volume c, module 3: special populations: individuals with co-occurring disorders, women, and young...

Volume C, Module 3:Volume C, Module 3: Special Populations: Special Populations:Individuals with Co-occurring Disorders, Women, and Individuals with Co-occurring Disorders, Women, and

Young PeopleYoung People

Treatnet Training Volume C: Module 3 – Updated 18 October 2007

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Module 3: Training goalsModule 3: Training goals

1.1. Increase knowledge of the extent and Increase knowledge of the extent and nature of co-occurring psychiatric and nature of co-occurring psychiatric and substance use disorders and their substance use disorders and their treatment methods treatment methods

2.2. Increase knowledge of the critical Increase knowledge of the critical aspects of women’s addiction and aspects of women’s addiction and treatmenttreatment

3.3. Increase knowledge of the critical Increase knowledge of the critical aspects of young peoples’ addiction aspects of young peoples’ addiction and treatmentand treatment

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Module 1: WorkshopsModule 1: Workshops

Workshop 1:Workshop 1: Individuals with co-occurring psychiatric and Individuals with co-occurring psychiatric and substance use disorders: Identification and substance use disorders: Identification and treatment issuestreatment issues

Workshop 2:Workshop 2: Women: Addiction and treatment issuesWomen: Addiction and treatment issues

Workshop 3Workshop 3: : Young people: Addiction and treatment Young people: Addiction and treatment issuesissues

Workshop 1:Workshop 1: Individuals with Co-occurring Individuals with Co-occurring Psychiatric and Substance Use Psychiatric and Substance Use Disorders: Identification and Disorders: Identification and Treatment IssuesTreatment Issues

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Icebreaker Icebreaker

Who are the people most affected by Who are the people most affected by drug use in your country / region? How drug use in your country / region? How does their drug use affect your does their drug use affect your community?community?

15 Min.

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Training objectivesTraining objectives

At the end of this training you will:At the end of this training you will: Understand how psychiatric and substance use Understand how psychiatric and substance use

disorders interactdisorders interact

Understand the key issues in identifying and Understand the key issues in identifying and diagnosing these interacting disordersdiagnosing these interacting disorders

Understand the importance of and the methods for Understand the importance of and the methods for integrating treatment for individuals who have co-integrating treatment for individuals who have co-occurring disordersoccurring disorders

Know about promising practises for treating Know about promising practises for treating individuals with these disordersindividuals with these disorders

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What’s the problem?What’s the problem?

Estimates of psychiatric co-morbidity among clinical Estimates of psychiatric co-morbidity among clinical populations in substance abuse treatment settings range populations in substance abuse treatment settings range from 20% - 80%from 20% - 80%

Estimates of substance use co-morbidity among clinical Estimates of substance use co-morbidity among clinical populations in mental health treatment settings range populations in mental health treatment settings range from 10% - 35%from 10% - 35%

Differences in incidence due to: nature of population served (e.g, Differences in incidence due to: nature of population served (e.g, homeless vs. middle class), sophistication of psychiatric homeless vs. middle class), sophistication of psychiatric diagnostic methods used (psychiatrist or DSM checklist) and diagnostic methods used (psychiatrist or DSM checklist) and severity of diagnoses included (major depression vs. dysthymia).severity of diagnoses included (major depression vs. dysthymia).

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Categories of mental health and substance use Categories of mental health and substance use disordersdisorders

Mental DisordersMental Disorders Major DepressionMajor Depression Antisocial PersonalityAntisocial Personality Borderline PersonalityBorderline Personality Bipolar IllnessBipolar Illness Schizoaffective Schizoaffective SchizophreniaSchizophrenia Posttraumatic StressPosttraumatic Stress Social PhobiaSocial Phobia OthersOthers

Addiction DisordersAddiction Disorders Alcohol Abuse / Alcohol Abuse /

DependencyDependency Cocaine/ Cocaine/

AmphetaminesAmphetamines OpiatesOpiates Volatile ChemicalsVolatile Chemicals MarijuanaMarijuana Polysubstance Polysubstance

combinationscombinations Prescription drugsPrescription drugs

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Drug-induced psychopathologyDrug-induced psychopathology

Drug StatesDrug States WithdrawalWithdrawal

AcuteAcute ProtractedProtracted

IntoxicationIntoxication Chronic useChronic use

Symptom GroupsSymptom Groups DepressionDepression AnxietyAnxiety PsychosisPsychosis ManiaMania

(Source: Rounsaville, 1990)(Source: Rounsaville, 1990)

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The four quadrant framework for The four quadrant framework for co-occurring disordersco-occurring disorders

A four-quadrant A four-quadrant conceptual conceptual framework to framework to guide systems guide systems integration and integration and resource resource allocation in allocation in treating treating individuals with individuals with co-occurring co-occurring disordersdisorders

Less severemental disorder/

less severe substance

abuse disorder

More severemental disorder/

less severe substance

abuse disorder

More severemental disorder/

more severe substance

abuse disorder

Less severemental disorder/

more severe substance

abuse disorder

High severity

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DSM and ICD: The “Bibles”DSM and ICD: The “Bibles”

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DSM-III diagnosesDSM-III diagnoses (rates per 100 people)(rates per 100 people)

1 Month1 Month LifetimeLifetime

Any Alcohol, Drug or Any Alcohol, Drug or Mental Health Mental Health DisorderDisorder

15.715.7 32.732.7

Any Mental DisorderAny Mental Disorder 13.013.0 22.522.5

Alcohol DependenceAlcohol Dependence 1.71.7 7.97.9

Drug DependenceDrug Dependence 0.80.8 3.53.5(Source: Regier et al., 1990)

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Lifetime prevalence and odds ratiosLifetime prevalence and odds ratios

Alcohol OROtherDrug OR

Any mental 36.6% 2.3 53.1% 4.5

Schizophrenia 3.8% 3.3 6.8% 6.2

Any affective 13.4% 1.9 26.4% 4.7

Anti-social 14.3% 21.0 17.8% 13.4

Alcohol 47.3% 7.1

Regier, 1990

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Likelihood of a suicide attemptLikelihood of a suicide attempt

(Source: NIMH / NIDA ECA Evaluation)(Source: NIMH / NIDA ECA Evaluation)

Risk FactorRisk Factor Increased Odds of Increased Odds of Attempting SuicideAttempting Suicide

Cocaine useCocaine use 62 times more likely62 times more likely

Major depressionMajor depression 41 times more likely41 times more likely

Alcohol useAlcohol use 8 times more likely8 times more likely

Separation or divorceSeparation or divorce 11 times more likely11 times more likely

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Suicide: Certain populations are at higher riskSuicide: Certain populations are at higher risk

Suicide rates among those withSuicide rates among those with

ADDICTIONADDICTION

are 5-10 times higher than for those are 5-10 times higher than for those without addiction….without addiction….

(Source:(Source: Preuss / Schuckit, Am. J. Psych., 2003)Preuss / Schuckit, Am. J. Psych., 2003)

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Is suicide a mental health or co-occurring disorder Is suicide a mental health or co-occurring disorder issue?issue?

Alcohol strongest predictor of completed Alcohol strongest predictor of completed suicide over 5-10 years after attempt, OR = 5.18 suicide over 5-10 years after attempt, OR = 5.18 (Beck, 1989)(Beck, 1989)

40% - 60% of completed suicides across 40% - 60% of completed suicides across USA/Europe are alcohol / drug affected USA/Europe are alcohol / drug affected (Editorial: Dying for a Drink: Brit. Med. J., 2001)(Editorial: Dying for a Drink: Brit. Med. J., 2001)

Higher suicide rates (+8%) in 18- vs 21-year-old Higher suicide rates (+8%) in 18- vs 21-year-old legal drinking age states for those 18-21 legal drinking age states for those 18-21 (Birckmayer, J., Am. J. Pub. Health, 1999)(Birckmayer, J., Am. J. Pub. Health, 1999)

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Suicide in alcoholic populationsSuicide in alcoholic populations

4.5% of alcoholics attempted suicide within 5 4.5% of alcoholics attempted suicide within 5 years of detoxificationyears of detoxification (Mean age 40, N = 1,237)(Mean age 40, N = 1,237)

0.8% in non-alcoholic comparison group 0.8% in non-alcoholic comparison group (Mean age 42, N = 2,000)…(Mean age 42, N = 2,000)…

P < .001………..7X increased riskP < .001………..7X increased risk (Source: Preuss / Schuckit, Am. J. Psych., 2003)(Source: Preuss / Schuckit, Am. J. Psych., 2003)

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What do substance abuse treatment centers need to What do substance abuse treatment centers need to do?do?

Acknowledge that about half of their patients have been or Acknowledge that about half of their patients have been or are suicidal.are suicidal.

Be aware that these patients are at just as high a risk for Be aware that these patients are at just as high a risk for suicide than most “mental health” (MH) patients.suicide than most “mental health” (MH) patients.

Educate staff on recognising suicidal risk and have clear Educate staff on recognising suicidal risk and have clear procedures for intervening.procedures for intervening.

Deliver assessment and emergency treatment on site, or Deliver assessment and emergency treatment on site, or have close working relationship with MH agency and have close working relationship with MH agency and emergency service.emergency service.

Know that individuals with suicidal risk can be managed in Know that individuals with suicidal risk can be managed in substance abuse treatment. Much of the suicidal ideation substance abuse treatment. Much of the suicidal ideation and connected feelings will remit as withdrawal symptoms and connected feelings will remit as withdrawal symptoms reduce in early treatment.reduce in early treatment.

Continue monitoring for suicidal risk throughout treatment, Continue monitoring for suicidal risk throughout treatment, knowing that individuals who continue to use drugs while knowing that individuals who continue to use drugs while receiving services (e.g., those in harm minimisation receiving services (e.g., those in harm minimisation services) are at high ongoing risk of suicide.services) are at high ongoing risk of suicide.

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98% reported exposure to at least one 98% reported exposure to at least one traumatic event in their lifetimetraumatic event in their lifetime

43% of sample received a current diagnosis of 43% of sample received a current diagnosis of Post Traumatic Stress Disorder (PTSD), but Post Traumatic Stress Disorder (PTSD), but only 2% had PTSD diagnosis in their chartsonly 2% had PTSD diagnosis in their charts

Sexual abuse in childhood is related to PTSD Sexual abuse in childhood is related to PTSD for both men and womenfor both men and women

Sexual abuse in childhood may increase Sexual abuse in childhood may increase vulnerability to trauma in adulthoodvulnerability to trauma in adulthood

Substance abuse and traumaSubstance abuse and trauma

Continued

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60% to 90% of a treatment-seeking sample 60% to 90% of a treatment-seeking sample of substance abusers also had a history of of substance abusers also had a history of victimizationvictimization

More than 80% of women seeking treatment More than 80% of women seeking treatment for a substance use disorder reported for a substance use disorder reported experiencing physical / sexual abuse during experiencing physical / sexual abuse during their lifetimetheir lifetime

Between 44% and 56% of women seeking Between 44% and 56% of women seeking treatment for a substance use disorder had treatment for a substance use disorder had a lifetime history of PTSDa lifetime history of PTSD


Continued

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10.3% of the men and 26.2% of the women 10.3% of the men and 26.2% of the women with a lifetime diagnosis of alcohol with a lifetime diagnosis of alcohol dependence also had a history of PTSDdependence also had a history of PTSD

Severely mentally ill patients who were Severely mentally ill patients who were exposed to traumatic events tended to exposed to traumatic events tended to have been multiply traumatized, with have been multiply traumatized, with exposure to an average of 3.5 different exposure to an average of 3.5 different types of traumatypes of trauma


Continued

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Despite the prevalence of PTSD in Despite the prevalence of PTSD in patients, it is rarely diagnosed: Only 3 out patients, it is rarely diagnosed: Only 3 out of 119 identified patients in one study of 119 identified patients in one study received a chart diagnosis of PTSDreceived a chart diagnosis of PTSD

(Source: Mueser, K.T., Trumbetta, S.D., Rosenberg, S.D., Vidaver, R., Goodman, L.B., Osher, F.C., Auciello, P., & Foy, D.W. (1998). Journal of Consulting and Clinical Psychology, 66(3), 493-499.)


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Exposure to a traumatic event in which the Exposure to a traumatic event in which the person:person: experienced, witnessed, or was confronted experienced, witnessed, or was confronted

by death or serious injury to self or others by death or serious injury to self or others AND AND

responded with intense fear, helplessness, responded with intense fear, helplessness, or horroror horror

(Source: American Psychiatric Association - Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.)

Definition of PTSDDefinition of PTSD

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SymptomsSymptoms: : appear in 3 symptom clusters: re-appear in 3 symptom clusters: re-

experiencing, avoidance / numbing, experiencing, avoidance / numbing, hyperarousalhyperarousal

last for > 1 monthlast for > 1 month cause clinically significant distress or cause clinically significant distress or

impairment in functioningimpairment in functioning

Symptoms of PTSDSymptoms of PTSD

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Persistent re-experiencing of Persistent re-experiencing of 1 of the following: 1 of the following: recurrent distressing recollections of eventrecurrent distressing recollections of event recurrent distressing dreams of eventrecurrent distressing dreams of event acting or feeling event was recurringacting or feeling event was recurring psychological distress at cues resembling psychological distress at cues resembling

eventevent physiological reactivity to cues resembling physiological reactivity to cues resembling

eventevent

PTSDPTSD

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Avoidance of stimuli and numbing of general Avoidance of stimuli and numbing of general responsiveness indicated by 3 or more of the following:responsiveness indicated by 3 or more of the following:

avoid thoughts, feelings, or conversationsavoid thoughts, feelings, or conversations avoid activities, places, or peopleavoid activities, places, or people inability to recall part of traumainability to recall part of trauma interest in activitiesinterest in activities estrangement from othersestrangement from others restricted range of affectrestricted range of affect sense of foreshortened futuresense of foreshortened future

PTSDPTSD

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2 or more persistent symptoms of increased arousal:2 or more persistent symptoms of increased arousal: difficulty sleepingdifficulty sleeping irritability or outbursts of angerirritability or outbursts of anger difficulty concentratingdifficulty concentrating hypervigilancehypervigilance exaggerated startle responseexaggerated startle response

PTSDPTSD

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Take the trauma into accountTake the trauma into account

Avoid triggering trauma reactions and / or re-Avoid triggering trauma reactions and / or re-traumatizing the individualtraumatizing the individual

Adjust the behavior of counsellors, other staff, Adjust the behavior of counsellors, other staff, and the organisation to support the and the organisation to support the individual’s coping capacityindividual’s coping capacity

Allow survivors to manage their trauma Allow survivors to manage their trauma symptoms successfully so that they are able to symptoms successfully so that they are able to access, retain, and benefit from the servicesaccess, retain, and benefit from the services

(Source: Adapted from Maxine Harris, Ph.D.)

Guidelines for clinicians (1)Guidelines for clinicians (1)

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Provide services designed specifically to Provide services designed specifically to address violence, trauma, and related address violence, trauma, and related symptoms and reactionssymptoms and reactions

The intent of the activities is to increase skills The intent of the activities is to increase skills and strategies that allow survivors to manage and strategies that allow survivors to manage their symptoms and reactions with minimal their symptoms and reactions with minimal disruption to their daily obligations and to their disruption to their daily obligations and to their quality of their life, and eventually to reduce or quality of their life, and eventually to reduce or eliminate debilitating symptoms and to prevent eliminate debilitating symptoms and to prevent further traumatization and violencefurther traumatization and violence

(Source: Adapted from Maxine Harris, Ph.D.)

Guidelines for clinicians (2)Guidelines for clinicians (2)

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Is it major depression or “just” substance-induced Is it major depression or “just” substance-induced mood disordermood disorder

Does it matter?Does it matter?

Comparative lethalityComparative lethality

Can clinicians tell the difference?Can clinicians tell the difference?

Assessment methodsAssessment methods

Different treatment approachesDifferent treatment approaches

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Antidepressants and addictionsAntidepressants and addictions

Numerous studies of non-depressed clients Numerous studies of non-depressed clients show little or no benefit on substance useshow little or no benefit on substance use

Several studies of mild / moderately Several studies of mild / moderately depressed clients show little or no benefit on depressed clients show little or no benefit on substance use and no or mild effect on moodsubstance use and no or mild effect on mood

Studies of severely depressed / hospitalized Studies of severely depressed / hospitalized patients show moderate positive effect on patients show moderate positive effect on both mood and substance useboth mood and substance use

(Source: McGrath et al., Psych. Clin. N. Am., 2001.)

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Medications for treating individuals with bipolar Medications for treating individuals with bipolar disordersdisorders

Treatments for bipolar disordersTreatments for bipolar disorders Atypical neuroleptics for acute mania: olanzapine, Atypical neuroleptics for acute mania: olanzapine,

risperidone, quetiapine, ziprasidone, aripiprazole.risperidone, quetiapine, ziprasidone, aripiprazole.

Atypicals for bipolar depression: quetiapineAtypicals for bipolar depression: quetiapine

Atypicals for bipolar maintenance treatment: Atypicals for bipolar maintenance treatment: olanzapine, aripiprazoleolanzapine, aripiprazole

Mood stabilizers include: lithium, divalproex, and Mood stabilizers include: lithium, divalproex, and carbamazepine for acute mania / maintenance, and carbamazepine for acute mania / maintenance, and lamotrigine for bipolar depression and maintenance lamotrigine for bipolar depression and maintenance

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Medications for treating individuals with borderline Medications for treating individuals with borderline personality disorderspersonality disorders

Borderline personality disorder medications are used for the Borderline personality disorder medications are used for the following clinical features / symptom clusters:following clinical features / symptom clusters:1. Affective dysregulation (i.e., mood lability):1. Affective dysregulation (i.e., mood lability): SSRIs and related antidepressants (e.g., fluoxetine, sertraline, & SSRIs and related antidepressants (e.g., fluoxetine, sertraline, &

venlafaxine). Mood stabilizers (e.g., lithium, carbamazepine, & valproate.venlafaxine). Mood stabilizers (e.g., lithium, carbamazepine, & valproate. low-dose neuroleptics (atypicals may be used, e.g., olanzapine & low-dose neuroleptics (atypicals may be used, e.g., olanzapine &

risperidone. risperidone. SSRIs and related antidepressants (fluoxetine, sertraline, etc.). Mood SSRIs and related antidepressants (fluoxetine, sertraline, etc.). Mood

stabilizers (lithium, carbamazepine, & valproate). Low-dose atypical and stabilizers (lithium, carbamazepine, & valproate). Low-dose atypical and typical neuroleptics (olanzapine, quetiapine, haloperidol; clozapine for typical neuroleptics (olanzapine, quetiapine, haloperidol; clozapine for refractory severe self-mutlilation/aggression).refractory severe self-mutlilation/aggression).

2. Perceptual disturbances / psychotic symptoms2. Perceptual disturbances / psychotic symptoms atypical neuroleptics most commonly used (olanzapine, risperidone, atypical neuroleptics most commonly used (olanzapine, risperidone,

quetiapine, aripiprazole, or clozapine for refractory symptoms), but there quetiapine, aripiprazole, or clozapine for refractory symptoms), but there is evidence supporting use of typical neuroleptics as well (haloperidol, is evidence supporting use of typical neuroleptics as well (haloperidol, perphenazine)perphenazine)

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Medications for treating individuals with Medications for treating individuals with schizophreniaschizophrenia

Medications for treating schizophrenia Medications for treating schizophrenia AtypicalAtypical (or "second generation") neuroleptics: (or "second generation") neuroleptics:

risperidone, aripiprazole, olanzapine, risperidone, aripiprazole, olanzapine, quetiapine, ziprasidone, clozapine.quetiapine, ziprasidone, clozapine.

TypicalTypical (or "first generation") neuroleptics: (or "first generation") neuroleptics: haloperidol, fluphenazine, chlorpromazine, haloperidol, fluphenazine, chlorpromazine, perphenazine, trifluoperazine, thiothixene, perphenazine, trifluoperazine, thiothixene, pimozide.pimozide.

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Comorbidity of depression and anxiety disordersComorbidity of depression and anxiety disorders

49% of social anxiety disorder patients have panic disorder**

50% to 65% of panic disorder patients have depression†

11% of social anxiety disorder patients have OCD**

67% of OCD patients have depression*

70% of social anxiety disorder patients have depression Depression

OCD

Social Anxiety Disorder

Panic Disorder

HIGHLY COMMON…

HIGHLY COMORBID

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Treatment of co-occurring disorders: Areas of Treatment of co-occurring disorders: Areas of promise - Depressionpromise - Depression

Integration of substance abuse (SA) Integration of substance abuse (SA) treatment and treatment of affective treatment and treatment of affective disordersdisorders

DepressionDepression Use of tricyclics and SSRIs produces excellent Use of tricyclics and SSRIs produces excellent

treatment response in SA patients with treatment response in SA patients with depression. Can be used with SA populations depression. Can be used with SA populations with minimal controversy.with minimal controversy.

Good evidence of effectiveness with methadone Good evidence of effectiveness with methadone patients, women with alcoholism and patients, women with alcoholism and depression.depression.

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Treatment of co-occurring disorders: Areas of Treatment of co-occurring disorders: Areas of promise - Bipolar disorderspromise - Bipolar disorders

Bipolar disorder (BPD) and SA disordersBipolar disorder (BPD) and SA disorders Medications for BPD often essential to Medications for BPD often essential to

stabilise patients to allow SA treatment to be stabilise patients to allow SA treatment to be effectiveeffective

Challenges often occur in diagnosisChallenges often occur in diagnosisCocaine / methamphetamine use disorders often Cocaine / methamphetamine use disorders often

mimic BPD, medications for these disorders have mimic BPD, medications for these disorders have not yet demonstrated efficacy and these not yet demonstrated efficacy and these disorders do not respond to medications for disorders do not respond to medications for bipolar disordersbipolar disorders

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Treatment of co-occurring disorders: Areas of Treatment of co-occurring disorders: Areas of promise - Anxietypromise - Anxiety

Anxiety DisordersAnxiety Disorders Social anxiety disorders: SSRIsSocial anxiety disorders: SSRIs Panic attacks: SSRIsPanic attacks: SSRIs PTSD: PsychotherapiesPTSD: Psychotherapies Generalized anxiety disordersGeneralized anxiety disorders Many forms of psychotherapy, relaxation Many forms of psychotherapy, relaxation

training, biofeedback, exercise, etc. can be training, biofeedback, exercise, etc. can be usefuluseful

Concerns about use of benzodiazepines with Concerns about use of benzodiazepines with individuals in SA treatmentindividuals in SA treatment

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Treatment of co-occurring disorders: Areas of Treatment of co-occurring disorders: Areas of promise - Schizophreniapromise - Schizophrenia

Schizophrenia and SA DisordersSchizophrenia and SA Disorders Differential diagnosis with Differential diagnosis with

methamphetamine psychosis can be methamphetamine psychosis can be difficult.difficult.

Medication treatments frequently essential.Medication treatments frequently essential. Knowledge about medication side effects Knowledge about medication side effects

and the possibility that these side effects and the possibility that these side effects can trigger drug use is important.can trigger drug use is important.

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Sleep problems in those recovering from Sleep problems in those recovering from alcoholism / addictionalcoholism / addiction

Abnormal for weeks / months in mostAbnormal for weeks / months in most Is this “normal toxicity” and should it be Is this “normal toxicity” and should it be

tolerated?tolerated? Poor sleep associated with relapse, Poor sleep associated with relapse,

anxiety, depression, PTSD, and anxiety, depression, PTSD, and protracted withdrawal protracted withdrawal

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Medications for sleep problemsMedications for sleep problems

Treat the comorbid disorder causing the sleep Treat the comorbid disorder causing the sleep problem….(e.g., depression / anxiety) with an problem….(e.g., depression / anxiety) with an antidepressantantidepressant

And / or, for protracted withdrawal, with And / or, for protracted withdrawal, with anticonvulsants for 1 to several months anticonvulsants for 1 to several months (efficacy not established)(efficacy not established)

Prazosin for PTSD nightmaresPrazosin for PTSD nightmares

Antihistamines, trazedone, remeron as non-Antihistamines, trazedone, remeron as non-specific aidsspecific aids

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Summary of co-occurring disordersSummary of co-occurring disorders

There is a problemThere is a problem We have documented it for a long timeWe have documented it for a long time We need more information to figure it We need more information to figure it

outout The current state of affairsThe current state of affairs What we do about itWhat we do about it

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Treatment of co-occurring disordersTreatment of co-occurring disorders

Treatment system paradigmsTreatment system paradigms Independent, disconnectedIndependent, disconnected

Sequential, disconnected Sequential, disconnected

Parallel, connectedParallel, connected

IntegratedIntegrated

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Independent, disconnected “model”Independent, disconnected “model” Result of very different and somewhat Result of very different and somewhat

antagonistic systemsantagonistic systems

Contributed to by different funding streamsContributed to by different funding streams

Fragmented, inappropriate, and ineffective careFragmented, inappropriate, and ineffective care

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Sequential ModelSequential Model Treat SA disorder, then MH disorderTreat SA disorder, then MH disorder

OrOr Treat MH disorder, then SA disorderTreat MH disorder, then SA disorder Urgency of needs often makes this approach Urgency of needs often makes this approach

inadequateinadequate Disorders are not completely independentDisorders are not completely independent Diagnoses are often unclear and complexDiagnoses are often unclear and complex


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Parallel ModelParallel Model Treat SA disorder in SA system, while Treat SA disorder in SA system, while

concurrently treating MH disorder in MH concurrently treating MH disorder in MH system. Connect treatments with ongoing system. Connect treatments with ongoing communicationcommunication

Easier said than doneEasier said than done Languages, cultures, training differences Languages, cultures, training differences

between systemsbetween systems Compliance problems with patientsCompliance problems with patients

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Integrated ModelIntegrated Model Model with best conceptual rationaleModel with best conceptual rationale Treatment coordinated bestTreatment coordinated best ChallengesChallenges

Funding streamsFunding streamsStaff integrationStaff integrationThreatens existing systemThreatens existing systemShort-term cost increases (but better long-term Short-term cost increases (but better long-term

cost outcomes)cost outcomes)

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Elements of an integrated model: StaffingElements of an integrated model: Staffing

A true team approach including: A true team approach including: psychiatrist (trained in addiction medicine / psychiatrist (trained in addiction medicine /

psychiatry)psychiatry)nursing supportnursing supportpsychologistpsychologistsocial workersocial workermarriage and family counsellor marriage and family counsellor counsellor with familiarity with self-help counsellor with familiarity with self-help

programs programs

(Other possibilities: vocational, recreational, (Other possibilities: vocational, recreational, educational specialists)educational specialists)

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Elements of an integrated model: Preliminary Elements of an integrated model: Preliminary assessmentassessment

Preliminary assessment of mental health Preliminary assessment of mental health and substance use urgent conditions:and substance use urgent conditions:

SuicidalitySuicidality

Risk to self or othersRisk to self or others

Withdrawal potentialWithdrawal potential

Medical risks associated with alcohol / drug Medical risks associated with alcohol / drug useuse

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Elements of an integrated model: Diagnostic Elements of an integrated model: Diagnostic processprocess

Diagnostic process that produces provisional diagnosis of Diagnostic process that produces provisional diagnosis of psychiatric and substance use disorders using:psychiatric and substance use disorders using:

Urine and breath alcohol testsUrine and breath alcohol tests Review of signs and symptoms (psychiatric and Review of signs and symptoms (psychiatric and

substance use)substance use) Personal history timeline of symptom emergence Personal history timeline of symptom emergence

(What started when?)(What started when?) Family history of psychiatric / substance use Family history of psychiatric / substance use

disordersdisorders Psychiatric / substance use treatment historyPsychiatric / substance use treatment history

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Elements of an integrated model: Initial treatment Elements of an integrated model: Initial treatment planplan

Initial treatment plan (minimum 1 day; maximum 10 days) Initial treatment plan (minimum 1 day; maximum 10 days) that includes:that includes: Choice of a treatment setting appropriate to initially Choice of a treatment setting appropriate to initially

stabilise medical conditions, psychiatric symptoms, stabilise medical conditions, psychiatric symptoms, and drug / alcohol withdrawal symptomsand drug / alcohol withdrawal symptoms

Initiation of medications to control urgent psychiatric Initiation of medications to control urgent psychiatric symptoms (psychotic, severe anxiety, etc.) symptoms (psychotic, severe anxiety, etc.)

Implementation of medication protocol appropriate for Implementation of medication protocol appropriate for treating withdrawal syndrome(s)treating withdrawal syndrome(s)

Ongoing assessment and monitoring for safety, Ongoing assessment and monitoring for safety, stabilization, and withdrawalstabilization, and withdrawal

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Elements of an integrated model: Early stage Elements of an integrated model: Early stage treatment plantreatment plan

Early stage treatment plan (minimum 2 days; maximum 10 days) Early stage treatment plan (minimum 2 days; maximum 10 days) that includes:that includes: Selection of treatment setting / housing with adequate Selection of treatment setting / housing with adequate

supervisionsupervision Completion of withdrawal medicationCompletion of withdrawal medication Review of psychiatric medicationsReview of psychiatric medications Completion of assessment in all domains (psychological, Completion of assessment in all domains (psychological,

family, educational, legal, vocational, recreational)family, educational, legal, vocational, recreational) Initiation of individual therapy and counselling (extensive use Initiation of individual therapy and counselling (extensive use

of motivational strategies and other techniques to reduce of motivational strategies and other techniques to reduce attrition)attrition)

Introduction to behavioral skills group and educational Introduction to behavioral skills group and educational groupsgroups

Introduction to self-help programsIntroduction to self-help programs Urine testing and breath alcohol testingUrine testing and breath alcohol testing

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Elements of an integrated model: Intermediate Elements of an integrated model: Intermediate treatment plantreatment plan

Intermediate treatment plan (up to six weeks) that includes:Intermediate treatment plan (up to six weeks) that includes: Housing plan that addresses psychiatric and substance Housing plan that addresses psychiatric and substance

use needsuse needs Plan of ongoing medication for psychiatric and Plan of ongoing medication for psychiatric and

substance use treatment with strategies to enhance substance use treatment with strategies to enhance compliancecompliance

Plan of individual and group therapies and Plan of individual and group therapies and psychoeducation, with attention to both psychiatric and psychoeducation, with attention to both psychiatric and substance use needssubstance use needs

Skills training for successful community participation Skills training for successful community participation and relapse preventionand relapse prevention

Family involvement in treatment processesFamily involvement in treatment processes Self-help program participationSelf-help program participation Process of monitoring treatment participation Process of monitoring treatment participation

(attendance and goal attainment)(attendance and goal attainment) Urine and breath alcohol testing Urine and breath alcohol testing

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Elements of an integrated model: Extended treatment Elements of an integrated model: Extended treatment planplan

Extended treatment plan (up to 6 months) that includes:Extended treatment plan (up to 6 months) that includes: Housing planHousing plan Ongoing medication for psychiatric and substance use Ongoing medication for psychiatric and substance use

treatmenttreatment Plan of individual and group therapies and Plan of individual and group therapies and

psychoeducation, with attention to both psychiatric psychoeducation, with attention to both psychiatric and substance use needsand substance use needs

Ongoing participation in relapse prevention groups Ongoing participation in relapse prevention groups and appropriate behavioural skills groups and family and appropriate behavioural skills groups and family involvementinvolvement

Initiation of new skill groups (e.g., education, Initiation of new skill groups (e.g., education, vocational, recreational skills) vocational, recreational skills)

Self-help involvement and ongoing testingSelf-help involvement and ongoing testing Monitoring attendance and goal attainmentMonitoring attendance and goal attainment

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Elements of an integrated model: Ongoing planElements of an integrated model: Ongoing plan

Ongoing plan of visits for review of:Ongoing plan of visits for review of: Medication needsMedication needs Individual therapiesIndividual therapies Support groups for psychiatric and substance use Support groups for psychiatric and substance use

conditionsconditions Self-help involvementSelf-help involvement Instructions to family on how to recognise Instructions to family on how to recognise

psychiatric problems and relapse to substance psychiatric problems and relapse to substance useuse

In short, a chronic care model is used to reduce In short, a chronic care model is used to reduce relapse, and if / when relapse (psychiatric or relapse, and if / when relapse (psychiatric or substance use) occurs, treatment intensity can be substance use) occurs, treatment intensity can be intensified.intensified.

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Challenges of building integrated modelsChallenges of building integrated models

Cost of staffingCost of staffing

Training of staffTraining of staff

Resistance from existing systemResistance from existing system

Providing comprehensive, integrated care with Providing comprehensive, integrated care with efficient protocolsefficient protocols

Providing full integration of the treatment team Providing full integration of the treatment team at the same site, which is optimalat the same site, which is optimal

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Moving towards integrationMoving towards integration

The most likely strategy for moving towards this The most likely strategy for moving towards this system is in incrementssystem is in increments

Psychiatrist attends at AOD centersPsychiatrist attends at AOD centers

Relapse prevention groups introduced to Relapse prevention groups introduced to mental health centersmental health centers

Staff exchanges, attending case Staff exchanges, attending case conferences, joint trainingsconferences, joint trainings

Gradual shifting of fundingGradual shifting of funding

Thank you for your time!Thank you for your time!

End of Workshop 1End of Workshop 1

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Questions?Questions?

Comments?Comments?

Workshop 2Workshop 2 Women: Addiction and Treatment IssuesWomen: Addiction and Treatment Issues

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At the end of this training you will understand At the end of this training you will understand the:the: Impact of alcohol and drug use on womenImpact of alcohol and drug use on women

Medical and substance abuse treatment issues Medical and substance abuse treatment issues important to the treatment of womenimportant to the treatment of women

Women-Specific TreatmentWomen-Specific Treatment

VulnerabilitiesVulnerabilitiesTreatment IssuesTreatment IssuesPregnancyPregnancy

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Brainstorm: How are we different?Brainstorm: How are we different?

In what waysIn what waysare men and are men and women different?women different?

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Women: Women: Vulnerability to AOD effectsVulnerability to AOD effects

The same level of consumption of a The same level of consumption of a psychoactive drug will have a greater psychoactive drug will have a greater impact on females than males because of impact on females than males because of their:their: lower body weightlower body weight a higher fat-to-fluid ratio resulting in less a higher fat-to-fluid ratio resulting in less

dilution of the drugdilution of the drug variable responses to drugs because of variable responses to drugs because of

menstrual hormonal fluctuationsmenstrual hormonal fluctuations Result:Result:

women become more easily intoxicatedwomen become more easily intoxicated women sustain tissue damage at lower women sustain tissue damage at lower

doses.doses.

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Prevalence of AOD use in women (1)Prevalence of AOD use in women (1)

Recently, the traditionally higher prevalence Recently, the traditionally higher prevalence of AOD use among men compared to women of AOD use among men compared to women has narrowedhas narrowed

There is a trend for older women, i.e., those There is a trend for older women, i.e., those > 40, towards increasing levels of alcohol > 40, towards increasing levels of alcohol consumptionconsumption

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Prevalence of AOD use in women (2)Prevalence of AOD use in women (2)

Increased prevalence of binge drinking in Increased prevalence of binge drinking in young women (i.e., young women (i.e., >> 4 drinks in a session) 4 drinks in a session) increases the risk of:increases the risk of: Overdose in conjunction with other drugsOverdose in conjunction with other drugs Drunk drivingDrunk driving Vulnerability to physical / sexual abuseVulnerability to physical / sexual abuse Unsafe sexUnsafe sex Babies with fetal alcohol syndromeBabies with fetal alcohol syndrome Other intoxication-related harms (e.g., Other intoxication-related harms (e.g.,

accidents and injury) accidents and injury)

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Harm minimisation is a priorityHarm minimisation is a priority

Look for opportunities to:Look for opportunities to: Educate women about their greater Educate women about their greater

susceptibility to AOD-related harms susceptibility to AOD-related harms Provide information regarding drug Provide information regarding drug

interactionsinteractions Engage patients in discussions about Engage patients in discussions about

strategies to reduce AOD intake and strategies to reduce AOD intake and frequency of usefrequency of use

Routinely undertake physical assessmentRoutinely undertake physical assessment Provide regular health check-ups and Provide regular health check-ups and

discuss lifestyle issuesdiscuss lifestyle issues

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Janis is a 17-year-old Janis is a 17-year-old apprentice hairdresser. She apprentice hairdresser. She presents requesting testing presents requesting testing for hfor hepatitis C. In a epatitis C. In a discussion of risk factors discussion of risk factors she admits to occasionally she admits to occasionally using heroin.using heroin.

How would you respond?How would you respond?

Case studyCase study

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Identifying harms from drug useIdentifying harms from drug use

Intoxication• lower tolerance• severe physical reactions• overdose• victimisation• falls• drunk driving• unsafe sex• accidents and injury

Regular/ Excessive Use

• organ damage at lower dose

• organ damage at lessor duration

• conception difficulties• pregnancy – risk to the

fetus• work• relationships• finances• child-rearing

Dependence• family and societal censure• child welfare intervention• marginalisation• reluctance to seek help• overdose potential• rapid deterioration in health

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Why can it be difficult to detect AOD problems in female patients?

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Treatment issues (1)Treatment issues (1)

Women perceive that the costs associated with Women perceive that the costs associated with treatment are greater, compared to men treatment are greater, compared to men

social / family censure, financial, separation social / family censure, financial, separation from childrenfrom children

Many women who present to AOD treatment have Many women who present to AOD treatment have been physically, sexually, or emotionally abused been physically, sexually, or emotionally abused at some timeat some time

Women have reported feeling vulnerable, or have Women have reported feeling vulnerable, or have experienced sexual harassment in mixed-sex experienced sexual harassment in mixed-sex programs. This may lead to premature ending of programs. This may lead to premature ending of treatment.treatment.

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Treatment issues (2)Treatment issues (2)

Women-only treatment services may be of value Women-only treatment services may be of value with some populations of women, especially with some populations of women, especially where abuse and violence are commonwhere abuse and violence are common

Mixed-sex programs may be appropriate where Mixed-sex programs may be appropriate where policies & protocols supporting the specific policies & protocols supporting the specific needs of women have been adoptedneeds of women have been adopted

Child-care arrangements may be required before Child-care arrangements may be required before some women will agree to enter treatmentsome women will agree to enter treatment

Holistic treatments offering conventional and / or Holistic treatments offering conventional and / or complementary therapies may be preferredcomplementary therapies may be preferred

Female health professionals may be preferredFemale health professionals may be preferred

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Female-oriented treatment Female-oriented treatment

Interventions oriented towards women are Interventions oriented towards women are associated with:associated with:

greater progress towards goals during treatmentgreater progress towards goals during treatment higher rates of abstinence during treatment than higher rates of abstinence during treatment than

for women in conventional mixed-sex treatmentfor women in conventional mixed-sex treatment

Women are more likely to present to female-Women are more likely to present to female-only treatments and to complete treatment if:only treatments and to complete treatment if:

they have dependent childrenthey have dependent children they are lesbianthey are lesbian their mothers experienced an AOD-related their mothers experienced an AOD-related

problemproblem they have suffered sexual abuse.they have suffered sexual abuse.

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Comorbidity in women (1)Comorbidity in women (1)

Women with AOD problems commonly Women with AOD problems commonly experience anxiety and / or depressionexperience anxiety and / or depression more likely than males with AOD problems to more likely than males with AOD problems to

experience a combination of anxiety and experience a combination of anxiety and depressiondepression

Concurrent benzodiazepine and alcohol Concurrent benzodiazepine and alcohol dependence presents additional treatment dependence presents additional treatment challenges, e.g., consider:challenges, e.g., consider: pharmacotherapy options pharmacotherapy options risk of substitution of dependencerisk of substitution of dependence graduated reduction / withdrawalgraduated reduction / withdrawal

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Comorbidity in women (2)Comorbidity in women (2)

Younger women who are drug-dependent are Younger women who are drug-dependent are increasingly likely to be polydrug usersincreasingly likely to be polydrug users

Association between eating disorders Association between eating disorders (particularly bulimia) and high-risk alcohol use(particularly bulimia) and high-risk alcohol use the eating disorder usually predates the alcohol the eating disorder usually predates the alcohol

problemproblem drinking temporarily suppresses stress, shame, & drinking temporarily suppresses stress, shame, &

anxiety associated with the eating disorderanxiety associated with the eating disorder cognitive-behavioural treatment for eating cognitive-behavioural treatment for eating

disorders and AOD problems is similar, so there is disorders and AOD problems is similar, so there is an opportunity for dual intervention.an opportunity for dual intervention.

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Relapse prevention for women (1)Relapse prevention for women (1)

Women with alcohol dependence: Women with alcohol dependence: tend to drink at home and / or alone more often than tend to drink at home and / or alone more often than

men (Males are more likely to engage in dependent men (Males are more likely to engage in dependent patterns of drinking in social settings)patterns of drinking in social settings)

tend to report feelings of powerlessness and tend to report feelings of powerlessness and distress about life events prior to drinking episodes, distress about life events prior to drinking episodes, and to a greater extent than their male counterpartsand to a greater extent than their male counterparts

are more likely to live with a male who is alcohol-are more likely to live with a male who is alcohol-dependent (than the converse).dependent (than the converse).

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Relapse prevention in women (2)Relapse prevention in women (2)

Social supports are a vital factor in preventing Social supports are a vital factor in preventing relapse. Relapse prevention may need to relapse. Relapse prevention may need to address issues such as:address issues such as: lonelinessloneliness low self-esteem or perceptions of self-efficacylow self-esteem or perceptions of self-efficacy guiltguilt depression depression difficulties in social and family relationships difficulties in social and family relationships

(including children)(including children)

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MothersMothers

Pregnant women and women with Pregnant women and women with dependent children tend to engage in treatment dependent children tend to engage in treatment longer than other womenlonger than other women

Women who are dependent on AOD may Women who are dependent on AOD may experience difficulty conceivingexperience difficulty conceiving

Lower fertility can occur for those women with Lower fertility can occur for those women with dependent patterns of psychoactive drug usedependent patterns of psychoactive drug use

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Fertility and AOD useFertility and AOD use

High-risk or dependent patterns of High-risk or dependent patterns of psychoactive drug use can affect female psychoactive drug use can affect female fertility causing: fertility causing: disruption of hypothalamic-pituitary-gonodal axis disruption of hypothalamic-pituitary-gonodal axis

(alcohol and heroin)(alcohol and heroin) menstrual irregularities, ovulatory failure, early menstrual irregularities, ovulatory failure, early

menopause (alcohol)menopause (alcohol) amennorhoea (heroin, amphetamines, cocaine)amennorhoea (heroin, amphetamines, cocaine) increased risk of sexually transmitted disease increased risk of sexually transmitted disease

(which affects fertility)(which affects fertility)

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Assessment of ‘mothers-to-be’ (1)Assessment of ‘mothers-to-be’ (1)

Assess for factors that may be associated with high-Assess for factors that may be associated with high-risk patterns of AOD use: risk patterns of AOD use: pharmacotherapy options pharmacotherapy options poor nutritionpoor nutrition inadequate / poor / unsafe accommodations or inadequate / poor / unsafe accommodations or

environmentenvironment presence of blood-borne viruses (BBV)presence of blood-borne viruses (BBV) high-risk sexhigh-risk sex risk or likelihood of sharing injection equipmentrisk or likelihood of sharing injection equipment social isolation & mental health issuessocial isolation & mental health issues relationship stress / violencerelationship stress / violence

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Assessment of ‘mothers-to-be’ (2)Assessment of ‘mothers-to-be’ (2)

Access possible sources of information on Access possible sources of information on the patient’s drug use and lifestyle to the patient’s drug use and lifestyle to determine her risks (be aware of determine her risks (be aware of confidentiality)confidentiality)

Determine:Determine: quantities and types of AODs used quantities and types of AODs used frequency / patterns of use frequency / patterns of use route(s) of administration route(s) of administration concurrent drug use (including over-the-counter concurrent drug use (including over-the-counter

and “herbal” preparations)and “herbal” preparations)

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Alerting the ‘mother-to-be’Alerting the ‘mother-to-be’

Take care not to over- or understate potential for Take care not to over- or understate potential for AOD-related fetal damageAOD-related fetal damage because of the high prevalence of binge because of the high prevalence of binge

drinking among women, many fear the drinking among women, many fear the occurrence of possible fetal damage during first occurrence of possible fetal damage during first trimester trimester

if the patient has high-risk or dependent if the patient has high-risk or dependent patterns of use, she may fear her children will patterns of use, she may fear her children will be removed from her care be removed from her care

Provide accurate information Provide accurate information The precise “dose-damage threshold” by stage of The precise “dose-damage threshold” by stage of

pregnancy for many drugs is unknown (most pregnancy for many drugs is unknown (most information relates to alcohol & tobaccoinformation relates to alcohol & tobacco))

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‘‘Red Flags’ suggestive of Red Flags’ suggestive of high-risk AOD use (2)high-risk AOD use (2)

Family history of high-risk drug useFamily history of high-risk drug use Chaotic lifestyleChaotic lifestyle Repeated injuries, emergency department Repeated injuries, emergency department

visitsvisits Partner who is abusive and / or uses drugs Partner who is abusive and / or uses drugs

in a high-risk mannerin a high-risk manner Lack of antenatal care, missed Lack of antenatal care, missed

appointments, non-compliance.appointments, non-compliance.

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Intoxication or drowsiness during visitIntoxication or drowsiness during visit Requests for opioids or benzodiazepines, Requests for opioids or benzodiazepines,

STDs, HIV, HBV, HCVSTDs, HIV, HBV, HCV Mental health issuesMental health issues Previous pre-term delivery, fetal demise, or Previous pre-term delivery, fetal demise, or

placental abruptionplacental abruption Previous child with Fetal Alcohol Syndrome Previous child with Fetal Alcohol Syndrome

(FAS) or Neonatal Abstinence Syndrome (FAS) or Neonatal Abstinence Syndrome (NAS)(NAS)

‘‘Red Flags’ suggestive of Red Flags’ suggestive of high-risk AOD use (2)high-risk AOD use (2)

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A good time for change...A good time for change...

Pregnancy is a strong motivator for women Pregnancy is a strong motivator for women to change their SA behaviors. Many to change their SA behaviors. Many pregnant women will wish to cease risky pregnant women will wish to cease risky levels of drug use to protect their baby.levels of drug use to protect their baby.

Most pregnant women will respond to Most pregnant women will respond to offers of treatment.offers of treatment.

If the patient is dependent, advise ongoing If the patient is dependent, advise ongoing care or drug titration / maintenance, as care or drug titration / maintenance, as rapid drug cessation (and the resulting rapid drug cessation (and the resulting withdrawal) may pose a significant risk to withdrawal) may pose a significant risk to the fetus.the fetus.

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Opportunistic engagementOpportunistic engagement

When contact with pregnant women who When contact with pregnant women who engage in high-risk AOD use is limited or engage in high-risk AOD use is limited or inconsistent:inconsistent: Be flexibleBe flexible Derive maximum benefit from each contactDerive maximum benefit from each contact Do not judge or make the mother feel (more) guiltyDo not judge or make the mother feel (more) guilty Be clear about the dangers, but express hope Be clear about the dangers, but express hope

(use examples of success for similar patients)(use examples of success for similar patients) Be patient! Most pregnant women do eventually Be patient! Most pregnant women do eventually

engage in treatmentengage in treatment

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Antenatal shared care (1)Antenatal shared care (1)

Dependent drug use in the mother requires Dependent drug use in the mother requires coordinated shared care, ideally with coordinated shared care, ideally with specialist involvement: specialist involvement: obstetricianobstetrician neonatologistneonatologist addiction medical specialist with expertise in addiction medical specialist with expertise in

pregnancypregnancy

Antenatal care is essentialAntenatal care is essential

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Antenatal shared care (2)Antenatal shared care (2)

Involve relevant support organisationsInvolve relevant support organisations Consider counselling to terminate the Consider counselling to terminate the

pregnancy when the woman is concerned pregnancy when the woman is concerned about damage having already occurred and / about damage having already occurred and / or is HIV-positiveor is HIV-positive

Consider benefits of withdrawal treatment or Consider benefits of withdrawal treatment or pharmacotherapy maintenance regimes if pharmacotherapy maintenance regimes if she is dependentshe is dependent involve specialist AOD centresinvolve specialist AOD centres

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The ‘drug vulnerable’ fetusThe ‘drug vulnerable’ fetus

Almost all drugs used in a high-risk manner by Almost all drugs used in a high-risk manner by the mother may result in:the mother may result in: increased risk of miscarriage, premature labour, increased risk of miscarriage, premature labour,

still birthstill birth fetal distressfetal distress reduced birth size / weight and associated slow reduced birth size / weight and associated slow

growthgrowth developmental delaysdevelopmental delays

Dependent drug use in a mother may result in Dependent drug use in a mother may result in Neonatal Abstinence Syndrome (NAS) Neonatal Abstinence Syndrome (NAS) (withdrawal shortly after birth)(withdrawal shortly after birth)

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Risk for the fetus: Alcohol (1)Risk for the fetus: Alcohol (1)

The first few weeks after conception present the greatest The first few weeks after conception present the greatest risk to the fetus, as alcohol enters the fetus’ bloodstream risk to the fetus, as alcohol enters the fetus’ bloodstream

High peak blood alcohol levels (i.e., drinking to High peak blood alcohol levels (i.e., drinking to intoxication) are particularly dangerous for the fetusintoxication) are particularly dangerous for the fetus

Fetal death has been associated with high intake Fetal death has been associated with high intake (> 42 standard drinks per week) throughout pregnancy(> 42 standard drinks per week) throughout pregnancy

Abstinence is preferred during pregnancy. While there is Abstinence is preferred during pregnancy. While there is no evidence that consumption of no evidence that consumption of 1 standard drink per 1 standard drink per day results in harm to the fetus, there is no established day results in harm to the fetus, there is no established safe consumption limitsafe consumption limit

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Fetal Alcohol Syndrome (FAS)Fetal Alcohol Syndrome (FAS) occurs in 1/1,000 live birthsoccurs in 1/1,000 live births

FeaturesFeatures characteristic facial malformations (e.g., flat midface, characteristic facial malformations (e.g., flat midface,

small head, thin upper lip, small eyes, short upturned small head, thin upper lip, small eyes, short upturned nose, prominent epicanthic folds, low-set ears etc.) nose, prominent epicanthic folds, low-set ears etc.)

prenatal and postnatal growth retardation (e.g., prenatal and postnatal growth retardation (e.g., underweight, small body length, lack catch-up growth)underweight, small body length, lack catch-up growth)

central nervous system dysfunction (e.g., mental central nervous system dysfunction (e.g., mental retardation, short attention span, developmental delays, retardation, short attention span, developmental delays, long-term learning difficulties, behavioural problems).long-term learning difficulties, behavioural problems).


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Fetal Alcohol Effects (FAE)Fetal Alcohol Effects (FAE) Occurs in 1 in 100, when some but not all features of FAS Occurs in 1 in 100, when some but not all features of FAS

are described. Symptoms include:are described. Symptoms include: low birth weightlow birth weight behavioural difficultiesbehavioural difficulties learning difficultieslearning difficulties

High-risk patterns of drinking during pregnancy may High-risk patterns of drinking during pregnancy may result in:result in: spontaneous abortion, cardiac malformation, stillbirth, spontaneous abortion, cardiac malformation, stillbirth,

intrauterine growth retardationintrauterine growth retardation


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Nicotine Nicotine Crosses placenta and is found in breast milk Crosses placenta and is found in breast milk Restricts placental blood flow with reduced Restricts placental blood flow with reduced

oxygenationoxygenation Higher quantities of cigarettes smoked are Higher quantities of cigarettes smoked are

associated with lower birth weightassociated with lower birth weight Smoking Smoking

Inhibits fetal breathing, leading to increased risk Inhibits fetal breathing, leading to increased risk of SIDS, stillbirth, perinatal deathof SIDS, stillbirth, perinatal death

Higher incidence of respiratory infections, Higher incidence of respiratory infections, asthma, middle ear infections in babiesasthma, middle ear infections in babies

Risk for the fetus: Smoking (1)Risk for the fetus: Smoking (1)

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Impact of cannabis is similar to tobaccoImpact of cannabis is similar to tobacco there are concerns about the cumulative effects there are concerns about the cumulative effects

of THC (stored in the fatty tissues of the brain) on of THC (stored in the fatty tissues of the brain) on the child both before and after birththe child both before and after birth

Interventions Interventions advise cessation of use of tobacco or cannabis advise cessation of use of tobacco or cannabis

before or as soon as becoming pregnantbefore or as soon as becoming pregnant although nicotine patches or gum are generally although nicotine patches or gum are generally

contraindicated when pregnant, these may contraindicated when pregnant, these may present the safest option for the fetuspresent the safest option for the fetus

Risk for the fetus: Smoking (2)Risk for the fetus: Smoking (2)

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Unclear whether general effects to the fetus Unclear whether general effects to the fetus are a result of heroin use per se or poor are a result of heroin use per se or poor nutrition / health / lifestyle factorsnutrition / health / lifestyle factors

Opiate use may contribute to many Opiate use may contribute to many obstetrical complications, e.g.:obstetrical complications, e.g.: placental abruption / spontaneous abortionplacental abruption / spontaneous abortion intrauterine growth retardation or death (with low intrauterine growth retardation or death (with low

birthweight)birthweight) premature labour premature labour

Risk of transmission of HIV / HCV through Risk of transmission of HIV / HCV through unsafe using or sexual practices unsafe using or sexual practices

Risk for the fetus: HeroinRisk for the fetus: Heroin

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Methadone and pregnancyMethadone and pregnancy

Pregnant women should Pregnant women should notnot be advised to quit be advised to quit heroin (i.e., go “cold turkey”). Methadone is heroin (i.e., go “cold turkey”). Methadone is treatment of choice. treatment of choice.

Slow reductions in dose during 2nd trimester.Slow reductions in dose during 2nd trimester. Little methadone is present in breast milk, but slow Little methadone is present in breast milk, but slow

weaning of feeding is advised when methadone weaning of feeding is advised when methadone dose dose > 80 mg.> 80 mg.

Hepatitis-C-positive mothers should stop feeding if Hepatitis-C-positive mothers should stop feeding if nipples begin to bleed.nipples begin to bleed.

Use methadone in conjunction with coordinated Use methadone in conjunction with coordinated treatment (psychosocial, obstetric, paediatric, and treatment (psychosocial, obstetric, paediatric, and AOD services).AOD services).

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Psychostimulants increase the risk of:Psychostimulants increase the risk of: maternal hypertensionmaternal hypertension placental abruption and haemorrhageplacental abruption and haemorrhage

Effects will vary considerably depending on:Effects will vary considerably depending on: gestational period in which use occursgestational period in which use occurs frequency, amount, concurrent drug usefrequency, amount, concurrent drug use individual differences in metabolismindividual differences in metabolism

Risk for the fetus: Risk for the fetus: Amphetamines and cocaineAmphetamines and cocaine

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Use in pregnancy may result in:Use in pregnancy may result in: congenital facial (e.g., cleft lip / palate), urinary tract, or congenital facial (e.g., cleft lip / palate), urinary tract, or

neurological malformations neurological malformations Neonatal Abstinence Syndrome (particularly if used in Neonatal Abstinence Syndrome (particularly if used in

conjunction with other drugs)conjunction with other drugs)

High doses before delivery may cause:High doses before delivery may cause: respiratory depression, sedationrespiratory depression, sedation hypotonia (floppy baby syndrome)hypotonia (floppy baby syndrome) hyperthermiahyperthermia poor feedingpoor feeding

Risk for the fetus: BenzodiazepinesRisk for the fetus: Benzodiazepines

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Reduced oxygen levels to the fetal brainReduced oxygen levels to the fetal brain Effects can be similar to Fetal Alcohol Effects can be similar to Fetal Alcohol

SyndromeSyndrome Neonatal renal problemsNeonatal renal problems Decreased body weightDecreased body weight Damage to reproductive cells reducing Damage to reproductive cells reducing

future conception & pregnancyfuture conception & pregnancy Possibly fatal to mother and baby at high Possibly fatal to mother and baby at high

dosesdoses

Risk for the fetus: Risk for the fetus: Solvents and other volatile substancesSolvents and other volatile substances

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May be an association between low birth May be an association between low birth weight and > 5–6 cups of coffee / tea, > 6 weight and > 5–6 cups of coffee / tea, > 6 cans of cola per daycans of cola per day

Irregular fetal heart rate late in pregnancyIrregular fetal heart rate late in pregnancy

Neonatal Abstinence Syndrome (NAS) has Neonatal Abstinence Syndrome (NAS) has been observed in relation to high caffeine been observed in relation to high caffeine levels in the motherlevels in the mother

Risk for the fetus: CaffeineRisk for the fetus: Caffeine

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Neonatal Abstinence Syndrome (NAS) (1)Neonatal Abstinence Syndrome (NAS) (1)

High incidence of NAS from prenatal High incidence of NAS from prenatal exposure to heroin or methadone, but also exposure to heroin or methadone, but also results from dependent patterns of alcohol results from dependent patterns of alcohol and benzodiazepine useand benzodiazepine use

NAS characterised by:NAS characterised by: CNS hyper-irritability (e.g., wakefulness, tremor, CNS hyper-irritability (e.g., wakefulness, tremor,

hyperactivity, seizures, irritability)hyperactivity, seizures, irritability) gastrointestinal dysfunction, failure to gain gastrointestinal dysfunction, failure to gain

weightweight respiratory distress or alkalosis, apnoeic attacksrespiratory distress or alkalosis, apnoeic attacks autonomic symptoms – yawning, sneezing, autonomic symptoms – yawning, sneezing,

mottling, fevermottling, fever lacrimation, light sensitivitylacrimation, light sensitivity

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Symptoms appear within 72 hours, more likely in full-term Symptoms appear within 72 hours, more likely in full-term infantsinfants

Rule out hypoglycaemia, infections, hypocalcaemia (which Rule out hypoglycaemia, infections, hypocalcaemia (which mimic NAS)mimic NAS)

NAS has potential to disrupt bonding with mother if treatment NAS has potential to disrupt bonding with mother if treatment is too intrusive, though neonatal ICU may be appropriate is too intrusive, though neonatal ICU may be appropriate

Mothercraft (nurses specialised in young children and their Mothercraft (nurses specialised in young children and their families) provides calming effect / relieffamilies) provides calming effect / relief

Pharmacological treatment if NAS poses serious risks, e.g., Pharmacological treatment if NAS poses serious risks, e.g., aqueous solution of morphine administered orallyaqueous solution of morphine administered orally

Refer to specialist outpatient treatment once infant is Refer to specialist outpatient treatment once infant is stabilisedstabilised

Neonatal Abstinence Syndrome (NAS) (2)Neonatal Abstinence Syndrome (NAS) (2)

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Risks to a baby from continued drug useRisks to a baby from continued drug use

Increased risk of SIDSIncreased risk of SIDS Increased risk of child neglect and abuseIncreased risk of child neglect and abuse NAS (Neonatal Abstinence Syndrome) may NAS (Neonatal Abstinence Syndrome) may

be pronounced if opioid-dependent be pronounced if opioid-dependent

Clinicians should assess environment and Clinicians should assess environment and social factors and encourage development social factors and encourage development of parenting skills through appropriate of parenting skills through appropriate parenting networksparenting networks

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Breast feedingBreast feeding

The level of alcohol in breast milk is the The level of alcohol in breast milk is the same as in the mother’s bloodstream. same as in the mother’s bloodstream. Feeding after consuming alcohol may result Feeding after consuming alcohol may result in: in: irritabilityirritability poor feedingpoor feeding sleep disturbances sleep disturbances

Smoking / alcohol use reduces milk supplySmoking / alcohol use reduces milk supply Smoking exposes the baby to the effects of Smoking exposes the baby to the effects of

passive smoke (an identified risk factor for passive smoke (an identified risk factor for SIDS)SIDS)

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Recommendations for Recommendations for breast feeding and AOD Usebreast feeding and AOD Use

Discourage breast feeding if mother continues to Discourage breast feeding if mother continues to use illicit drugs, or is on maintenance use illicit drugs, or is on maintenance pharmacotherapiespharmacotherapies

If the mother wishes to consume alcohol, advise:If the mother wishes to consume alcohol, advise: abstinence is preferred while breastfeedingabstinence is preferred while breastfeeding however, if she wants to consume alcohol, recommend however, if she wants to consume alcohol, recommend

doing so immediately after feeding, or at times other than doing so immediately after feeding, or at times other than when about to breast feed (not within 2–4 hours of when about to breast feed (not within 2–4 hours of needing to feed)needing to feed)

drink no more than 1 standard drink between feedsdrink no more than 1 standard drink between feeds

NHMRC (2001)

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Shared care: Child protectionShared care: Child protection

Drug-dependent parents may have experienced Drug-dependent parents may have experienced psychological, sexual, or emotional abuse as psychological, sexual, or emotional abuse as children. They may in turn inflict similar treatment children. They may in turn inflict similar treatment on their children.on their children.

Discharge planning meeting should involve health / Discharge planning meeting should involve health / welfare personnel & the family welfare personnel & the family

Management plans should be agreed upon and Management plans should be agreed upon and documenteddocumented

Where specific risk factors are identified, statutory Where specific risk factors are identified, statutory child protection agencies must be notified child protection agencies must be notified

inform the patient of your statutory obligationsinform the patient of your statutory obligations

Workshop 3 Workshop 3 Young People: Addiction and Treatment Young People: Addiction and Treatment IssuesIssues

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At the end of this training you will understand the:At the end of this training you will understand the:

Impact of alcohol and drug use on young peopleImpact of alcohol and drug use on young people

Medical and substance abuse treatment issues Medical and substance abuse treatment issues important to the treatment of young peopleimportant to the treatment of young people

Young PeopleYoung People

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Who is young?Who is young?

A “young person” is internationally accepted as A “young person” is internationally accepted as someone who is between 10- and 24-years-old.someone who is between 10- and 24-years-old.

World Health Organization

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Case vignetteCase vignette

Your patient, Sue, confides in you about her son: Your patient, Sue, confides in you about her son:

““I was putting Jason’s clothes I was putting Jason’s clothes away in his drawer a few days ago, and I away in his drawer a few days ago, and I found a bong.” found a bong.”

She asks you, “How concerned should I be? What do I She asks you, “How concerned should I be? What do I say to him?”say to him?”

What may be Sue’s main concerns?What may be Sue’s main concerns?

What are your main concerns?What are your main concerns?

What would you advise? What would you advise?

Why do young people use Why do young people use drugs?drugs?

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The spectrum of useThe spectrum of use

Drug using patterns range across a spectrum, from Drug using patterns range across a spectrum, from no use to dependent use, and may include more than no use to dependent use, and may include more than one drugone drug

Abstinent Experimental Recreational Regular Dependent

A person can move along the spectrum (in either direction) and cease using at any point

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Intoxication• accidents• misadventure• poisoning• hangovers• truancy / absenteeism• high-risk behaviour• pregnancy• overdose• BBV

Types of problemsTypes of problems

Regular Use• health• finances• relationships

Dependence• impaired control• drug-centred behaviour• severe problems • withdrawal

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Intoxication-related harmIntoxication-related harm

A non-judgemental approach towards young A non-judgemental approach towards young people and their intoxication is recommended people and their intoxication is recommended

Potential harms resulting from alcohol Potential harms resulting from alcohol intoxication are immense. In Australia, alcohol intoxication are immense. In Australia, alcohol is linked to: is linked to: 30% 30% of of all road, falls, and fire injuries, and 30% of all road, falls, and fire injuries, and 30% of

drowningsdrownings 50% of assaults, 12% of suicides (probably an 50% of assaults, 12% of suicides (probably an

underestimate for young people, and particularly underestimate for young people, and particularly indigenous youth)indigenous youth)

overdose, drug-related rape and violencoverdose, drug-related rape and violencee

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Indicators of regular drug useIndicators of regular drug usein young peoplein young people

Family & friends remark on a “personality change”Family & friends remark on a “personality change”

Extreme mood swings may be evidentExtreme mood swings may be evident

Possible change in physical appearance or wellbeingPossible change in physical appearance or wellbeing

Change in school / job performanceChange in school / job performance

Increase in secretive communicationIncrease in secretive communication

Change in social groupChange in social group

Seeking money, or increase in money supply if Seeking money, or increase in money supply if dealingdealing

Unexplained accidentsUnexplained accidents

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Assessment: Assessment: The basic approach (1)The basic approach (1)

Often young people are not very forthcoming Often young people are not very forthcoming with information until you win their trustwith information until you win their trust

If the young person is likely to suffer harm, If the young person is likely to suffer harm, and / or harm others, then strenuous attempts and / or harm others, then strenuous attempts must be made to gain relevant information from must be made to gain relevant information from any source any source

However, if a crisis does not exist, then it is not However, if a crisis does not exist, then it is not justifiable to intervene without the consent of justifiable to intervene without the consent of the young person, or to engage in any the young person, or to engage in any deceptive practisesdeceptive practises, which, which can permanently can permanently damage the young person's trust in health damage the young person's trust in health professionalsprofessionals

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Must be conducted sensitively Must be conducted sensitively Use open-ended questionsUse open-ended questions Take particular note of:Take particular note of:

which drug/s (think polydrug use) have been used which drug/s (think polydrug use) have been used immediately before their presentation immediately before their presentation (i.e., responsible for intoxication)(i.e., responsible for intoxication)

quantity and the route of administration quantity and the route of administration (to assess potential harms)(to assess potential harms)

past history of drug use (indicators of long-term harm)past history of drug use (indicators of long-term harm) the “function” drug use serves for themthe “function” drug use serves for them environment in which drug use occurs environment in which drug use occurs

(e.g., whether safe, supported)(e.g., whether safe, supported)

Assessment: Assessment: The basic approach (2)The basic approach (2)

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What does the young person want?What does the young person want?

Determine why the young person is Determine why the young person is presenting nowpresenting now

What does he or she perceive immediate What does he or she perceive immediate needs to be?needs to be?

Try and meet his or her requests Try and meet his or her requests whenever possible as a starting point whenever possible as a starting point (even if far short of clinically ideal)(even if far short of clinically ideal)

Often young people are pre-Often young people are pre-contemplators in regard to their AOD usecontemplators in regard to their AOD use

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Parental involvement (1)Parental involvement (1)

Parental involvement can be extremely important to Parental involvement can be extremely important to success of treatment with adolescents and is generally success of treatment with adolescents and is generally a desired part of treatmenta desired part of treatment

However, some parents view treatment as a method of However, some parents view treatment as a method of punishment and want to control all aspects of punishment and want to control all aspects of treatment and have total access to communications treatment and have total access to communications between the youth and clinical staff. It is inappropriate between the youth and clinical staff. It is inappropriate for parents to dictate the terms of treatment.for parents to dictate the terms of treatment.

Remember, the young person, not the parent, is the Remember, the young person, not the parent, is the patient.patient.

Respect and acknowledge the parent’s concerns about Respect and acknowledge the parent’s concerns about the child’s drug use, but insure treatment is designed the child’s drug use, but insure treatment is designed to meet the needs of the youth.to meet the needs of the youth.

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Parental involvement (2)Parental involvement (2)

Reassure parents/caregivers that a harm Reassure parents/caregivers that a harm minimisation approach is effective: minimisation approach is effective: reducing the risks is the priority until the young reducing the risks is the priority until the young

person decides he or she wishes to moderate person decides he or she wishes to moderate AOD useAOD use

Reduce the parents’ sense of guiltReduce the parents’ sense of guilt seldom are parents responsible for their child’s seldom are parents responsible for their child’s

drug usedrug use drug use is far from unusual in young people drug use is far from unusual in young people

Offer information, support, counselling and Offer information, support, counselling and referralreferral

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‘‘Treatment’ (1)Treatment’ (1)

Harm minimisation approaches and support Harm minimisation approaches and support have greater effect. Discuss:have greater effect. Discuss: keeping safe when intoxicated keeping safe when intoxicated first-aid knowledge, hydrationfirst-aid knowledge, hydration being aware of potential drug interactionsbeing aware of potential drug interactions safe drug-using practises safe drug-using practises using in safe places, with known and trusted peopleusing in safe places, with known and trusted people planning drug use and activities while intoxicatedplanning drug use and activities while intoxicated monitoring consumption and thinking about monitoring consumption and thinking about

unwanted consequences of useunwanted consequences of use

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Encourage involvement with youth Encourage involvement with youth services (with specialist AOD workers) & services (with specialist AOD workers) & school programs, particularly when peer-school programs, particularly when peer-support programs are offeredsupport programs are offered peer-led delivery of harm minimisation AOD peer-led delivery of harm minimisation AOD

packages for homeless youth had better packages for homeless youth had better outcomes than adult delivery outcomes than adult delivery

peers speak the same language, are realistic, peers speak the same language, are realistic, non-judgemental, humourous, creative, and non-judgemental, humourous, creative, and “to-the-point”“to-the-point”

Fors & Jarvis (1995); Gerard & Gerard (1999)


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Non-drug-focused, stimulating youth activitiesNon-drug-focused, stimulating youth activities e.g., drug-free concerts, exhibitions, sporting events, e.g., drug-free concerts, exhibitions, sporting events,

youth zones for skateboarding, etc.youth zones for skateboarding, etc.

Influence family interactions whenever possibleInfluence family interactions whenever possible potential to alter communication patternspotential to alter communication patterns focus on behaviour focus on behaviour negotiate compromisenegotiate compromise encourage healthy interdependenceencourage healthy interdependence

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Family therapyFamily therapy

A number of family therapy approaches A number of family therapy approaches have been found to be very useful in have been found to be very useful in treating youthful substance userstreating youthful substance users

Approaches include:Approaches include: Family systems therapyFamily systems therapy Multidimensional family therapyMultidimensional family therapy Brief strategic family therapyBrief strategic family therapy Network therapyNetwork therapy

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Questions?Questions?

Comments?Comments?

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Post-assessmentPost-assessment

Please respond to the post-assessment Please respond to the post-assessment questions in your workbook.questions in your workbook.

(Your responses are strictly confidential.)(Your responses are strictly confidential.)

10 Min.

Thank you for your Thank you for your time!time!

volume c, module 3: special populations: individuals with co-occurring disorders, women, and young...

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