Dr Fixit's FAQs:
Dr Fixit on Treating Young People (Oct 2009)
[Note: This article was written by Gerry Woodley and Dr Charlie Lowe to accompany Network 27.]
Connor, aged 16 years, came to see me last week. He has been registered with the practice since he was born. He explained that he had developed a heroin problem and he needed help. He was really embarrassed because he knows that I know his mum, but he knew that I saw people with drug problems. He had started smoking heroin about 4 months ago after he was unable to get cannabis, enjoyed it and soon found he was dependant. He had smoked cannabis prior to this for 2 years. Connor was really worried because he was arrested last week in possession of Class A drugs and was waiting to hear about court. His goals are to avoid a prison sentence and to eventually become drug free. He has not been able to tell his family because he fears they wouldn't understand.
There is no specific service for young people in my area and our local Child and Adolescent Mental Health Service (CAMHS), by their own admission, have no experience or competence in working with young people who use drugs. I'm willing to try to help but would be grateful for your advice.
The use of a prescribed intervention represents a valuable treatment opportunity for a young person that becomes heroin dependent and GPs faced with such presentations quite naturally want to help. In statistical terms this represents a small percentage (about 5%) of the young people presenting, with the majority misusing cannabis, alcohol, speed or ecstasy for which there are no prescribed interventions. Any new prescription requires a sound assessment, drug screening and a care plan in advance, followed by a reliable system of monitoring treatment, including exit pathways and transfer to adult services later. That said, a competent GP working collaboratively alongside other youth workers can provide such interventions but the commitment from that GP will be greater as managing the risks in this age group are quite different. Even when they are not in trouble, young people tend to take more risks in their lives than adults. Even more so is the maxim true that the prescription is not the treatment and psychosocial inputs are vital with the prescribing GP needing to be involved in this process. GPs should never undertake such prescribing alone.
Adult services provide services for those aged 18 years and over and despite the National Treatment Agency (NTA) position that every Drug and Alcohol Team area should have a commissioned specialist service for young, we know that this is not the case in all areas. The Clinical Guidelines 2007 (Ref 1) indicated that GPs should not routinely become involved in the care of drug using young people, however there is a dearth of experience of prescribing by psychiatric doctors within CAMHS and Adult Addiction Psychiatrists have no training with this age group. GPs with good knowledge of a young person and their family and who have experience of buprenorphine prescribing, do represent an important resource to fill this gap and in many areas this role has been taken on by a general practitioner with a special interest or GP Specialist. Indeed meetings have been held this year between the NTA and representatives from both the Royal College of General Practitioners and the Royal College of Psychiatrists to explore a way forward that will standardise the training for this small group of specialist prescribers. The positive contributions already made in this field by CAMHS consultants should be acknowledged, notably Professor Ilana Crome who has established a Masters course in Adolescent Addiction at Keele University. Others have contributed to policy documents for the NTA and conducted a national prescribing audit. The future seems best served by harnessing the skills of both GPs and CAMHS Consultants within an accountable and supportive framework that ensures high safety and quality standards. We should recall that some young people will not want to use GP services for genuine reasons and so alternatives must be available.
The needs of each young person will be individual but some common themes will emerge within this subset of particularly vulnerable teenagers. These include insecure family networks and high chances of becoming NEETs (Not in Education, Employment or Training). For this reason a drug worker with experience of working with young people is an essential component to any structured treatment intervention, particularly involving prescribing. GPs do not have the time to advocate on behalf of the young person with the many agencies that get involved like schools, the pharmacy, the police, housing, youth offending services (YOS) and social services. Indeed, due to his arrest, Connor should have come to the notice of the YOS and a drug worker can liaise with the team, with Connor's permission, and help with some of his concerns about going to court.
A drug worker can attend meetings more readily and most importantly support the young person to remain engaged in treatment when their lifestyle and immaturity pull them in the opposite direction. On a rare occasion a specialist rehab placement will need to be considered.
At the age of 16 Connor can be treated without his parents' consent, if he can prove that it would be detrimental not to treat him - the Fraser Guidelines (Ref 2) can be referred to for guidance. However, if he is in contact with the criminal justice system it is likely that they will find out.
I suggest you consider the following with Connor within your assessment:
- Competence to consent to treatment.
- if Connor is not competent then a parent or guardian in litem is needed.
- Who are in the family? Are there other carers?
- Do other family members misuse drugs or alcohol? If so are they receiving treatment or propose to?
- Is there a history of mental illness for Connor or family members?
- Does he have children?
- Is contraception needed or treatment for sexually transmitted diseases?
- Are there any child protection concerns or history of Social Services involvement?
- Is there a risk of exploitation?
- Full drug and alcohol history especially injecting and overdose risk.
- If he injects does he use a needle exchange scheme?
- History of using of friends and acquaintances .
- Accommodation needs.
- Education/Training/Employment & Leisure.
- Blood borne virus testing and hepatitis A & B vaccination.
- Past experience of prescriptions with buprenorphine or methadone.
- Past use of illicit buprenorphine or methadone.
- Script induction process.
The National Drug Treatment Monitoring System have launched a young person specific data set and all clients in treatment have quarterly Treatment Outcome Profile returns. All Tier 3 or GP community prescribed interventions need to be counted in this way and all drug agencies, both statutory or voluntary sector, have systems to collect this data so it pays to work collaboratively with them to reduce your admin demands!
Last but not least, the prescription. First line is daily supervised consumption of buprenorphine at a dose of at least 12mg daily. My personal preference is to use 16mg to improve chances of stopping use on top. Buprenorphine is licensed for use with 16 year olds whilst methadone is licenced for use with 18 year olds. At times prescribing has to go outside of licence if the clinical situation demands this. Expect to stop scripts periodically and have to sweet talk frustrated pharmacists into restarting. Maintenance prescribing is usually short lived in this age group as they are keener to detox - at times with unrealistic awareness of relapse risks.
Finally please have realistic expectations of opiate using young people. Many of them are the adult service users of the future with a history of multi-generational substance misuse. There is a risk that as we process our own distress in seeing a young person squander the opportunities of their youth, we can transfer higher demands for treatment success. We must be patient and expect several turns around the cycle of change before new learning consolidates into a lower risk drug usage or abstinence, so keep the door open.
1. Department of Health (2007) Drug Misuse and Dependence - Guidelines on Clinical Management