Setting up a Drug and Alcohol service for the “Marginalized Tribe” Trials and Tribulations _________________

Dr. K.A H Mirza MRCPsych, FRCP©Senior Clinical Lecturer and Consultant Adolescent Psychiatrist

Drug and Alcohol Use in the Drug and Alcohol Use in the Young:reasons for Young:reasons for

concern concern More Young people are using drugs and alcohol High risk of accidents, suicides and violent

crimes Disrupts Families, causes distress to near and

dear School failure ; Dropping out, Blighted Future High rates of Mental illness such as Depression,

Anxiety, and Psychosis. Most important risk factor for suicide in young

people with Severe Mental Illness. High health Care costs, Burden to society

Developing Services : Session Plan

Principles of service development Historical perspectives Developmental Perspectives Systemic Perspective

Practice 4-Tier model of service delivery Our Tier2-3-4 teams A few anecdotes and evidence so far….

"The children now love luxury;

they have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise. Children are now tyrants… They contradict their parents, chatter before company, and tyrannize their teachers”.

"The trouble with youngsters today..."

The Story of Drugs and Society:Faustian Pact

All societies and civilisations grappled with the benefits and dangers of Drugs and Alcohol.

Alcohol, cannabis and opiates were used as Medicines or as an integral part of religious festivities from as early as 3000 B.C

Attitudes towards drugs changed over time Attitudes towards drugs oscillated between

unbridled enthusiasm or outright condemnation

Alcohol: Fury of the Emperor

“Drunkenness is the root and source of all evil and of all perditions….it is the cause of all the adulteries, rapes, corruption of virgins, and fights with relatives and friends, all the thefts and robberies, and banditry and violence; it is also the cause of all lying, and gossip, and slander”

Calderon Naraez, Emperor of Mexico, 1691

Drug and alcohol use

is not a problem for youngsters: it is an invariable part of normal adolescence.

They will grow out of it …Why make a fuss?

Developmental perspective Our Favourite Myths and

Preferred Truths

Once they have dabbled in drugs they seldom get out . A single puff and you are hooked for life!

‘Slippery slope’ towards the life of a junkie….

Most young people are exposed to drugs A large Majority experiment with drugs Many use drugs and alcohol socially Highest peak of use between 15-18 years Most show decline in use by 24 years of age A Substantial Minority of Young People

continue to show Drug and Alcohol problems in to adult life.

Developmental Perspective “The truths”: from research

Natural History Of Drug and Alcohol Use

-0.1

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

7 9 11 13 15 17 19 21 23 25

AlcoholCigarettesMarijuanaPsychedelicsCocaine

Kandel and Yamaguchi, 1972

Definition of Substance use: Developmental perspective

Non-use (abstinence) Experimental stage Social stage At Risk or Prodromal stage Problem use Dependence

* (Mirza et al , 2005)

Experimental Stage

Primary motives : curiosity and risk taking

Setting: alone as well with peer group A rite of passage with themes of defiance Emotional impact : Mind altering effects

of drug are secondary to the associated thrill

Frequency of use: occasional at best

Social stage

Primary motive: Social acceptance-“to fit in” Setting: facilitated by Peer Group Mind altering effects (on mood and

behaviour) are recognised as important variables.

Frequency: occasional but variable May be associated with significant dangers

At risk or Prodromal Stage

Primary motive: Coping with painful, traumatic issues in life, or negative emotions, or simply getting a high

Setting: usually private Active drug seeking behaviour Frequent use Relationships strained, school work suffer Seldom seek help (suffer in silence) Many young people attending our services are at this stage

Stage of Problem Use

Substance use become the primary means of recreation, coping with stress or both

Regular use Life style changes to accommodate substance use Negative consequences in various spheres of life Continued use despite negative consequences Change in peer group

Majority of young people we see fit this profile

Stage of Dependence

Compulsive use and Loss of control over use Development of Tolerance Physiological Withdrawal symptoms Physical/Psychological complications Significant problems in almost all areas of life/ Personality changes Rapid reinstatement after abstinence

Very few young people present with this profile

Drug and Alcohol use: A systemic view of Risk and protective factors

Adolescent

Family

School

Drug

Peer Group

Society

High Risk Groups

Children of drug misusing parents Young Offenders Excluded from school /Truants Young people looked after Young homeless Young people leaving care Those with Mental health

Problems Frequent attendees of A&E

services

Maria:the girl with angelic face

Homage Maria is a frail young girl. She is almost

17 but looks much younger. She experienced multiple traumas in early childhood (Drug abuse in father, mental illness in mother, sexual and physical abuse, neglect etc).

She was taken in to care at the age of 7, was looked after by many caregivers. She was reasonably bright but had specific problems with reading and writing.

She struggled at school, both academically and in making friends.

Started using cigarettes at 11 years, alcohol

at 13years and cannabis at the age of 14. Regular use of Cannabis to “get through the day”.

Left school at 14 years, ran away from foster homes /children’s homes,(frequent breakdowns in care placement).

Maria is currently in B& B accommodation by Social services. She is engaged in prostitution and uses multiple drugs including crack cocaine.

She has little contact with any care agencies except the voluntary worker whom she sees once in a week.

Maria:the girl with angelic face

Maria: the girl with no face:

More recently she was found to be overactive, hearing voices and being physically aggressive to strangers…….

What are the risks involved? How could we engage her in

treatment? How do we manage our own

nightmares?

Is there a Role for CAMHS?

Significant rates of Co-morbid mental health issues (affect course, treatment response etc)

Similarities in Risk and protective factors Striking similarities between the

neurobiological basis of addictions and mental illness

Similarities in response to treatment (esp.with Conduct and Oppositional defiant disorder).

Clear Roles for CAMHS and Child health

CAMHS and Paediatrics should be part of a Wider Consortium that includes Social Services, Voluntary Agencies, Youth Justice System and Education

Funding from multiple agencies

Clearly demarcated roles and responsibilities

A systemic frame work aiming at local solutions and actively involving the general public.

The National Drugs Strategy: key aims

Preventing today’s young people from becoming tomorrow’s problematic drug users

Universal programmes of education for all young people and their families

Early identification of drug or alcohol problems Provide support and treatment for the most

vulnerable young people

HAS (2002) Model of

Service Development: the 4-Tier Model

Tier 1: Generic services which includes drug education in school and community, policies in school, information about drug services, advise and support to young people and their cares.

Tier 2: Targeted Services for vulnerable young people (targeted prevention and early Intervention

Tier 3: Specialist substance misuse services and other specialist services working with an identified drug/alcohol problem and and co-existing mental health, social, family school issues

Tier 4: Specialist Services for those with severe drug use and co-existing complex needs. May include short term detoxification. substitute prescribing, Inpatient beds for those with Dual diagnosis, Day treatment services, Rehabilitation units

Matching Interventions to Stages of Substance use/misuse

Non-use (abstinence) Universal Prevention ________________________________________

Experimental use Universal prevention Social use _____________________________________ At risk stage Targeted Prevention

________________________________________ Problem use Treatment and Dependence Maintenance

Rules of engagement are different in an urban

Jungle Lambeth is well known for its Great Cultural

Diversity 38% Ethnic Minority; 157 languages in schools One of the most deprived boroughs in England One in five 16-18 year olds are not in education,

employment or training High rates of

Poverty, unemployment, Teenage pregnancy Children on at risk register/Looked after children

Plenty of Crack houses and a Million £ illegal drug trade

Many people in the borough have lost their ability to hope and dream (‘Marginalized Tribe’).

Little recreational facilities for young people

Universal audience: •28,000 YP in Lambeth between 10-19•87 Schools

Target groups:YOT: 470Looked After C: 665Excludees:54MH problems: 160

Making the 4-tier Model Work

Lambeth Solutions

Treatment Group: 170 YP

Specialist Treatment andhabilitation

Tier 4

Tier 3

Tier 2

Tier 1

Universal prevention

Targeted prevention

Treatment

Lambeth DAAT services

Drug Education Team:

work with schools targeted treatment

provision

Safe Space:needs of Young women

at risk of or involved With sexual exploitation

Social servicesLink Within

Children and families team

YOT:

specialist worker based within

the young offending team

ACAPS:

for the hardest to reach young people

especially from Black communities

HighNRG: specialist

counselling for young LGB

community

LCPTfor young people

from the Portuguese community

CAMHS: specialist team For those with

Substance misuse and mental health needs

Lambeth DAAT Virtual,

Integrated team

Whole Systems Approach

Skills development

InformationSharing

Case/ Risk Management

Clinical Support,

Psychiatric input

Peer Support and supervision

Research

Innovative service

Development

F Systemic/

Family Interventions

Lambeth DAAT Virtual,

Integrated Team

Planning of Services: Role of Clinicians on the coal-face reality

DAAT Sub group Social Services

YPSM Plan

Practitioners Group Support and development

Information from practice and case management ensure strategy is relevant to the real needs of Young people

The Safer Lambeth Partnership( Health,SS, education etc)

Children and Young people Plan

What We Have Achieved: some boring statistics

Strong network of services to meet the needs of all young people in Lambeth: easy accessibility to a range of services without stigma

Young people substance misuse services made meaningful contact with over 6000 young people in 2005/06

Over 1900 people (117 YP) in Lambeth received treatment for substance misuse in 2005/06

Guidance and best practice: Stand and deliver – drug education. Working with substance using parents, their children YP directory of services/ website

What We Have Achieved: some boring statistics

• Development of innovative practices, research Group treatment (YP: recreational therapies Parent Groups using narrative/systemic ideas Pilot study of Motivational Intervening:

feasibility,costs, and fidelity to therapeutic approach Developed Substance use screening tool MASQ:

data analysis currently under way to establish validity Early stages of a pilot study to explore the efficacy

and safety of Systemic Motivational therapy in young people and their families

Conclusions: Take Home Points

Substance Use is not a normal, invariable part of adolescence.

Substance use can lead to persistent problems in a significant minority of young people, especially if there are more risk factors than protective factors.

Drug use is often just one of the problems and interventions should address multiple difficulties

Effective treatment strategies are available now Flexible, Muli-modal, Interventions involving all

people/systems involved show the best outcome Therapeutic Nihilism is our worst enemy!`

k.mirza@iop.kcl.ac.uk or kamirza@gmail.com

Thank You