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SERVICES FOR YOUNG PEOPLE WITH PROBLEMATIC DRUG MISUSE: A GUIDE TO PRINCIPLES AND PRACTICE

Chapter 7: Which Interventions?

Given the wide range of young people's needs and the involvement of a wide range of services, a number of different approaches and interventions will need to be available. In this Chapter we set out some approaches to providing specialist substance misuse interventions for young people and indicate the availability of evidence for effectiveness. As set out above, these services should complement a range of accessible but more generic services, such as education, health, social care and leisure services.

Interventions work in different ways for different people at different times.

In specifying particular interventions and approaches there is a danger that the method becomes more significant than the outcome. When planning services and deciding the most appropriate approach the first consideration should always be ' what are we trying to achieve?'. Once the desired outcomes are clear it is then possible to decide which approaches are likely to be the most effective.

The literature review (EIU, June 2002) commissioned by the Effective Interventions Unit assessed the evidence for effective treatment and care services for drug using young people up to the age of 16 years in the following five key outcome areas:

• reducing drug use;

• reducing the physical harms associated with drug use;

• improving the psychological well being of young drug users;

• improving the family and social relations of young drug users;

• encouraging the up-take of other health and social services.

The small number of papers included in the review (7 reviews and 11 primary papers) demonstrated the lack of good quality studies on the effectiveness of drug interventions for young people up to the age of 16 years. Nevertheless, they provide useful insights into the types of interventions that have been evaluated using moderately strong research designs. Practically all of the studies were conducted in North America or Canada. More detailed information about the studies can be found in the full reports (EIU, June 2002). In this Chapter we draw on the available evidence and other information to set out possible intervention options and key issues to address.

Diversionary and preventative approaches

This Guide and the research commissioned to inform it have focused primarily on intensive support, treatment and care services for young people who have already developed problems with substance misuse. Prevention, education and diversionary approaches were not specifically included within the review. However, it has become clear that it is difficult and perhaps undesirable to establish rigid boundaries between prevention and more intensive treatment and care work, particularly with those young people most vulnerable to developing problems. Findings from the literature review (EIU, June 2002) highlighted the importance of early intervention because improved outcomes were associated with:

• low pre-treatment substance abuse

• reduced psychopathology and

• better school attendance and school performance

It is clear that intervening before problems become critical and entrenched, particular with those young people most at risk, is likely to enhance the effectiveness of the intervention. These early interventions will need to be carefully targeted and delivered in a flexible way that is able to build upon the positive events and protective factors present in a young person's life.

Mechanisms for natural change and recovery, particularly as part of the maturing process, may be encouraged by changes in peer group, success at school, structured activities, and support from the family. Substantial numbers of young people will attempt to reduce their drug use themselves, for example by drawing support from friends or family (HAS, 2001). A skilled therapeutic intervention may be able to harness these existing mechanisms to encourage and support the young person to change without the need for a formal 'treatment' programme. ³ It may be possible to support the young person to change through providing meaningful and attractive options and diversions that help to develop capacity for change and resilience rather than concentrating on negative factors and vulnerabilities. This approach should form part of a spectrum of services. It may also form a useful part of more intensive interventions that aim to both address issues and promote alternatives.

Risk reduction services

A small number of young people under 16 may be exposing themselves to very serious risk through intravenous drug use. In Scotland adult drug users continue to inject and to share their injecting equipment. In 2000/01 over one third of current injectors in contact with services reported that they had shared injecting equipment in the previous month (EIU April 2002). This exposes individuals to a range of risks, particularly HIV/AIDS and hepatitis. Needle and syringe exchange schemes are seen as an essential part of strategies to prevent the transmission of bloodborne viruses and under 16s may need to access these services. Health Department Letter (HDL (2002) 90) has recently revised guidance on the number of sets that can be given at any one visit to a needle exchange. The HDL acknowledges that some needle exchange clients may be under 16 and it suggests that workers should give due consideration to the particular needs of these clients. The revised Lord Advocate's Guidance states:

The supply of needles and syringes to be used for injecting controlled drugs is not a criminal offence under statute. However, the existence of common law crimes in Scotland - and in particular the crime of reckless conduct - makes it impossible to say that such supply could never amount to the commission of a criminal offence here. That does not mean that such supply would generally or normally be a criminal offence. The Lord Advocate's view is that the crime of reckless conduct would only arise very exceptionally as regards the supply of needles and syringes by doctors and pharmacists. But to ensure that even the remote possibility of the commission of an offence does not have any inhibiting effect on the special schemes the Lord Advocate has stated that he will not authorise the prosecution of any participating registered medical practitioner (or staff under the supervision of such a practitioner for this purpose and properly authorised by him) in respect of controlled supply in accordance with approved schemes.

The full text of the Health Department Letter and the Lord Advocate's revised guidance is available at http://www.show.scot.nhs.uk/sehd/hdl.asp

Counselling' and behavioural approaches

The design and delivery of counselling services varies significantly. Broadly, counselling encourages the young person to talk about themselves, their feelings, their wider circumstances and their substance misuse. It is primarily delivered on a one to one basis. The intervention requires the young person to be participative and to be able to articulate their feelings. The literature review (EIU, June 2002) found that intensive counselling delivered in a culturally sensitive way was effective in reducing drug use. From the review, less intense health education counselling was not found to be effective in reducing drug use.

The EIU research - A survey of NHS services for opiate dependents in Scotland - found clinicians included a range of interpretations and interventions within the 'counselling' label. These included relapse prevention, cognitive behavioural techniques, motivational interviewing and anxiety management. In general, clinicians hoped that counselling would help clients to define goals, gain an insight into their problems and develop problem solving skills. It was also seen as a way of addressing individual issues, specific personal problems - such as abuse - and enhancing self esteem.

We need greater understanding of the counselling process, and the difference between using broad 'counselling skills' and applying a specific counselling approach. The literature review identified that carefully planned interventions with clear aims, objectives and target audience are more likely to be successful. Clarifying these will be particularly important for counselling interventions if the approach itself is fairly wide-ranging.

The following questions will need to be considered:

• Is the intervention appropriate, accessible and designed for young people? For example, are the counsellors trained to work with young people and do they understand the cultural setting in which the young people operate?

• What are the goals of care? What is the counselling intervention aiming to achieve with the client? Are these well-understood by the young person?

• Is there evidence or reasons to believe that this approach is likely to be effective with this client group? If there is little existing evidence then it is critical that the therapist is involved in designing an appropriate evaluation of the intervention.

• What is the optimum length for the counselling process? How and when will the end point be agreed and the client supported to move on?

• Is there clear and regular managerial and non-managerial supervision available for the counsellor? The close relationships developed during the counselling process will place particular demands on staff and they will need established mechanisms to receive support and guidance.

• Confidentiality - and the limits to confidentiality - need to be clearly understood and agreed between the counsellor and the young person.

A number of literature reviews, in both the drugs and alcohol fields, have broadly found psycho-social interventions - including cognitive behavioural therapy, brief interventions, relapse prevention and '12 step' programmes - to be effective in reducing drug use. However, it can not be assumed that approaches that work for adults will work the same way for young people.

Effectiveness does appear to vary amongst the different approaches. The literature review (EIU, June 2002) found fairly strong evidence that behaviour therapy and cognitive behaviour therapy were more effective than counselling in reducing drug use. Studies found that young people responded more positively to behaviour therapy than adults. There was also limited evidence that behaviour therapy would also have a positive impact on psychological well-being, school work, school attendance and family relations.

Working with families

The literature review (EIU, June 2002) found good evidence that family therapy and other family interventions are effective in reducing drug use, psychological problems and family and social problems. However, the literature recognised the diversity of family therapy and there is a lack of evidence as to which type is most effective. Nonetheless, there was evidence that involving parents in the therapeutic process improved outcomes.

Although the literature review identified positive results for 'family therapy', it is clear that this is not being offered systematically in Scotland at present. For Scotland's Children identifies the need for specially skilled and trained workers who are able to work with families to effect positive change in the lives of children. It states 'a much more robust and change-orientated approach to working with families is generally seen to be required'.

The 'Substance of young needs' (HAS, 2001) says 'some, often adult orientated services or professionals are reluctant to engage parents because of possible issues of confidentiality and the theoretical possibility of reduced engagement of the young person. However, it is important to assess family functioning and communication with the aim to help and support the family (this may be by another service), allow individuation and maturation of the child, and reframe parents' anxieties'.

Pharmacological therapies

'Pharmacotherapy is directed at a number of specific areas: treatment of overdose in emergencies, detoxification, substitution or maintenance therapy, adjuncts to relapse prevention as well as treatment of co-morbid disorders. It should be used in conjunction with a comprehensive plan incorporating a variety of individual interventions (education, psychotherapies) designed to meet the needs of the young person' (HAS, 2001).

The literature review (EIU, June 2002) did not include any studies that demonstrated the effects of substitute prescribing, such as methadone, for young drug users. The wider research similarly found that prescribing to under 16s was very rare in Scotland. The decision to prescribe substitute medication, such as methadone, to under-16s needs to be taken extremely carefully and with full consideration of the implications for the young person.

Drug Misuse and Dependence - Guidelines on Clinical Management (1999) sets out principles of good practice in caring for young drug users to medical practitioners, particularly those working in general practice. These include some points relevant to prescribing decisions such as:

• The practitioner should involve other children's and young people's services and substance misuse services;

• Interventions should follow a comprehensive assessment of need, developmental maturity, family factors and the risk of substance-related harm;

The document makes specific recommendations in relation to prescribing for young drug users:

• Since a person under 16 is unlikely to fully understand the implications of being prescribed controlled drugs, doctors should avoid doing so unless they have first sought explicit consent from a person with parental responsibility for the young person.

• Even with consent, it is recommended that controlled drugs should only be prescribed to a young person after a full assessment and supervision by a specialist.

• Generalists, including child psychiatrists, should not prescribe substitute drugs without either specific training or formal liaison with a drug misuse treatment specialist.

• Longer-term or 'maintenance' prescribing is not recommended.

• The pharmacist should be informed in writing if a parent or guardian is to supervise the consumption of the drug. This arrangement should be agreed prior to the commencement of the prescription by all parties.

• If possible, where family supervision is not available, daily supervised consumption should be arranged with the community pharmacist, with clear dispensing instructions.

The Guidelines also highlight that:

• Drug misuse, even with some significant dependence, is not in itself an indication to prescribe substitute medication.

• Regular but not daily, non-dependent injecting of opiates is not necessarily an indication for prescribing substitute medication.

The spirit of the Guidelines and other advisory material suggests that prescribing to under-16s should be a highly unusual occurrence that is only undertaken in the most extreme circumstances. It is absolutely vital that any decision to prescribe is taken as part of a multidisciplinary approach that includes a range of psychological, social and medical interventions. Nonetheless, a very small number of young people may benefit from stabilisation on methadone and occasions may arise when this is necessary.

The HAS report (HAS, 2001) suggests that 'the majority of adolescents are not dependent and so do not generally require detoxification'. The report also highlights that the ' pharmacological management of young drug users is faced with considerable difficulty. Many of the medications are not licensed in children. Thus, treatment is based on clinical acumen, and extremely careful monitoring by trained staff in conjunction with parents/carers'.

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