Transcript Dr Gerry McCarney – Complex Range of Needs

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
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
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 alFagan, 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
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:
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
Self-actualisation
Autonomy &
aesthetic
Help me ,
I cannot
stop
using!
Self-esteem
Love & Belonging
Safety
Physiological needs
The ‘need’ to use drugs can override all of the above
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, nonjudgemental 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
Exploratory
experimental
dependent
hedonist
DRUG USE
habitual
Social peer grp
compensatory
Why treat?
‘Normal for adolescents’?- rebellion, peer
involvement, individuating, experimentationBUT….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!
COST-EFFECTIVE- Godfrey 2004- UK studyfor every £1 invested in Rx, save between £918. Looked at settings from Tier 1 to Tier 4.
Keating- $7 return for every $1 spent.
Crime- proposed link to 29% drop in crime199599 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
Needs may
pre-date, worsen
with or be a
consequence of
drug use.
COPING /LIFE
SKILLS,
DEPRESSION,
ANXIETY,
CRAVINGS, VIRAL
STATUS,
OVERDOSE RISK,
ABCSCESSES,
TRAUMA,
DEPRESSION,
ANXIETY,ADHD
HUNGER
COLD
Young Person
SELF HARM,
ACCOMODATION,
BENEFITS,
PSYCHOSIS,
FAMILY ACCESS,
MOTIVATION ,
TRAUMA,
DOMESTIC
VIOLENCE,
ANGER,
LEGAL ISSUES,
EMPLOYMENT,
CONCENTRATION
EMOTIONAL
DYSREGULATION
SCHOOL,
SEXUALITY
Response to treatment needs
MULTI-AGENCY
medical /surgical
Rx/ Medication
PARTNERSHIP
Substitution Rx
WORKING
Needle exchange
Screening &
education
Functional
analysis
Viral Screening
Young Person
Counselling
Brief MI
CBT
Family therapy
Informatio
n
Liaison with
SW,
probation,
childcare,
family,
contraceptive
advice
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
Listen to what young people tell us- try to develop
services that they will engage with.
Careful common assessment, information sharing, multiagency 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
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
Tier
level
Specialist skills
available to help
young drug
users
Type of
adolescent
accessing
service
Type of
intervention for
drug use
Intervention
delivered by
Examples of
such
services
Intensity
and
duration
NOT either
CAMH or CAA
Start of drug
use
Basic advice +/referral
Individual
professional
Teacher,
SW, GP,
A&E, PO
Low
intensityongoing
Either CAMH or
CAA
Problems
due to drug
use
Basic
counselling,
brief
intervention,
harm reduction
Individual or
MDT
CAMHS,
Addiction
DTF,
Medium
intensityMedium
duration
Both CAMH &
CAA based in
the community
Substantial
problems
due to drug
use
Specialist
counselling,
family therapy,
medication
Specialist
MDT in
adolescent
addiction
Specialist
adolescent
addiction
service
Hiintensity,
Short /
medium/
long term
CAMH & CAA at
In-Patient / Day
hospital
Severe
problems or
drug
dependence
Individual &
family therapy
medication,
residentialdetox / stabilise
specialist
MDT in
adolescent
addiction
Specialist
day hospital
or in-patient
adol.
Addiction
Very high
intensity ,
Short/
medium/
long term
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
‘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
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
90
80
70
Opiates
Methadone
Cocaine
Cannabis
Benzo.s
Amphet.
Alcohol
60
50
40
30
20
10
0
2004
2005
2006
Ready to stop?
Prochaska &
Di Clemente
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
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
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
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
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
Early menarche- more smoking & drinking
Disinhibition, reduced recall and selfawareness
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
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
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
U17s by gender, 1995-2004.
500
450
400
350
300
Male
Female
250
200
150
100
50
0
1995
1997
1999
2001
2003
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
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
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!
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.’