Complex needs of young drug users our treatment response
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COMPLEX NEEDS OF YOUNG DRUG USERS & OUR TREATMENT RESPONSE . National Drug Treatment Centre Board Conference Dublin, November 16/17 th , 2006 Dr. Gerry McCarney. Complex needs of young drug users and our treatment response. A look at the needs of young people Drug use in adolescence

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Complex needs of young drug users our treatment response

COMPLEX NEEDS OF YOUNG DRUG USERS & OUR TREATMENT RESPONSE

National Drug Treatment Centre Board Conference

Dublin, November 16/17th, 2006

Dr. Gerry McCarney


Complex needs of young drug users and our treatment response

Complex needs of young drug users and our treatment response

  • A look at the needs of young people

  • Drug use in adolescence

  • Why treat now?

  • Principles of development and delivery

  • How we are responding to this need in an Irish context – service model

  • Special needs / vulnerable groups


Review of early clients

review of early clients

  • 86 consecutive clients, 54/46 - female : male

  • Adolescent age range 14-18, mean 16.8 yrs

  • Drug history -Opiate users +/- other drug use

  • 1st drug use age 12 , heroin @ 14.7

  • Daily opiate use 12/12

  • Polydrug use 60%, inc. street methadone (78%)

  • IVDA hx. 59% (33% currently), 64% not tested

Study carried out by Dr.John Fagan et al-

Fagan, Smyth & Naughton.


Ypp study findings cont d

58% living with parents

30% homeless!

(half in hostels)

9% partner

48% had been homeless

27% in care before

51% has SW input

Left school @14.4yrs, boys earlier

14% expelled, 50% dropped out

37% had work history

YPP- study findings cont’d


Ypp study findings

YPP- study findings

  • 52% in relationship, 45% overall had a heroin using partner

  • 45% hx. sibling opiate, 58% parental EtOH

  • 48% convicted, 31% prison, 38% charges

  • 52% saw psych., 11% admitted, 33% DSH

  • BOYS earlier to leave school, use heroin, be in care,+ family hx.

  • GIRLS-more likely to have relationship with user


What this says attendees at ypp exhibit a history of

What this says.. attendees at YPP exhibit a history of:

  • Early drug use progressing to daily use

  • Have early care disruption/chaos

  • + family history of substance misuse

  • Use many drugs, many IVDA not tested

  • Significant forensic involvement

  • Significant co-morbidity

  • Multi agency integration approach required


Maslow s hierarchy of need

Maslow’s Hierarchy of Need

Help me , I cannot stop using!

The ‘need’ to use drugs can override all of the above


Needs of young drug misusers

Needs of young drug misusers

  • Physical- shelter, food, clothes,

  • Safety- from adults, peers, society, drugs

  • Belonging- need for love-family attachment, communication, contact from others, non-judgemental care,

  • Self-esteem- esteem, self concept, negative self view, anxiety, depression

  • Autonomy- still dependent -on whom?

  • Self actualisation- SUD can delay developmental process


Why people use drugs

Why people use drugs


Why treat

Why treat?

  • ‘Normal for adolescents’?- rebellion, peer involvement, individuating, experimentation- BUT….adult addiction starts in adolescence.

  • SUD has ‘epidemic character’ in adolescence

  • Critical time – development, social & emotional learning, education & employment.

  • Co-morbidity , psychosocial damage, criminality, trans-generational prevention.

  • What can we prevent now- (Harrison 2001) – while ¼ remain clean, Rx does reduce overall use, symptoms, criminality, emotional distress


More reasons to treat

More reasons to treat!

  • COST-EFFECTIVE- Godfrey 2004- UK study- for every £1 invested in Rx, save between £9-18. Looked at settings from Tier 1 to Tier 4.

  • Keating- $7 return for every $1 spent.

  • Crime- proposed link to 29% drop in crime1995-99 in Dublin area due to increased MMT

  • Hospital visits- alcohol, heroin, prescription drugs, injury, overdose- heroin related to more ‘all cause’ visits over time ( Tait 2002)


Treatment needs of young people

Treatment needs of young people

Needs may pre-date, worsen with or be a consequence of drug use.

CRAVINGS, VIRAL STATUS, OVERDOSE RISK,

ABCSCESSES, TRAUMA, DEPRESSION, ANXIETY,ADHD

biological

HUNGER

COLD

COPING /LIFE SKILLS, DEPRESSION, ANXIETY,

SELF HARM,

PSYCHOSIS,

MOTIVATION , TRAUMA,

ANGER, CONCENTRATION

EMOTIONAL DYSREGULATION

ACCOMODATION, BENEFITS,

FAMILY ACCESS,

DOMESTIC VIOLENCE,

LEGAL ISSUES, EMPLOYMENT,

SCHOOL, SEXUALITY

social

psychological


Response to treatment needs

Response to treatment needs

medical /surgical Rx/ Medication

Substitution Rx

Needle exchange

Viral Screening

MULTI-AGENCY

PARTNERSHIP

WORKING

biological

Screening & education

Functional analysis

Counselling

Brief MI

CBT

Family therapy

Young Person

Liaison with SW, probation, childcare, family, contraceptive advice

psychological

social

Information


Service development

Service development

  • Core aspiration- young people will use us! i.e., engagement & retention

  • Current best practice, evidence based, accessible.

  • Respect dignity, ethnicity, language, culture.

  • Non-complex presentation of information .

  • Information- how to get help, drugs, feelings, sexual matters, day activities, training, family.

  • Policies & rules-client & staff safety, legal framework- police, probation, courts.

  • Confidentiality- not absolute-child protection.


Service delivery

Service delivery

  • Listen to what young people tell us- try to develop services that they will engage with.

  • Careful common assessment, information sharing, multi-agency working. Multi-system intervention

  • Increase accessibility- self help programmes, drop in centres, OP access, day Rx centres.

  • Information based intervention is suitable for Tier 1. Peer support and advice. Can be delivered in schools and youth groups also.

  • Support & education for Tier 1 & 2 from Tier 3. Referral pathways clarified.

  • NEED TO INVOLVE FAMILY IF POSSIBLE.


4 tier model

4 TIER MODEL

  • Tier 1- No specialist skills in either adolescent MH or Addiction. Any professional working with young person.

  • Tier 2- specialist skills in one of addiction or adolescent

  • Tier 3- specialist skills in both areas. New developing service.

  • Tier 4- specialist skills in both, and an inpatient / day hospital service.


4 tier model camh child adolescent mental health caa child adol addiction

4 TIER MODELCAMH-child & adolescent mental health/ CAA- child & adol. addiction

Tier 1

Tier 2

Tier 3

Tier 4


Tier 4 service thus far

Tier 4 service thus far..

  • Tier 4 team – Project manager, key workers, nurses, counsellors, family therapist, SW, psychologist, doctors.

  • Complementary- Artwork, Reiki, Music

  • Token economy, card system, contingency mx, careplanning, case review, keyworker.

  • Offer intensive day hospital /residential.


Role of keyworker

ROLE OF KEYWORKER

  • ‘The link’ between young person & service

  • Co-ordinator / advocate / educator / identifier of resources / engager

  • Frequent positive contact & support

  • Monitor drug use & progress

  • Facilitate engagement with family & team

  • Limited outreach capacity

  • Contact, connection, care.


Tier 3 2 1 service

Tier 3,2,1 service

  • MDT Tier 3- two being developed in the community in Dublin.

  • Multidisciplinary- core competency mix

  • Local accessibility and integration

  • Adaptable- offer brief early intervention

  • Education and advice supportive role

  • Multi-agency Tiers 1 & 2- some already in place, others in need of development.


Ypp urinalysis results over past 3 years

YPP urinalysis results over past 3 years


Ready to stop

Ready to stop?


How do we approach a session

How do we approach a session?

  • Each is still a young person, and deserves culturally appropriate respect as a person. Generally, the process is as for any other.

  • Ensure the reason for and process of the assessment are explained.

  • Drug issues need not be the first topic.

  • If intoxicated, can ask advice of a colleague.

  • If threatening, ask advice of colleague, and do not continue session. This is not common!

  • Make the YP feel ‘it is about you & for you’.


Questions to ask re drug use

Age at first use?

Which drugs tried

When started using on daily basis

Method of taking – po, intranasal, IVDA

Weekly /daily pattern

Go thro’ each drug

What it does for you?

How much it costs

How they pay for it

Knowledge re: risks of drug use- effects of drugs, IVDA risk, sexual

Forensic history

Effect on friends & family

Family history-context

Questions to ask re: drug use


Symptoms and asud

Paranoid thoughts

Delusions

Hallucinations

Thought disorder

Concentration

Motivation

Behaviour change

Speech, affect

Depression / Mania

Anxiety

Restlessness

Appetite, energy

Skin, nose, eyes

Unexplained weight loss

Self care, strange

Symptoms and ASUD


Co morbidity dual diagnosis

Co-morbidity/ dual diagnosis

  • More violence, suicidal behaviour, service costs and poor Rx outcome in both populations.

  • Increased threshold for entry to both services.

  • 2003-UK. CMHT- 44% reported drug/harmful alcohol use. (adult)

  • In addiction services- anxiety & depression both near 30%.Personality disorders common. Psychosis 10%.

  • Poor coping, relationship problems, hopeless.

  • DD-adolescent- 31% had psych.visit – 54% with prior Dx visited- girls & internalisers more likely -Sterling SF 2005

  • High rates of depression, anxiety, eating dis, ADHD, CD.


Early age alcohol consumption

Early age alcohol consumption

  • Adolescent alcohol- 1% A/E admissions, 50% trauma admissions for that age group

  • Underage drinking in unsupervised locations

  • Aggression, violence, accidents and trauma

  • Road traffic accidents- young men especially.

  • DSH, depression, anxiety, PTSD , ADHD(CD).

  • Alcohol problems are more predictive of suicidal behaviour in males.


Sexual risks

Sexual risks

  • Early menarche- more smoking & drinking

  • Disinhibition, reduced recall and self-awareness

  • Sex for drugs, sex work

  • STIs and early pregnancy

  • Sexual / contraception knowledge

  • Condom negotiation skills


Profile of pregnant drug user

Single & Poor

Unemployed

Unskilled

Lack child care facilities

Suffered trauma

Poor parenting skills or confidence

Increased stigma when pregnant

Fear / suspicion of services

Poor nutrition & dental care

Infectious disease risk

50% have partner using

Profile of Pregnant Drug User


Treatment aims day 2003

Treatment Aims (Day, 2003)

  • Practical & emotional support offered

  • Ante- and post-natal use of multiple services- obstetric, medical, addiction, SS.

  • Early booking appt. ensures safety & allows education re: care and benefits

  • Promotion of child welfare

  • Period of engagement is for duration of pregnancy and beyond, including advice re: family planning.


Forensic association

Forensic association

  • Crime association- may share same risk factors only.

  • predictive dose-response relationships in both directions.

  • Violence, vandalism, fraud ~ adolescent drug use

  • Theft not only assoc. with drug use. Peer behaviour & prior forensic hx also determine crime (Hammersley).

  • Criminality reduces after residential Rx.

  • High rate of SUD in prison population- all should be screened-Audit Commision UK & others

  • Polydrug use ~90% boys .


Drug offence prosecutions for u 17s by gender 1995 2004

Drug offence prosecutions for U-17s by gender, 1995-2004.


Homeless vicious cycle

Homeless – vicious cycle

  • Family breakdown & drug / alcohol use.

  • SUD can exclude from a/c- many young

  • Predictors- peer & family drug use & attitudes, psychological well-being

  • Very difficult to engage- often hx of care

  • Safety- violence, sexual violence, adult manipulation, criminality

  • Treatment access after leaving prison


Early school leaving

Early School- leaving

  • Many leave school early- < 14.

  • Link in with delinquent peer group.

  • 1/10 no qualifications, 1/5 no Leaving Cert.

  • Effects of drug use- poor school performance, lose positive peer group and social skills enhancement.

  • ESPAD figures. Comiskey & Miller 2000.

  • Polydrug use.


Adolescent drug users different from adults at presentation

Adolescent drug users - different from adults at presentation

  • Less dependence evident

  • Binge pattern more common

  • Intoxication effects prominent

  • Often reluctant patients, hence ENGAGEMENT a big issue- this can be over months.

  • Peer influence greater- family support vital.

  • Rehabilitation- creative thinking required.

  • Harm reduction is the overall aim- includes abstinence & stabilisation.


Thank you

THANK YOU!

  • Un Convention on the Rights of the Child Article 33 of UN CRC –

  • ‘States parties shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances.’


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