1. 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

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

3. 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….

4. "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..."

5. 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

6. 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

7. 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….

8. 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

9. Natural History Of Drug and Alcohol Use Kandel and Yamaguchi, 1972

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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

16. Drug and Alcohol use: A systemic view of Risk and protective factors Adolescent Family School Drug Peer Group Society

17. 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

18. 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.

19. 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

20. 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?

21. 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).

22. 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.

23. 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

24. 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

25. Matching Interventions to Stages of Substance use/misuse Non-use (abstinence)Universal Prevention ________________________________________ Experimental useUniversal prevention Social use _____________________________________ At risk stage Targeted Prevention ________________________________________ Problem useTreatment and Dependence Maintenance

26. 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

27. Universal audience: 28,000 YP in Lambeth between 10-19 87 Schools Target groups: YOT: 470 Looked After C: 665 Excludees:54 MH problems: 160 Making the 4-tier Model Work Lambeth Solutions Treatment Group: 170 YP Specialist Treatment and habilitation Tier 4 Tier 3 Tier 2 Tier 1 Universal prevention Targeted prevention Treatment

28. 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 services Link 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 LCPT for young people from the Portuguese community CAMHS : specialist team For those with Substance misuse and mental health needs Lambeth DAAT Virtual, Integrated team

29. Whole Systems Approach Skills development Information Sharing Case/ Risk Management Clinical Support, Psychiatric input Peer Support and supervision Research Innovative service Development F Systemic/ Family Interventions Lambeth DAAT Virtual, Integrated Team

30. 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

31. 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

32. 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

33. 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!`

34. k.mirza@iop.kcl.ac.uk or kamirza@gmail.com k.mirza@iop.kcl.ac.ukkamirza@gmail.com Thank You