Addressing the harms related to youth substance use: treatment of individuals and population focused legislative responses

Substance use, and substance use disorders (SUD), are major contributors to global burden of disease among youth. They constitute an important risk factor for other disorders, including mental disorders. This thesis seeks to examine methods to reduce the harm associated with youth substance use, looking at the impact of treatment on the individual adolescent with a SUD and at legislative measures operating at the population level. While treatment models for SUD have become more liberal and harm reduction orientated in recent decades, legislation remains conservative and prohibitionist. The archetypal harm reduction treatment is opiate substitution treatment (OST) used with heroin dependence. The evidence base for OST in adolescents is sparse. Outcome of OST was examined. It emerged that OST delivers early reductions in heroin use, which continue to improve significantly from month three to month twelve of treatment. Evidence of improved psychological wellbeing is also demonstrated by adolescents on OST. In order to explore the impact of conservative legislative measures on harm related to substance use, a quasi-experimental approach was undertaken to explore changes which occurred in Ireland before, during and after the arrival of a vast network of head shops selling new psychoactive substances (NPS). Evidence is presented indicating that the expansion of head shops coincided with increased NPS addiction episodes among both adolescents and young adults. There was also evidence of increased drug related psychiatric admissions. All of these harms began to diminish within months of the closure of the head shops. Overall, these findings lend support to the position of providing tolerant and responsive treatment which does not demand abstinence for the small subset of youth who develop a SUD, while simultaneously maintaining an intolerant and conservative approach to prevention of substance use at the wider population level

Changes in first-time registration for opioid agonist treatment in Ireland between 1999 and 2019

To improve the understanding of problematic opioid use, monitoring of patterns of use is essential. We investigated changes in first-time registrations for opioid agonist treatment (OAT) in Ireland from 1999 to 2019. Data on individuals aged 15–64 years registering for OAT in Ireland for the first time from 1999 to 2019 were retrieved from the Central Treatment List, the database of all individuals receiving OAT in Ireland. Secular changes in numbers and rates of first-time registrations by age and sex were analyzed. The overall incidence of first-time treatments for opioid use decreased from 40.7 per 100,000 in 1999 to 23.0 per 100,000 in 2019 (p  The trends observed indicate a sustained decline in opioid use disorder in Ireland in younger individuals. These favorable findings support the view that recent drug policy in Ireland has contributed in part to the decline in heroin use among this group.</p

Opioid substitution treatment and heroin dependent adolescents: reductions in heroin use and treatment retention over twelve months

Background: Opioid dependence is a major health concern across the world and does also occur in adolescents. While opioid substitution treatment (OST) has been thoroughly evaluated in adult populations, very few studies have examined its use in adolescents. There are concerns that OST is underutilised in adolescents with heroin dependence. We sought to measure changes in drug use among adolescents receiving OST and also to examine treatment attrition during the first 12 months of this treatment. Methods: We included all heroin dependent patients aged under 18.5 years commencing OST at one outpatient multidisciplinary adolescent addiction treatment service in Dublin, Ireland. Psycho-social needs were also addressed during treatment. Drug use was monitored by twice weekly urine drugs screens (UDS). Change in the proportion of UDS negative for heroin was examined using the Wilcoxon signed rank test. Attrition was explored via a Cox Regression multivariate analysis. Results: OST was commenced by 120 patients (51% female and mean age 17.3 years). Among the 39 patients who persisted with OST until month 12, heroin abstinence was 21% (95% confidence interval [CI] = 9–36%) at month three and it was 46% (95% CI = 30–63%) at month 12. Heroin use declined significantly from baseline to month three (p < 0.001) and from month three to month 12 (p = 0.01). Use of other drugs did not change significantly. People using cocaine during month 12 were more likely to be also using heroin (p = 0.02). Unplanned exit occurred in 25% patients by 120 days. The independent predictors of attrition were having children, single parent family of origin, not being in an intimate relationship with another heroin user and evidence of cocaine use just before treatment entry. Conclusions: We found that heroin dependent adolescent patients achieved significant reductions in heroin use within three months of starting OST and this improved further after a year of treatment, about half being heroin abstinent at that stage. Patient drop out from treatment remains a challenge, as it is in adults. Cocaine use before and during treatment may be a negative prognostic factor

Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment

Background: Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. This paper aims to describe patients’ experience of, and attitude towards, screening and therapeutic interventions for problem alcohol use in primary care. Methods: This qualitative study recruited problem drug users (N = 28) from primary care based methadone programmes in the Ireland’s Eastern region, using a stratified sampling matrix to include size of general practice and geographical area. Semi-structured interviews were conducted and analysed using thematic analysis, and audited by a third reviewer. Results: We identified three overarching themes relevant to the purpose of this paper: (1) patients’ experience of, and (2) attitude towards, screening and treatment for problem alcohol use in primary care, as well as their (3) views on service improvement. While most patients reported being screened for problem alcohol use at initial assessment, few recalled routine screening or treatment. Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the issue. Nevertheless, patients felt that healthcare professionals should be more proactive in the management of problem alcohol use at a primary care level and that primary care can play an important role in their treatment. Conclusions: Problem alcohol use is an important challenge in the care of problem drug users. While primary care is well placed to address this issue, little data has reported on this topic. The development of interventions which promote screening and brief interventions in practice are likely to benefit this at-risk group and further research and education, that help achieve this goal, are a priority. Strategies such as dissemination of clinical guidelines, educational videos, academic detailing and practice visits, should be explored

Genetic pre-determinants of concurrent alcohol and opioid dependence: a critical review

Concurrent alcohol dependence poses a significant burden to health and wellbeing of people with established opioid dependence. Although previous research indicates that both genetic and environmental risk factors contribute to the development of drug or alcohol dependence, the role of genetic determinants in development of concurrent alcohol and opioid dependence has not been scrutinised. To search for genetic pre-determinants of concurrent alcohol and opioid dependence, electronic literature searches were completed using MEDLINE (PubMed) and EBSCO (Academic Search Complete) databases. Reference lists of included studies were also searched. In this discussion paper, we provide an overview of the genes (n=33) which are associated with the opioid, serotonergic, dopaminergic, GABA-ergic, cannabinoid, and metabolic systems for each dependency (i.e., alcohol or opioid) separately. The current evidence base is inconclusive regarding an exclusively genetic pre-determinant of concurrent alcohol and opioid dependence. Further search strategies and original research are needed to determine the genetic basis for concurrent alcohol and opioid dependency

Youth mental health in deprived urban areas: A Delphi study on the role of the GP in early intervention.

Background: GPs, as healthcare professionals with whom young people commonly interact, have a central role in early intervention for mental health problems. However, successfully fulfilling this role is a challenge, and this is especially in deprived urban areas. Aims: To inform a complex intervention to support GPs in this important role, we aim to identify the key areas in which general practice can help address youth mental health and strategies to enhance implementation. Methods: We conducted a modified Delphi study which involved establishing an expert panel involving key stakeholders / service providers at two deprived urban areas. The group reviewed emerging literature on the topic at a series of meetings and consensus was facilitated by iterative surveys. Results: We identified 20 individual roles in which GPs could help address youth mental health address youth mental health, across five domains: 1. Prevention, Health Promotion and Access, 2. Assessment and Identification, 3. Treatment Strategies, 4.Interaction with Other Agencies/Referral, and 5. Ongoing Support. With regard to strategies to enhance implementation, we identified a further 19 interventions, across five domains: 1.Training, 2. Consultation Improvements, 3. Service-Level Changes, 4. Collaboration, and 5.Healthcare-system Changes. Conclusions: GPs have a key role in addressing youth mental health and this study highlights the key domains of this role and the key components of a complex intervention to support this role

Development and process evaluation of an educational intervention to support primary care of problem alcohol among drug users

Purpose: This paper describes the development and process evaluation of an educational intervention, designed to help general practitioners (GPs) identify and manage problem alcohol use among problem drug users. Methodology: The educational session was developed as part of a complex intervention which was informed by the Medical Research Council framework for complex interventions. A previous Cochrane review and a modified Delphi-facilitated consensus process formed the theoretical phase of the development. The modelling phase involved qualitative interviews with professionals and patients. The training’s learning outcomes included alcohol screening and delivery of brief psychosocial interventions and this was facilitated by demonstration of clinical guidelines, presentation, video, group discussion and/or role play. Findings: Participants (N=17) from three general practices and local medical school participated in four workshops. They perceived the training as most helpful in improving their ability to perform alcohol screening. Most useful components of the session were the presentation, handout and group discussion with participants appreciating the opportunity to share their ideas with peers. Value: Training primary healthcare professionals in alcohol screening and brief psychosocial interventions among problem drug users appears feasible. Along with the educational workshops, the implementation strategies should utilise multi-level interventions to support these activities among GPs

Psychosocial Interventions for Problem Alcohol Use in Primary Care Settings (PINTA): baseline feasibility data.

Objectives. Primary care is a key provider of long-term care for people who attend primary care for substance use treatment, especially those in methadone maintenance treatment. As many drink alcohol excessively, there is a need to address alcohol use to improve health outcomes. We examined problem alcohol use and its treatment among people who attend primary care for substance use treatment, using baseline data from a feasibility study of an evidence-based complex intervention to improve care. Methods. Data on addiction care processes were collected by (1) reviewing clinical records (n=129) of people who attended 15 General Practices (GP) for substance use treatment, (2) administering structured questionnaires to both patients (n=105), and General Practitioners (GPs) (n=15). Results. Clinical records indicated 24 (19%) were screened for problem alcohol use in the 12 months prior to data collection, with problem alcohol use identified in 14 (11%). Of those who screened positive for problem alcohol use, five received a ‘brief intervention’ by a GP, and none were referred to specialist treatment (SBIRT). Alcohol Use Disorders Identification Test (AUDIT) scores revealed the prevalence of hazardous, harmful and dependent drinking to be 23%, 5%, and 16% respectively; intraclass correlation coefficient (ICC) for the proportion of patients with negative AUDITs was 0.038 (Standard Error 0.01). The ICCs for SBIRT were 0.16 (SE= 0.014), -0.06 (0.017), and 0.22 (0.026) for screening, brief intervention and referral, respectively. Only 12 (11.5%) AUDIT questionnaires concurred with corresponding clinical records that a patient had any/ no problem alcohol use. Regular use of primary care was evident, as 25% had attended their GP more than 12 times during the past three months. Conclusions. Comparing clinical records with patients’ experience of SBIRT can shed light on the process of care. Alcohol screening of people who attend primary care for substance use treatment is not routinely conducted. Interventions that enhance the care of problem alcohol use among this high-risk group are a priority

How social context impacts on the development, identification and treatment of mental and substance use disorders among young people - a qualitative study of health care workers

Introduction: Social context has a major influence on the detection and treatment of youth mental and substance use disorders in deprived urban areas, particularly where gang culture, community violence, normalisation of drug use and repetitive maladaptive family structures prevail. This paper aims to examine how social context influences the development, identification and treatment of youth mental and substance use disorders in deprived urban areas from the perspectives of health care workers. Method: Semi-structured interviews were conducted with health care workers (n=37) from clinical settings including: primary care, secondary care and community agencies and analysed thematically using Bronfenbrenner’s Ecological Theory to guide analysis. Results: Health care workers’ engagement with young people was influenced by the multilevel ecological systems within the individual’s social context which included: the young person’s immediate environment / ‘microsystem’ (e.g. family relationships), personal relationships in the ‘mesosystem’ (e.g. peer and school relationships), external factors in the young person’s local area context / ‘exosystem’ (e.g. drug culture and criminality) and wider societal aspects in the ‘macrosystem’ (e.g. mental health policy, healthcare inequalities and stigma). Conclusions: In deprived urban areas, social context, specifically the micro- meso- exo- and macro-system impact both on the young person’s experience of mental health or substance use problems and services which endeavour to address these problems. Interventions that effectively identify and treat these problems should reflect the additional challenges posed by such settings

Psychosocial INTerventions for Alcohol use among problem drug users (PINTA): protocol for a feasibility study in primary care.

Background Alcohol use is an important issue among problem drug users. Although screening and brief intervention are effective in reducing problem alcohol use in primary care, no research has examined this issue among problem drug users. Objectives To determine if a complex intervention, incorporating screening and brief intervention for problem alcohol use among problem drug users, is feasible and acceptable in practice and effective in reducing the proportion of patients with problem alcohol use. Methods PINTA is a pilot feasibility study of a complex intervention comprising screening and brief intervention for problem alcohol use among problem drug users with cluster randomisation at the level of general practice, integrated qualitative process evaluation, and involving general practices in two socioeconomically deprived regions. Participants: Practices (N=16) will be eligible to participate if they are registered to prescribe methadone and/or at least 10 patients of the practice are currently receiving addiction-treatment. Patient inclusion criteria are: aged 18 or over and receiving addiction treatment / care (e.g. methadone) or known to be a problem drug user. Interventions: A complex intervention, supporting screening and brief intervention for problem alcohol use among problem drug users (experimental group) compared to an ‘assessment only’ control group. A delayed intervention being available to ‘control’ practices after follow up. Page 3 Outcome: Primary outcomes are feasibility and acceptability of the intervention to patients and professionals. Secondary outcome is the effectiveness of the intervention on care process (documented rates of screening and brief intervention) and outcome (proportion of patients with problem alcohol use at the follow up). Randomisation: Stratified random sampling of general practices based on level of training in providing addiction-related care and geographical area. Blinding: Single-blinded; GPs and practice staff, researchers and trainers will not be blinded, but patients and remote randomisers will. Discussion This is the first study to examine feasibility and acceptability of primary care based complex intervention to enhance alcohol screening and brief intervention among problem drug users. Results will inform future research among this high-risk population and guide policy and service development locally and internationally