COMPLEX NEEDS OF YOUNG DRUG USERS & OUR TREATMENT RESPONSE

1. COMPLEX NEEDS OF YOUNG DRUG USERS & OUR TREATMENT RESPONSE National Drug Treatment Centre Board Conference Dublin, November 16/17th, 2006 Dr. Gerry McCarney

2. 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

3. 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.

4. 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

5. 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

6. 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

7. Maslow’s Hierarchy of Need Help me , I cannot stop using! The ‘need’ to use drugs can override all of the above

8. 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

9. Why people use drugs

10. 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

11. 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)

12. 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

13. 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

14. 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.

15. 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.

16. 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.

17. 4 TIER MODELCAMH-child & adolescent mental health/ CAA- child & adol. addiction Tier 1 Tier 2 Tier 3 Tier 4

18. 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.

19. 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.

20. 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.

21. YPP urinalysis results over past 3 years

22. Ready to stop?

23. 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’.

24. 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

25. 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

26. 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.

27. 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.

28. 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

29. 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

30. 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.

31. 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 .

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

33. 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

34. 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.

35. 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.

36. 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.’