer pressure, curiosity, broken family, family negligence, academic failure, and relationship failure.Sawhney and Kaur also reported similar age of onset, and the reasons were enjoyment, showing manhood and fun, frustration, curiosity, peer pressure, and imitating their father and siblings. 25e finding of this research suggests that adolescents with SUD have reduced QoL across all domains.
Therefore, a biopsychosocial approach through a multidisciplinary team should be implemented while

Conclusion
The quality of life is impaired in adolescents with SUD.
The psychological domain is the most impaired among the four domains of the WHOQOL-BREF scale.In addition, physical health, psychological, and social relationships domains are significantly impaired in multiple substance users.The physical health domain is significantly lower among those who seek services.A comprehensive management plan is necessary to improve the health of adolescents with SUDs.
Longitudinal studies using a more representative sample are warranted.
This cross-sectional study was done from October 2020 to September 2021 in the Central Drug Addiction Treatment Centre (CDC), Tejgaon, Dhaka, and Ashokti Punorbashon Nibash (APON), Singair, Manikganj.A total of 44 adolescents within the range of 11 to 19 years of either sex with SUD who attended the inpatient and outpatient department of the CDC and APON were purposively included in the study.However, adolescents in an intoxication or withdrawal state who were mute and those with non-communicable were excluded from the study.We obtained ethical approval from the Institutional Review Board of Bangabandhu Sheikh Mujib Medical University.Research instruments a. Questionnaire for socio-demographic and related variables for the study of QoL A semi-structured questionnaire in Bangla was designed by the researcher to collect information regarding sociodemographic variables such as age, sex, residence, religion, level of education, family type, family history of substance use, age of onset of taking the drug, the reason for initiation of substance use, name of substance currently using, route of administration, monthly expenditure, history of receiving treatment and admission in hospital for substance use, etc.

FIGURE 1 FIGURE 2
FIGURE 1 Perception of quality of life and satisfaction about health among the participants of substance use disorder (n=44).
Therefore, assessment of the psychological domain and providing appropriate interventions toward treating both SUD and psychiatric disorders simultaneously is mandatory for a better QoL.The impairment in physical health may be due to increased risk for injury and violence associated with substance use, respiratory problems due to smoking, or inhalation of substances.Co-occurring psychiatric disorders may have contributed to lower scores in the psychological domain.In an aspect of social relationships, adolescents with multiple substance use may be more neglected by the family or society due to social stigma.Those who go to hospital might have severe problems of SUD as indicated by our data.
managing such patients.Management should include treatment of co-morbid physical and psychiatric illness, psychological intervention, and social rehabilitation to improve and maintain QoL.Proper psychological assessment by a psychiatrist and a more integrated approach are needed for a better QoL.Awareness programs for society about the disease, treatment, and outcome of SUD should be implemented.Psychiatrists, governmental organizations, and non-governmental working on drug use should deal with this condition holistically.The QoL assessment, therefore, should be considered in health care.QoL measures are needed to be routinely included in the evaluation of treatments.This study has several limitations too.First, SUDs were diagnosed by psychiatrists using DSM-5 criteria, where a structured interview could give a more accurate diagnosis.Second, small number of participants from selected drug addiction treatment centres, lack the representativeness, and therefore, findings cannot be generalized.Third, a cross-sectional study design cannot provide a causal relationship.

TABLE 1 Socio-demographic characteristics and substance use among the study participants with substance use disorder (n=44)
-four adolescents with SUDs were included in this study, among which 24 were from APON and 20 from CDC.The mean age of the study participants was 16.5 (2.3), 88.6% being male.The majority (79.6%) of the respondents were from urban areas.About half (43.2) of the parents were divorced, widows, widowers, or separated.About 80% were from nuclear families (TABLE1).About 47.7% of the respondents had a family history of substance use.The mean age of onset of substance use was 12.2 years.The mean monthly expenditure due to substance use wasBDT 11,579.A little less than half (40.9%) of them rated their QoL as poor, and 31.8% as very poor.About 48.0% of the respondents were dissatisfied with their health, but 9.1% were satisfied (FIGURE1).and biological, and conditions like SUDs may affect adolescents' behavior, lifestyle, and future life.Nowadays, SUD has increased significantly among adolescents and Khan R et al.Bangabandhu Sheikh Mujib Medical University Journal 2023; https://doi.org/10.3329/bsmmuj.v16i4.60341Quality of life among adolescents with substance use disorders 200

TABLE 2 Relationship of WHOQOL-BREF scores and socio- demographic variables of the respondents (n=44) Variables Mean (standard deviation) scores of Quality of Life Physical Health Psycho- logical Social Relation- ships Environ- mental
Khan R et al.Bangabandhu Sheikh Mujib Medical University Journal 2023; https://doi.org/10.3329/bsmmuj.v16i4.60341Quality of life among adolescents with substance use disorders 201 *Student t-test or ANOVA