Society for the Study of Addiction by liaoqinmei


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

         Dr John Fagan
        Dr Bobby Smyth
       Dr Leena Naughton
1. 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).
2. By international standards, Dublin has a relatively high incidence of
   young opiate abusers.
3. Young people with major addiction issues have complex and multiple
   needs in addition to substance misuse (Chrome et al 2000, Spooner et
   al 2000).
4. 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
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
          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

    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
  • 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
  • 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

• 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.
• 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).
 Structure of Primary Family :
• 28 cases (30%) – single mother.
• 6 cases (7%) – single father.
• 19 cases (22%) - a parent-partner
• 26 cases (30%) - both biological parents.
• 2 cases (2%) - foster parents.
• 3 cases (3%) – other relative.
• 2 cases (2%) – adopted family.
          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
• 23 (27%) had a history of foster-care, and a further 44 (51%)
  reported they had received input from social workers in childhood.
               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.
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.
                    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.
              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.
                                  First Heroin use and school

• Mean age of first Heroin   45
  use was 14.7 years         40
  (IQR14-16).                35
- 20 (23%) did so before     25
  leaving school.            20
- 24 (28%) did so in the     15
  year they left school.     10
- 42 (49%) did so after      5
  leaving school.            0
                                  Before    Same        After
        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
1.   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.
2.   Early school leaving and its relationship to school leaving.
3.   Teenagers are less able to make changes to their social environment and
     this environment may work against recovery.
4.   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?
5.   Just over half of these young people accessing treatment were female.
     This contrasts with adult services where men outnumber women.
6.   Overall these young people come from a background of major
     disadvantage, family dysfunction and psychiatric co-morbidity.
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
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
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.

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