Opiate dependant teenagers in Dublin: A Descriptive study at treatment entry.

1. Opiate dependant teenagers in Dublin: A Descriptive study at treatment entry. Dr John Fagan Dr Bobby Smyth Dr Leena Naughton

2. Introduction • Ireland lies in the midband of the estimates for problematic drug users in the population aged 15-64, at 5.6/1000 in 2001 ( NACD 2003). • By international standards, Dublin has a relatively high incidence of young opiate abusers. • Young people with major addiction issues have complex and multiple needs in addition to substance misuse (Chrome et al 2000, Spooner et al 2000). • Earlier onset of drug use is associated with a poorer outcome (Robins LN 1984, Kandel et al 1992, HAS report 1996). 5. These very young opiate abusers are exposed to similar levels of risk to adults. 6. Methadone maintenance significantly reduces harm associated with opiate abuse (Farrell et al 1994, Marsch L 1998, Gossop et al 2001). 7. There is controversy over the prescribing of methadone to young people. 8. Burniston et al (2002), looking at the UK experience, maintain that there is no evidence that the abstinence approach works with young people, and that a treatment focus on the immediate goal of abstinence may in fact discourage engagement and retention in treatment. 9. AACAP (1998) guidelines say that abstinence should be kept as a long-term goal, but acknowledges the acceptability of interim harm reduction strategies.

3. Rational for this study: As a step in the development of a treatment programme specifically for opiate dependant teenagers, it is necessary to identify co-existing psycho-social problems so as to better address these where present, thus reducing/preventing further harm whilst laying the foundation for stabilisation and an eventual successful detoxification. To explore for gender differences. As a baseline study for further research on treatment outcomes.

4. SETTING AND HISTORY OF THE YOUNG PEOPLES PROGRAMME The Drug Treatment Centre Board is the largest and longest established Addiction Treatment Centre in Ireland. Its aim is to provide a broad range of specialist treatments for a variety of drug using populations and those requiring specialist psychiatric, psychological, social and medical interventions. • In March 2001, a nurse and 2 project workers were assigned to identify, engage with, and support teenagers attending the adult floors. • In January 2003, with the appointment of a project manager, a part-time senior social worker and part-time family therapist, working under the supervision of a child and adolescence psychiatrist with a special interest in addictions, this initiative was transferred to a youth friendly unit on a separate floor to the adult. • In February 2004, the multi-disciplinary team was expanded with the appointment of a fulltime clinical-research senior psychologist and psychiatric registrar and a half time drug counsellor.

5. Participants: • Consecutive new attendees under 19 years old, who were assessed between October 2000 and September 2006. • Included if diagnosed as Opiate dependent (ICD-10) following assessment interviews by the project manager, psychiatric registrar and Consultant Psychiatrist, and commenced on methadone. • Excluded if level of drug use did not warrant methadone, or the young person dropped out of the assessment process. • Data was obtained through review of semi-structured interview tool, doctors case notes and supervised urine drug screens.

6. Results • Number of participants - 86 young people were included. • Age - the mean age was 16.8 years(14-18). • Gender – 46 (53.5%) of the group were female. • School - the mean age of leaving school was 14.4 years (IQR 14-16). - only 5 reported ongoing school attendance. - of those with a recorded reason for early school leaving, 43 (50%) dropped out, and 12 (14%) were expelled. • Work – 32 out of 81 (37%) had a history of employment. • Relationship - 44 (of 84 cases) in a relationship - 38 reported heroin use by their partner. - girls were more likely to have a partner (P<0.001).

7. Structure of Primary Family : • 28 cases (30%) – single mother. • 6 cases (7%) – single father. • 19 cases (22%) - a parent-partner household. • 26 cases (30%) - both biological parents. • 2 cases (2%) - foster parents. • 3 cases (3%) – other relative. • 2 cases (2%) – adopted family.

8. Living with at assessment: • Parents – 50 cases (58%). • Other relative – 3 cases (3.5%). • Partner – 8 cases (9.3%). • Friends – 6 cases (7%). • Squatting – 3 cases (3.5%). • Foster family – 3 cases (3.5%). • Hostel – 13 cases (15.1%). In addition: • 26 (30%) said they were homeless at the time of assessment. • 41 (48%) had experienced being homeless at some point in their lives. • 23 (27%) had a history of foster-care, and a further 44 (51%) reported they had received input from social workers in childhood.

9. Forensic History: • 38 (48%) had a history of a previous conviction. • 25 (31%) had spent time in prison or remand. • 33 (38%) were facing criminal charges at assessment.

10. Past Psychiatric: • 45 (52%) had seen a psychiatrist. • 9 (11%) had been admitted to a psychiatric hospital. • 27 (33%) had a history of deliberate self harm. Family Addiction History: • 38 (45%) had a history of opiate abuse by a sibling. • 11 (13%) had a parental history of opiate abuse. In 4 cases, both parents used opiates. • 46 (58%) had a history of parental alcohol abuse.

11. Drug History : • Median age of first illicit drug use was 12 years (IQR 11-14), and in 83% of cases this was cannabis. • Mean age of first heroin use was 14.7 years (IQR 14-16). • 26 (30%) were currently injecting and 15 (58%) of these had not been tested for blood-borne diseases. • 44 (51%) had a history of injecting – 24 (55%) never screened for blood-borne diseases. • 45 (52%)reported poly-drug use. • The median period of injecting drug use before seeking treatment was one year – (range 6-24 months). • Recorded current opiate of abuse was: • heroin in 66 cases (77%). • methadone in 1 case (1%). • heroin and methadone in 19 (22%) cases. • Patients reported using a median of 3.5 “bags” of heroin per day (IQR 2.5-5). • Street methadone - 67 cases (78%) admit to using in the past. - 44 cases (51%) admit to use in the last 30 days.

12. Blood Borne Disease • Self report of prior screening – - 19 (22%) said they were HCV negative. - 2 (2%) said they were HCV positive. - 56 (65%) said they had not been tested. - 9 (10%) were not sure ! • Actual HCV status after assessment – - 21 (24%) HCV positive. - 14 (16%) declined testing. - 3 of those who claimed to have not injected tested positive for HCV. - As expected, a history of injection strongly predicted a HCV positive result (P = 0.001). Gender did not predict HCV status. • No young person tested positive for HIV antibody.

13. First Heroin use and school leaving • Mean age of first Heroin use was 14.7 years (IQR14-16). - 20 (23%) did so before leaving school. • 24 (28%) did so in the year they left school. • 42 (49%) did so after leaving school.

14. Some significant findings by Gender: • Boys demonstrated earlier school leaving – P =0.01. • Boys were more likely to have a sibling misusing opiates P = 0.025 • Boys were more likely to have a sibling misusing alcohol P = 0.007 • Girls were more likely to report having a partner ( P< 0.001), however overall gender did not predict that this partner also misused drugs. • Girls were more likely to have a history of taking a deliberate overdose – P=0.007

15. Discussion • The drug profile of these opiate dependent youths can be compared to the results described by Ilana Chrome (2000) – - mean age of 1st drug use 12 yrs v 13.3 yrs. - mean age of 1st heroin use 14.7 yrs v 15.8 yrs. - currently injecting 30% v 62.5%. - history of injection 51% v 70%. - mean age of 1st heroin use to assessment 24 v 16 months. • Early school leaving and its relationship to school leaving. • Teenagers are less able to make changes to their social environment and this environment may work against recovery. • These teenagers have been diagnosed as opiate dependent, and are exposed to similar risks to adults. The majority have used methadone already – abuse or managing their own addiction? • Just over half of these young people accessing treatment were female. This contrasts with adult services where men outnumber women. • Overall these young people come from a background of major disadvantage, family dysfunction and psychiatric co-morbidity.

18. Discussion 1. The drug profile of these opiate dependent youths can be compared to the results described by Ilana Crome (2000). The mean ages of first use of any illicit drug and first opiate use are earlier - 12 yrs v. 13.3 yrs and 14.7 yrs v. 15.8 yrs respectively. However fewer were currently injecting ( 30% v. 62.5%), or had injected in the past (51% v. 70%). The mean time from first heroin use to assessment was longer (24 months v. 16 months). 2. Early school leaving and its relationship with drug use – see table 1. Though drugs may have contributed to poor academic performance and early school leaving, many of these young people began using heroin after leaving school. This highlights the possibility of prevention, if these at-risk students can be identified and engaged, instead of being allowed to simply drop out of school. 3. Adolescents are less able to make changes to their social environment and this environment may work against recovery. Many of these teenagers were currently homeless or had been homeless – was this in order to escape an intolerable home environment? This experience exposes them to escalating drug abuse and risk, and increases the need for engagement and treatment as early as possible, as drug abuse and homelessness are interrelated, and often create a vicious cycle. A recent NACD (2005) survey revealed family conflict as the most common cited reason leading to homelessness, and drug abuse the second most common reason for continued homelessness (after lack of access to alternative housing). 4. These teenagers are diagnosed as opiate dependant, and are exposed to similar risks to adults – why deny them access to methadone, an evidenced based treatment? 5. Majority have tried methadone – are they abusing diverted methadone or managing their own addiction? 6. Gender issues – why have as many females presented for treatment as males? This contrasts with adult services where men greatly outnumber women. Does this reflect the capture-recapture study in 2001 (O’Kelly et al) which showed a 48% drop in the prevalence of opiate abuse in males aged 15-24,whilst the prevalence among females did not change. 7. These young people come from a background of major disadvantage, family dysfunction and psychiatric co-morbidity. Complete abstinence may not be their priority in seeking treatment. Instead they may be seeking relief from instability in their lives. In order to move these teenagers towards change in their use of drugs, services need to recognise and address their needs and issues. To do this, services need to employ a wide range of bio-psycho-social interventions (including methadone) and facilitate efficient interagency co-operation.