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Special populations 

Special populations
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Special populations
DOI:
10.1093/med/9780198714750.003.0024
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Children

Introduction

When meeting children and families, health professionals should ask about alcohol and drug use as early as the first visit. This provides an opportunity not only to assess but also to educate individuals about the health effects of alcohol and drugs. The extent of alcohol or drug use may not be completely apparent at the first visit and it may take several consultations to get a clear picture. Careful observation of as much of the parent–child interaction (e.g. the parent’s manner towards the child and how the child responds) can yield useful information about possible problems that need further investigation.

It is helpful to have a basic understanding of the medical, psychiatric, and behavioural symptoms of children affected by substance misuse and to be familiar with local services and how to refer to them.

Developmental perspective

Children of substance-using parents

The majority of women who misuse substances are of child-bearing age and this has implications for child health and parenting.

Children born to women who used substances in pregnancy are at greater risk of prematurity, low birth weight, impaired physical growth and development, behavioural problems, and learning disabilities.

Some women continue to use substances after childbirth. Most drugs cross the placenta, but even if children are not exposed in utero they are at greater risk for childhood problems if their parents are involved in substance use. They grow up in an environment where there may be increased prevalence of mental health disorders, histories of physical or sexual abuse, serious medical problems, poor nutrition, relationship difficulties (including domestic violence), and limited social supports. This may manifest in the child as delays in language development, learning problems, behavioural disturbances or adjustment problems in home, health, social, and emotional domains (see Box 24.1).

Children who become substance users

There is a relationship between parental substance use and substance use in children. These children are found to be at increased biological, psychological, and environmental risk through many factors including genetic predisposition to substance use and mental health disorders, decreased parental monitoring, increased availability of substances in the child’s environment (sometimes being almost ‘normative’), permissive attitudes to substance use, social isolation including lack of encouragement to attend school or opportunity to pursue other constructive activities (e.g. sport, hobbies), stress, negative affect or other mental health conditions. Often a combination of risk factors exists.

Management of children from alcohol or other drug backgrounds

Linking with support services

Early detection of families where substance use is occurring enables monitoring of the child’s development and provision of assistance for families. While women may be reticent to disclose substance use, fearing the involvement of authorities such as Child Protection, a non-judgemental discussion about the supports available can help ameliorate some of this concern. Support can occur as early as antenatal classes in preparing for childbirth and childcare or parenting support in early childhood.

In some cases, assistance is required to deal with domestic violence, risk of homelessness, legal, or other complications. Referral to government-funded community health services or non-governmental agencies and social services is required in these situations.

Importance of intervention for parental substance use

A non-judgemental discussion with the parents about the importance of addressing substance use for the benefit of the child as well as for themselves is important. This can include treatment options and detail about services available.

In certain cases, child protection authorities do need to be notified because of the severity of psychosocial risk. In most cases, this management plan should be communicated openly and transparently to reduce the risk of further complications or negative outcomes.

Monitoring the growth and development of the child(ren)

The growth and development of children of substance-using parents should be monitored regularly if possible; otherwise opportunistically so that where problems (e.g. developmental delay, learning difficulties) are identified, early intervention can occur.

Adolescents

The nature of adolescence

Adolescence is an important developmental period during which the transition from childhood to adulthood occurs. Adolescent development is more than the physical phenomenon of puberty. Cognitive maturation and psychosocial development are also important aspects of adolescence. (See Table 24.1.)

Table 24.1 Developmental stages of early, middle, and late adolescence

Early adolescence (~11–13 years)

  • Characterized by the physical and physiological changes of puberty

  • Frequently concerned about whether their development is ‘normal’ and in keeping with their peers

  • Usually still dependent on family, but peers (usually of the same sex) become increasingly important

  • Characterized by concrete thinking

Middle adolescence (~14–16 years)

  • Characterized by the increasing development of autonomy

  • Identity becomes very important to the young person. Attachment to peer groups takes place and being attractive, accepted, and popular are often a focus

  • Experimentation and risk taking are very common. This may include with alcohol and other substances

Late adolescence (~17–20 years)

  • More mature intellectual abilities have developed

  • Independence and a sense of identity and self-worth are usually evident, plus plans and aspirations for the future, including employment and relationships

Physical development

commences with the onset of puberty, and is characterized by physical growth and the development of secondary sexual characteristics and reproductive capability.

Cognitive development

progresses into the young adult years (around 20 years of age). During this time, cognitive capabilities move from concrete thinking in early adolescence to abstract thinking by late adolescence. For instance, talking about the long-term effects of alcohol, such as liver disease, rarely has impact on the early adolescent. It is better to talk with the young adolescent about how heavy drinking contributes to difficulties in their relationships with peers or family, or difficulties performing at school.

Psychosocial development

includes the development of a stable and independent identity, relationships beyond family to peers, a moral and value system, an understanding of sexuality, and acquisition of skills for a future vocation.

Substance use and adolescent development

Regular or heavy substance use frequently inhibits adolescent development by delaying the time that psychosocial milestones are reached, impairing cognitive maturation, reducing educational achievements, impairing the development of healthy relationships, and increasing the likelihood of mental health problems in adolescence and adulthood.

Alcohol and drug use impacts on the developing brain in adolescence. It manifests as structural changes especially in the hippocampus and prefrontal cortex. Neurocognitive impairments particularly in relation to memory and learning have also been identified. Depending on the severity of the substance use, some changes do not reverse with prolonged abstinence.

Differentiating significant problems from occasional use

Adolescent substance use fits a spectrum. When consulting with an adolescent, it is important for the health professional to discern where the adolescent is in the spectrum of adolescent substance use.

Experimentation

with substances by young people is much more common than progression to regular use. Sometimes adolescents use drugs only in specific situations, for instance, only when attending parties or when socializing with certain peers. This is sometimes referred to as ‘situational’ or ‘recreational’ use. Other adolescents use drugs to self-medicate difficulties with sleep or emotional difficulties.

Abuse or harmful use:

here alcohol or drug use is repeated and is resulting in problems. Examples of problems include difficulties with family or friends, failure to fulfil study requirements, or even attend school because of substance use.

Dependence

on a substance refers to an internal drive to use psychoactive substances (sometimes termed compulsive drug-seeking behaviour despite negative consequences).

Risk factors for substance use and its progression

Research continues to explore what the determinants are of progression from experimentation to abuse or dependence. The role of environment in the expression of genetic risk for heavy alcohol or drug use is becoming evident.

Patterns of substance use that influence progression to problems include:

  • onset of alcohol or other drug use in early adolescence

  • heavy use, in terms of dose and/or frequency.

Risk factors and protective factors

Understanding how adolescent drug use comes about is often explained in terms of a risk factor and protective factor framework. This framework helps to understand why some adolescents follow trajectories that lead to substance use problems while others, even in the face of severe psychosocial stressors and substantial adversity, do not develop drug or alcohol, or other problems. Resilience refers to the ability to be well adjusted and interpersonally effective despite an adverse environment. Factors that counter risk factors and help people deal positively with life changes are referred to as protective factors. Protective factors may be events, circumstances, or life experiences (see Table 24.2).

Table 24.2 Some risk and protective factors for substance misuse in adolescents

Biological factors

Genetic, physiological factors

Temperament and personality traits

Antisocial personality disorder, sensation seeking trait, impulsivity

Familial factors

Familial attitudes that are favourable to substance use, parental modelling of substance use, poor or inconsistent parenting practices

Early onset of substance use

Alcohol or drug use before age 15 years

Emotional and behavioural problems

Depression, anxiety, conduct disorder, attention deficit/hyperactivity disorder

Poor social connections

To school and community groups

Peer use of substances

Attitudes and behaviour favourable to substance use

Approaches to managing adolescent substance use aim to reduce risk factors and strengthen protective factors where possible.

There is no one single risk factor that can be attributed to adolescent drug use. Psychosocial risk factors tend to ‘cluster’. That is, individuals tend to have several risk factors that impact on their development. This explains why many health-risk behaviours (alcohol misuse, heavy tobacco use, other substance use, unprotected sex, delinquency) often co-occur.

Specific aspects of the substance use history

Polysubstance use

Polysubstance use is common among adolescents. When obtaining a drug use history from young people, it is important to specifically ask about each substance, including alcohol and tobacco. Good communication skills are important (Table 24.3).

Table 24.3 Principles of engaging adolescents

Confidentiality

Confidentiality is extremely important in the relationship between a young person and a health professional Adolescents frequently will not disclose the details of their substance use if they are concerned that confidentiality will not be maintained by the health professional

Take a broad psychosocial history

Adolescents respond well to a holistic approach, rather than a focus on their substance use

Screen for mental health problems

Mental health problems often emerge in adolescence and should be screened for regularly

Avoid judgement

Any perception of judgement about the adolescent’s substance use on the part of the health professional impedes engagement with the young person

For any given substance, gather information on:

  • how often they take that substance

  • the dose used (i.e. how many drinks on a given occasion, how many cigarettes a day, how many times they use marijuana in a given week or on a given day)

  • whether episodic heavy use occurs and if so, how often.

Differentiating problematic from experimental use

In addition to the extent of use, it is helpful to find out whether the young person has experienced problems (physical, emotional, social, or legal) with their substance use (see Box 24.2). A sample question is ‘Do things happen when you use drugs/drink heavily that you later regret/wish didn’t happen?’.

Where there is a history of heavy substance use obtained, ask the young person whether they experience:

  • difficulty controlling use of the substance

  • withdrawal symptoms when they do not use a substance (e.g. ‘if you don’t’ use marijuana, how do you feel?’).

These features of physical drug dependence may commence in adolescence, rather than later in adulthood.

Management of substance disorders in adolescents

  • Management of substance use disorders in adolescents requires a multipronged approach, which takes into account the adolescent’s stage of development.

  • Management includes behavioural strategies, intervention for mental health and well-being, and in some cases, medication.

  • Open, non-judgemental discussion with young people about substance use is best.

  • Risks need to be communicated. For instance, with alcohol discussions can occur around loss of consciousness (‘coma drinking’), accidents and injuries, assaults and trauma (including road trauma), and sexual risk-taking (sexual assault, unprotected intercourse).

  • Discussing with the young person the pros and cons of potential strategies to reduce consumption is helpful.

  • In severe cases, alcohol withdrawal management (‘detox’) may be required.

  • Concomitant mental health problems need attention.

  • The use of pharmacotherapies for alcohol and for tobacco dependence in young people is under evaluation.

Cannabis

Cannabis use is particularly common among young people.

  • Advise that cessation of cannabis often leads to significant irritability, anxiety and/or insomnia and these symptoms can precipitate relapses if not anticipated and managed.

  • There is now sufficient evidence that in certain vulnerable individuals with a genetic predisposition, cannabis can increase their risk of developing a psychotic illness later in life.

  • Previous exposure to cannabis without apparent ill effect does not mean that subsequent exposure will be equally harmless.

Opioids

In most cases, pharmacological management of opioid dependence in the adolescent is with opioid substitution therapy. Careful diagnosis of dependence is required before commencing this treatment.

The family

Depression and anxiety often occur in parents of substance abusing adolescents, sometimes reaching clinical levels of severity. Parents frequently describe feelings of helplessness and a lack of confidence about having the appropriate parenting skills to deal with their teenager’s drug use.

The health professional can help empower parents through:

  • education about substance use

  • advice and/or referral for assistance with parenting strategies

  • management of depression of anxiety.

With more entrenched substance misuse, disengagement with the family may have occurred. Families are an integral part of the adolescent’s world and it is therefore important to try to assist the young person to rebuild connection. Depending on the individual circumstance this connection may be achieved through mediation by the health professional or more formally with family counsellors.

Increasing access to treatment

Outreach

Adolescents often do not engage with alcohol and drug services for adults. They sometimes need specific outreach and proactive services that cater appropriately for their developmental stage and incorporate a consideration of their cultural background, lifestyle, and in many cases their family.

Opportunistic healthcare

This is very important in young people, particularly the homeless, and can be a useful means of encouraging the young person to engage with healthcare services. In attending to screening and management of blood-borne viruses and STIs, addressing intercurrent health problems (chest infections, skin rashes, etc.), a rapport can be developed with the young person which encourages them to continue to attend to their healthcare.

Mental health problems should always be monitored in young people. Substance use may complicate depression and anxiety that are common in adolescence, but these conditions may not be articulated as such by the young person. Suicidal risk in the young person needs to be assessed frequently. Psychosis (drug induced or otherwise) can also occur with heavy substance use.

Transition from adolescent to adult drug treatment services

The transition from developmentally focused youth drug treatment services to more independently orientated adult services can be challenging for young people. The aims of successful transition of young people to adult-orientated health services are to optimize both their health and their ability to adapt to adult roles. The transition process needs to include the coordination of primary and specialty health services, as well as the development of up-to-date detailed written transition plans, in collaboration with young people and their families. Confidentiality and informed consent must be maintained for the adolescent or young person as they traverse systems and engage with different health professionals. This usually means discussing with the young person what information is clinically relevant for the adult health service to be aware of.

Harm reduction in the adolescent context

As for adults, principles of harm reduction apply to the adolescents, although they need to be appropriately modified for young people of differing developmental stages and they need to take into account the adolescent’s context. For example, specific advice on the less harmful methods of using drugs may be appropriate in adolescents whose substance misuse is unlikely to cease for some time.

Prevention of substance use disorders in adolescence

Resilience in adolescence can help protect against substance use. There is evidence that resilience can be promoted by increasing a sense of connectedness of the adolescent, e.g. to family, school, or to sporting, religious, or cultural groups (see Box 24.3).

Young adults

Cognitive development

Managing young adults differs from adolescents. Being more mature, young adults understand the broad impact of their substance misuse. It is important to note that in cases of severe substance misuse, there may be substantial cognitive impairment or acquired brain injury. If not excessive, this may improve with abstinence and cognitive rehabilitation, although research to date suggests that some degree of impairment will remain indefinitely.

Psychosocial development

When compared to adolescents, young adults tend to be more focused on their future and there is greater motivation to address substance misuse, mental health, education and employment. Intimate relationships are very important to the young adult and in many cases can be a strong motivating factor to address substance misuse and mental health.

Management of substance use disorders in young adults

Pharmacotherapy

Pharmacological management of substance dependence in young adults is similar to older adults. Concomitant treatment of mental health disorders such as depression, anxiety, or other disorders such as attention deficit disorder may also need pharmacological intervention in addition to psychological interventions

Psychosocial rehabilitation

Psychosocial rehabilitation is a significant aspect of management of young adults. Engaging the young adult in appropriate educational endeavours or in suitable employment, sometimes starting with minimal contact hours with gradual increases is recommended. It is important for the medical practitioner to have an awareness of local resources that can assist with this.

Adult drug treatment services

Adult drug treatment services differ from youth services in that there is greater onus on the young adult to drive their healthcare. Compared to youth workers, there is less capacity for adult treatment services to arrange and coordinate appointments or perform outreach for adults, although some services will provide this in the early stages of transition from youth to adult treatment services. It is best to advise individuals of the differences between treatment systems to avoid unnecessary distress about the change in paradigm. (See earlier section on ‘Transition from adolescent to adult drug treatment services’, p. [link]).

Relapses

Addiction is a chronic relapsing disorder. Young adults need to be aware that relapses will occur and therefore not to ‘lose heart’. Important messages include that they (1) can learn what the triggers for relapse tend to be for them and what works best to minimize their frequency and (2) rather than avoiding treatment (e.g. because of shame or despondency), it is easier to attend to relapses promptly to curtail their duration.

Further reading

Hermens DF, Lagopoulos J, Tobias-Webb J, et al. (2013). Pathways to alcohol-induced brain impairment in young people: a review. Cortex 49:3–17.Find this resource:

Kang MS, Skinner R, Sanci LA, et al. (2013). Youth Health and Adolescent Medicine. East Hawthorn: IP Communications.Find this resource:

    Saunders J, Rey J. (eds) (2011). Young People & Alcohol: Impact, Policy, Prevention, Treatment. Chichester: Wiley Blackwell Press.Find this resource:

      Spear L. (2000). The adolescent brain and age-related behavioral manifestations. Neurosci Biobehav Rev 24:417–63.Find this resource:

      Pregnancy and the neonate

      The number of women misusing drugs has increased considerably and a significant number of women presenting to drug misuse services for treatment are of child-bearing age. Every woman thought to have a possibility of pregnancy requires appropriate history-taking, assessment, and screening for alcohol and other drug use. Drug and alcohol use during pregnancy is associated with both maternal and fetal/neonatal outcomes. Maternal outcomes include not receiving adequate prenatal adverse care and fetal outcomes relate to a failure to thrive. Women of child-bearing age who smoke, consume more than two standard drinks a day, or use other psychoactive drugs, should be informed of the potential risks to both themselves and the fetus, and offered advice and if necessary told where to get help.

      Pregnancy offers healthcare professionals a window of opportunity to help reduce the harm associated with problematic alcohol, nicotine, and other drug use. Although pregnancy may act as a catalyst for change, drug misusers often fail to use general health services and are, therefore, more vulnerable to mental health, medical, and obstetrical complications. It is important that obstetric care is organized once pregnancy is confirmed. Where harmful, hazardous or dependent use of psychoactive substances is suspected or confirmed, a specialist healthcare professional with expertise in drug and alcohol misuse should be involved. In collaboration with the antenatal team, the drug and alcohol specialist(s) can provide specific guidance on treatment and will monitor the patient’s alcohol and other drug use during pregnancy. This is particularly important at 12, 18–20, 25 and 26 weeks.

      Following the birth of the baby, monitoring is continued by the neonatal team and the drug and alcohol expert(s). A risk assessment should be conducted and if the infant is considered to be at risk, involvement with child protection agencies or departments is mandatory.

      Effects on the fetus/infant

      The development of the fetus will be affected by factors such as quantity and frequency of substance use, and depending on the gestational stage, drug or alcohol use may lead to:

      • prematurity

      • low birth weight

      • perinatal mortality

      • respiratory distress

      • withdrawal syndromes

      • convulsions

      • sudden infant death syndrome: increased four- to fivefold in infants born to pregnant drug users

      • teratogenic effects.

      Effects on the mother

      Pharmacological effects of the drug

      Chaotic use may lead to:

      • overdose/intoxication

      • withdrawal syndromes (alcohol, nicotine, benzodiazepines, stimulants, cannabis).

      If injecting drugs,

      complications of injecting:

      • Bacterial infections:

        • Septicaemia

        • Subacute bacterial endocarditis, septic thrombophlebitis

      • Viral infections: hepatitis B, C, HIV (see Box 24.4)

      • Fungal infections: candidiasis.

      Other medical complications

      • STIs such as chlamydia and herpes

      • Poor nutrition

      • Vitamin deficiencies

      • Anorexia (especially stimulants)

      • Anaemia.

      Emotional/psychiatric complications

      • Anxiety

      • Depression

      • Insomnia.

      Obstetric complications

      • Placental insufficiency, abruptio placentae, placenta praevia

      • Intrauterine growth retardation (IUGR)/death

      • Premature rupture of membranes/premature labour

      • Pre-eclampsia/eclampsia

      • Chorioamnionitis

      • Premature delivery

      • Postpartum haemorrhage.

      Psychosocial issues

      • Domestic violence

      • Housing problems

      • Financial problems

      • Prostitution

      • Criminal activity.

      General complications of alcohol and other drug use during pregnancy

      In general, risk of damage is greatest in the first trimester of pregnancy (especially the first 8 weeks) but caution should be exercised during the second and third trimesters. Transport of drugs across the placenta is greatest in late gestation when placental blood flow is greatest.

      Women who misuse drugs and alcohol during pregnancy should receive education and advice about safe sex and risk reduction strategies, and be screened for blood-borne viruses that are spread by vertical transmission. It is advisable that tests are conducted for blood-borne viruses (hepatitis C, B, and HIV) early in pregnancy (see Box 24.4). All testing should be conducted in conjunction with pre- and post-test counselling (see sections p. [link]). Patient confidentiality must be maintained at all times.

      The significance of maternal infections is evident but has not been well documented in substance misusers. Women who misuse drugs and alcohol may be at greater risk because of promiscuous sexual behaviour and involvement in the sex industry is not unusual. Vertically transmitted infections such as syphilis may lead to malformations and neurodevelopmental delay. Maternal genital infections may increase neonatal infection by intrapartum transmission (genital herpes). For other infections such as Neisseria gonorrhoea and Chlamydia trachomatis infection, alcohol intoxication, substance misuse, and hazardous drinking levels were factors significantly associated with transmission (see Box 24.5). Education during pregnancy should include advice about safe sex and risk reduction strategies. In collaboration with Genitourinary Medicine Services, sexual health should be assessed and screening for STIs should be undertaken if necessary.

      Effects of specific drugs

      Nicotine

      The vasoconstrictor effects of nicotine impair placental blood supply, while carbon monoxide reduces availability of oxygen to the fetus. The risk of harmful effects is greater in older mothers who smoke. Smoking cessation in early pregnancy will give the greatest benefit, although quitting smoking at any time during pregnancy is beneficial for both the mother and fetus and is rarely addressed as a priority in substance misuse populations. (Also see Chapter 8.)

      Maternal risks:

      premature delivery and greater risk of complications

      Fetal/infant risks

      • Low birth weight (the risk increases in mothers who continue to smoke during pregnancy)

      • Increased risk of perinatal mortality

      • Sudden Infant Death Syndrome (SIDS).

      Nicotine replacement therapy:

      as yet there is only limited evidence regarding the safety of nicotine replacement therapy or bupropion during pregnancy and lactation.

      Alcohol

      There are no internationally agreed guidelines regarding safe limits of alcohol consumption during pregnancy. The UK Department of Health recommends not more than 1–2 units of alcohol once or twice a week. Many countries follow similar guidelines as the US which advises total abstinence during pregnancy or in women who are considering pregnancy.

      Fetal alcohol syndrome (FAS)

      FAS is the result of harmful exposure to alcohol early in pregnancy. It is reported to be the leading preventable cause of mental retardation in Western countries (see Box 24.6 and pp. [link][link]). There is a broader range of harmful effects which are termed fetal alcohol effects (FAEs). In North America, estimates for FAEs and alcohol-related neurodevelopment disorder (ARND) are 10-fold those for FAS. The term fetal alcohol spectrum disorders (FASDs) has been used to incorporate less severe fetal effects of drinking.

      The detrimental effects of alcohol are greatest during the first trimester of pregnancy, often before the woman knows that she is pregnant. Thus, all women of child-bearing age should also be advised of the risks of drinking and restrict their drinking to a minimum if they are likely to become pregnant. Risks are greater for women older than 30 years of age.

      The common pathway of alcohol teratogenesis appears to be its deleterious effects on the developing brain and nervous system. The times of greatest sensitivity of the fetal brain to maternal alcohol consumption are the first and third trimesters.

      Sudden cessation of alcohol consumption in pregnant alcohol dependent women is associated with a high risk of seizures. Alcohol detoxification should not be conducted in the community, and needs very careful supervision by obstetricians and alcohol treatment specialists.

      Heroin

      The incidence of opioid misuse is still increasing in many European countries, with most addicts seeking treatment for the first time between the ages of 20 and 30 years. An estimated 30,000 pregnant women use illicit opioids each year in the European Union. Despite some efforts to address the lack of guidance on managing the pregnant opioid user, an optimal methadone-dosing strategy has yet to be established.

      It is clinically agreed that opioid-dependent women fare better if they are maintained on opioids while pregnant rather than attempt abstinence. Conversion of heroin to methadone has been found to be the most effective treatment for opioid-dependent pregnant women, although in some countries buprenorphine may be preferred.

      Enrolment of the opiate-addicted woman in a methadone maintenance programme gives the medical community an opportunity to intervene and optimize neonatal outcome in these high-risk pregnancies. It has been demonstrated that methadone improves prenatal care, neonatal outcome, reduced illicit substance use, and improves the overall health of pregnant women. However, the benefits can be negated if inadequate methadone dose is prescribed and heroin is used ‘on top’. The dose of methadone may need to be increased in the third trimester of pregnancy.

      Pregnant intravenous drug users often have poor antenatal attendance, chaotic lifestyles, and poor nutrition, and detoxification of pregnant heroin-dependent women is risky. Maternal abstinence may result in fetal distress that is more harmful than passive dependence, and may induce abortion or premature labour. The highest risk period is before the 14th week and after the 32nd week of gestation.

      Methadone maintenance treatment in conjunction with a comprehensive drug and alcohol and prenatal programme is the treatment of choice to maintain the patient in a comfortable state (average dose of methadone: 30–80 mg daily). Although neonatal opioid dependence as well as neonatal abstinence syndrome (see Box 24.7) may occur, this is not life-threatening and can be managed easily in Special Care Baby Units. Babies born to opioid-dependent mothers should be monitored for the neonatal abstinence syndrome (Box 24.7).

      Benzodiazepines

      The use of benzodiazepines, particularly during the first trimester of pregnancy, is thought to be associated with decreased fetal growth. There is controversy as to whether fetal abnormalities occur and whether benzodiazepines should be prescribed in pregnancy.

      Examination of pooled data from cohort studies found no association between fetal exposure to benzodiazepines during the first trimester and risk of major malformations or malformations of the oral cleft alone (cleft lip and cleft palate), but case–control studies show a small increase in risk for oral cleft palate. Some authorities advise fetal ultrasonography to screen for cleft lip/palate when benzodiazepine abuse or dependence is observed.

      A neonatal benzodiazepine withdrawal syndrome is described (Box 24.8)

      Cocaine/crack cocaine

      Cocaine causes vasoconstriction, thus reducing the blood flow to the placenta and increasing the risk of placental abruption. It also increases uterine contractility, thus increasing the risk of spontaneous abortion and premature delivery. The use of cocaine during pregnancy is associated with an increased risk of Sudden Infant Death Syndrome (SIDS) in the baby. See Box 24.9.

      Multiple substance use

      Multiple drug use during pregnancy is common and associated with increased rates of prematurity and IUGR, and also with increased rates of problems during labour including premature rupture of the membranes, meconium-stained liquor, and fetal distress. Women using cocaine and multiple substances are at particular risk.

      Substance use is not necessarily attenuated during pregnancy. An Irish study showed that 2.8% of urines from a sample of 504 pregnant women screened positive for illicit substances at their first antenatal visit, whereas 5.6% of urines from a separate sample of 515 women screened positive 6 weeks after delivery. The substances identified included benzodiazepines, cannabis, amphetamines, opiates, and cocaine. Less than 2% tested positive for alcohol. Positive screens were associated with women being single, unemployed, and having had a previous pregnancy.

      Breastfeeding

      Breast milk is generally regarded as the best nutrition for the child. In general, mothers should not be discouraged from breastfeeding but should be given full information of the risks associated with continued use of alcohol and other substances. See Box 24.10.

      Further reading

      Cook J. (2003). Biochemical markers of alcohol use in pregnant women. Clin Biochem 36:9–19.Find this resource:

      Finnegan LP. (1991). Treatment issues for opioid dependent women during the perinatal period. J Psychoactive Drugs 23:191–201.Find this resource:

      Floyd R, O’Connor M, Skol RJ, et al. (2005). Recognition and prevention of fetal alcohol syndrome. Obstet Gynaecol 106:1059–64.Find this resource:

      NSW Department of Health (2006). National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn. Sydney: NSW Department of Health. Available at: www.health.nsw.gov.auFind this resource:

        Perez-Montejano R, Finch E, Wolff K. (2013) A national survey investigating methadone treatment for pregnant opioid dependent women in England and Wales. Int J Ment Health Addiction11(6):693–702.Find this resource:

        Fetal alcohol spectrum disorders

        Causes

        Alcohol consumption during pregnancy can result in adverse child outcomes, including miscarriage, premature birth, stillbirth, and birth abnormalities. The severity and type of condition is related to the amount of maternal alcohol consumption and timing of exposure.

        Definitions

        Prenatal alcohol exposure (PAE) can cause fetal alcohol spectrum disorders (FASDs). The term FASDs is not a clinical diagnosis, but an umbrella term that covers several categories of disorders resulting from fetal alcohol exposure. These disorders include:

        • fetal alcohol syndrome (FAS)

        • partial fetal alcohol syndrome (pFAS)

        • alcohol-related neurodevelopmental disorder (ARND)—this term is being replaced by:

        • neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)

        • alcohol-related birth defects (ARBDs)

        • other neurodevelopmental disorder associated with PAE.

        Diagnosis

        Fetal alcohol syndrome (FAS)

        diagnosis is based on:

        • Facial dysmorphia (Fig. 24.1):

          • Smooth philtrum

          • Thin vermillion border

          • Small palpebral fissures (≤10th percentile)

        • Below average height and/or weight

        • CNS abnormalities (IQ is typically low (≤70))

        • History of PAE.

        
Fig. 24.1 Diagnostic facial features of FAS.

        Fig. 24.1 Diagnostic facial features of FAS.

        Reproduced from Astley, S.J., Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code, Third Edition, Copyright (2004), with permission from University of Washington Publication Services.

        If information about PAE is unavailable, FAS is diagnosed if the other three criteria are present. Diagnosing other FASDs requires a history of PAE.

        Partial FAS (pFAS)

        is considered when a person with a history of PAE does not meet full diagnostic criteria for FAS, but has some facial features and growth deficits or CNS abnormalities.

        Alcohol-related birth defects (ARBDs)

        are structural birth defects associated with PAE, including cardiac, skeletal, renal, ocular, or auditory system malformations.

        Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)

        was introduced in (DSM-5) as a ‘Condition for Further Study’ (see Box 24.11).

        Diagnosis is based on deficits in the following in individuals with a history of more than minimal PAE:

        • Neurocognitive functioning

        • Self-regulation

        • Adaptive functioning.

        ‘More than minimal’ is defined as maternal alcohol consumption of 1–13 drinks per month, but ≤ 2 drinks per occasion. An ND-PAE diagnosis can be made with or without facial dysmorphia.

        Other neurodevelopmental disorders

        Patients with other birth defects and genetic conditions, such as Williams’ syndrome, may have clinical characteristics similar to FASDs. Careful evaluation is needed to exclude these conditions.

        Prevalence

        The prevalence of FASDs is estimated to be 2–5% of school-age children in developed countries. Higher rates are reported in populations with high alcohol consumption. FAS is estimated to affect 2–7 per 1000 children in developed countries.

        Prognosis and treatment

        FASDs are lifelong conditions. The extent of impairment ranges from profound developmental disabilities to subtle problems. Although the impact may be minor in less severe cases, public health significance is magnified by the prevalence of FASDs in the population. Such individuals often develop other conditions:

        • Mental health problems

        • Conduct disorders

        • Alcohol and drug dependence

        • Depression or other psychiatric problems

        • Disrupted school experience

        • Trouble with the law

        • Inappropriate sexual behaviour

        • Inability to live independently and/or hold a job as adults.

        There is no cure for FASDs. With early identification and diagnosis, children can receive services that help maximize their potential and decrease the risk of secondary conditions. Protective factors include:

        • diagnosis before age 6

        • living in a stable, nurturing home

        • not experiencing violence

        • receiving special education and social services.

        Individuals with FASDs benefit from early interventions, individualized education programmes, preparation for school to work transitions, and continuing services as adults.

        Effective prevention depends on knowledgeable physicians and educated women.

        Prevention

        FASDs are preventable. Any alcohol consumption during pregnancy may increase the risk for FASDs. Women should be educated about the risks of alcohol use during pregnancy and advised to avoid alcohol consumption while pregnant or when conception is possible. Physicians should be trained to implement screening and brief interventions for FASDs prevention.

        • There is no safe time to drink during pregnancy.

        • There is no known safe amount of alcohol consumption during pregnancy or when trying to conceive.

        Further reading

        American Academy of Pediatrics. The Fetal Alcohol Spectrum Disorders (FASD) Toolkit. Available at: http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/fetal-alcohol-spectrum-disorders-toolkit/

        Centers for Disease Control and Prevention (CDC).National Center on Birth Defects and Developmental Disabilities (NCBDDD). Available at: http://www.cdc.gov/ncbddd/fasd/index.html

        May PA, Gossage JP, Kalberg WO, et al. (2009). Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies. Dev Disabil Res Rev 15:176–92.Find this resource:

        Streissguth AP, Bookstein FL, Barr HM, et al. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. J Dev Behav Pediatr 25(4):228–38.Find this resource:

        The elderly

        The subject of substance use in the elderly is important because of the sheer scale of the problem, the morbidity and mortality, and the social impact and costs. By 2020, the prediction is that the proportion of older people (usually defined as over 60 years of age) in the population in the Western world and many Asian countries will reach 25%.

        Epidemiology

        Since older people are using more substances than in the last two decades, and the numbers of older people are rising, the likelihood is that there will be an increase in the need for treatment.

        The ‘baby boom’ generation (those born between 1946 and 1964), who were the first cohort to use drugs recreationally and dependently, are ageing. This group have had the benefit of improved treatment for substance misuse, but also suffer from a host of medical and psychiatric conditions.

        In the UK it is estimated that:

        • 13% of men and 12% of women over 60 years of age smoke

        • over the last 10 years there has been a 25% increase in the number of older men and a 300% increase in the proportion of older women drinking above recommended daily limits of alcohol

        • 25% of care home residents in the US are prescribed a benzodiazepine; 10% are misusing these due to the lack of vigilance about dependence.

        ‘Safe limits’

        • There is probably no such thing as a safe limit.

        • The recommended limits for adults are very likely not applicable to older people.

        • The US NIAAA has recommended that for some older people one US drink (14 g alcohol) a day and no more than seven US drinks per week is sufficient. More than three US drinks a day is considered likely to lead to harm.

        • Older people should be advised to eat before drinking, to drink slowly, not to drink and drive, not to use machinery when they have been drinking, and not to swim after drinking.

        • For those people with comorbid conditions and on medications, sensible advice might have to be that they do not drink.

        Costs

        Older people incur greater costs:

        • The cost of alcohol-related admissions in England for 55–74-year-olds was more than ten times that for 16–24-year-olds.

        • The cost of alcohol-related admission for older men was almost double that for older women.

        Distinctive issues in older people

        Even if older people continue to use substances in the same way as when they were an adult, the impact may be different. They do not need to use excessive amounts to be affected adversely especially if they are using combinations of substances.

        Older people are at greater risk of the impact of substances for the following reasons:

        • The development of chronic complex physical and mental health problems.

        • As a consequence older people are prescribed medications, often multiple, so that drug interactions are more likely.

        • Increased vulnerability due to physiological changes related to the ageing process, e.g. decreased metabolism leads to accumulation and increased brain sensitivity to substances leads to adverse effects.

        • Acute confusional states and memory difficulties may lead to consumption.

        • Presentation with somatic, mental, and functional impairment not attributable to substance use may lead to worsening of any aspect of health, and even overdose, due to inappropriate prescribing.

        The lifespan perspective

        Addiction can be a lifelong problem: some people start in their teens and continue relentlessly into older age, for some cessation with resumption is the pattern, whilst others begin when they reach older age.

        Risk factors in older age include boredom, isolation, losses associated with retirement, bereavements, disability, comorbid medical conditions, occupation, and ethnic group.

        The so-called geriatric giants, i.e. iatrogenesis, immobility, intellectual deterioration, incontinence, and instability, can reflect substance problems.

        Assessment

        Older people should not be exempt from a thorough physical and psychosocial assessment which should be updated with regularity and this should be recorded.

        The details of a substance use assessment have been covered in Chapter 5.

        Social factors are central

        • Assessment of consent and capacity

        • Social vulnerability, e.g. isolation, risk of falls, financial abuse

        • Social function: activities of daily living, support from formal and informal carers and family

        • Social environment: any change which presents as uncharacteristic behaviour or new symptomatology which is unexplained should be cause for suspicion, e.g. sleep, eating, mood, memory, weight loss, irritability, agitation and escalating doses of prescription drugs

        • Evidence of comorbid disorders and their treatment with medication.

        Barriers to detection

        • Lack of training, stigma, and stereotyping may lead to inability to detect presentations in older people especially if they are atypical.

        • Perception of too little time in which to undertake an assessment and lack of confidence in delivering an intervention and knowledge about appropriate referral.

        A formal aged care assessment is indicated when:

        • further assessment and observation is required

        • the patient is deteriorating

        • treatment, e.g. withdrawal management or stabilization, cannot take place at home

        • needs are complex due to physical, mental, and social problems

        • the patient is unable to be cared for at home

        • isolation and/or chaotic domestic situation

        • the person is unable to function at home

        • previous treatment is proving ineffective

        • the patient is suicidal.

        Pharmacological interventions

        Whether to prescribe to a patient who is already on multiple pharmaceuticals

        Pharmaceutical interventions should be initiated and prescribed with caution and care. Lower doses are usually appropriate for older people though formularies rarely give specific guidance for older people.

        Medications for substance use disorders such as acamprosate, naltrexone, and disulfiram should only be considered if the patient can be monitored by an expert team. A multidisciplinary team comprising an addiction specialist and a geriatrician with their teams should initiate and review treatment. Pharmacological interventions should only be provided if there is a psychosocial package of care in place.

        It is a clinical decision requiring experience, expertise, and sometimes even intuition as to whether an additional medication is appropriate for the patient (who may be on a host of other medications). However, it is also imperative that patients should not be denied the benefit of pharmacological agents just on the basis of age. This is sometimes a difficult balance that only those skilled can undertake.

        The specific medications should only be prescribed if the patient is dependent and/or in withdrawal, while taking consideration of all other medications they are prescribed and/or have consumed at the same time. Older people may not exhibit the features of dependence as younger people. However, low doses of drug may still impact on them adversely even if they do not present with the symptomatology. Older people and their carers often are not aware of the effects many substances may be having on functioning. Meticulous probing and corroboration with medical professionals and carers and family should be undertaken to ensure that it is safe. Older people are often using analgesics, sedative hypnotics and other substances which may or may not be obtained through legitimate sources (e.g. doctor, pharmacy) or through contacts and the Internet.

        Psychological interventions

        Most of the research that has been undertaken has been on psychological interventions in older alcohol misusers.

        The overall message is positive in that older people achieve comparable outcomes across a variety of domains (social, psychological, physical, legal) as their younger counterparts do: in some cases they may even fare better. Older adults who seek treatment do have the capacity to change, so that there is benefit in proactively seeking and providing treatment.

        Implications of substance dependence for retirement facility living

        Care home policies should include substance misuse assessment and management in their care plans.

        Patients in care homes need to be assessed and regularly monitored. Although alcohol is the most commonly misused drug, there should be a high index of suspicion about ongoing substance use and long-term prescription, e.g. benzodiazepines and opiates.

        Residents will be at risk of falls (due to effects of alcohol on muscle tone and balance, and osteoporosis). They will be at risk of interactions with many commonly prescribed medications for older people, e.g. antihistamines, acid-lowering drugs, epilepsy medication, and antibiotics. These interactions with, e.g. alcohol and benzodiazepines, will render them at risk of the development of intoxication whilst withdrawal may manifest as a confusional state or delirium.

        Short-term treatment with benzodiazepines can inadvertently merge into long-term dependence as may analgesics. Alcohol may enhance the sedative effects of hypnotics and sedatives as well as antidepressants and antipsychotic medication.

        It is the responsibility of the care home staff (both management and professional primary care, physicians and psychiatrists, and their teams) as well as family, friends, and carers to be aware that substance use may have an important bearing on the subsequent stability and treatment of the resident. The collaboration of these professionals is key in monitoring the prescription regimens in the context of the residents’ behaviour, symptomatology, and overall management. This might necessitate referral to addiction services so that medication can be safely reduced and lead to positive outcomes.

        Further reading

        Crome IB, Li TK, Rao R, et al. (2012). Alcohol limits in older people. Addiction 9:1541–3.Find this resource:

        Crome IB, Rao T, Tarbuck A, et al. (2011). Our Invisible Addicts: Council. Report 165. London: Royal College of Psychiatrists.Find this resource:

          Crome IB WuL-T Rao TCrome P (eds) (2014). Substance Use and Older People. London: Wiley.Find this resource:

            European Monitoring Centre for Drugs and Drug Addiction (2008). Substance use among older adults: a neglected problem. Drugs in Focus 18.Find this resource:

              Lingford-Hughes A, Welch S, Peters L, et al. (2012). BAP updated guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol 26(7):899–952Find this resource:

              Moore AA, Blow FC, Hoffing M, et al. (2011). Primary care-based intervention to reduce at-risk drinking in older adults: A randomized controlled trial. Addiction 106(1):111–20.Find this resource:

              Moy I, Frisher M, Crome P et al (2011). Systematic review of treatment for older people with substance problems. Eur Geriatr Med 2(4):212–36Find this resource:

              Rao TCrome IB. (2011). Substance misuse among care home residents. NRC 13(11):2–4.Find this resource:

                US Department of Health and Human Services (1998). Substance Abuse among Older Adults (Treatment Improvement Protocol (TIP) Series No. 26). Washington, DC: US Department of Health and Human Services.Find this resource:

                  Marginalized populations

                  The issue of marginalization

                  People can be marginalized for a variety of reasons—from their sexuality, sexual activity, or drug-taking, to their ethnicity, language, or appearance amongst many things. Being marginalized means a person’s perceived social worth is less, and they are often treated accordingly. This matters because marginalized populations face significant barriers in accessing services and receiving good quality treatment and care. They face stigma and discrimination—in some cases their behaviour is classed as illegal, making it harder again to access care. It is harder for them to achieve and to maintain good health, and so unsurprisingly their overall health and well-being is far lower than the general population. This is not because their physiology differs from any other person, but because of the social determinants of their health. According to the WHO, these are the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. And when working with marginalized clients, these are the things that have often determined the trajectory of their lives.

                  As a clinical workforce, we must be cognizant of this. We need to consider the early events in someone’s life that may have led to their substance use, the high likelihood of previous trauma amongst those who use drugs, and the common coexistence of mental health and substance use issues.

                  And in understanding this, we must advocate for, and provide, more flexible/appropriate/and non-judgemental health services. We may need to consider outreach services and early or late clinics in alternative locations other than hospitals. We must ensure our services are where they need to be, open during hours that work best for those we seek to see, and have staff that openly welcome all who enter. Consider co-location of services. Consider low literacy resources. We need to design our services to best suit our clients’ needs, rather than our own. Include them in the planning if you can.

                  General considerations when working with marginalized groups

                  • Be kind, be considerate, and leave your judgement at the door.

                  • Be honest and open, and acknowledge your own limitations.

                  • Acknowledge that they will know far more than you about certain details—so ask for their help and advice to improve your understanding.

                  • Focus on practicalities and on positives. Avoid catastrophizing, no matter how concerned you may be.

                  • Try and come up with small practical steps, rather than detail how someone might reshape their entire life.

                  • Take things slowly—trust takes time, and you need trust to develop a therapeutic relationship.

                  The following sections set out some considerations for special groups.

                  Sex workers

                  • Sex workers have lower rates of STIs than the general population. It is good to acknowledge this.

                  • There are many people who undertake sex work voluntarily, as well as those who do so less voluntarily (e.g. in order to fund their drug dependence). We should work respectively and sensitively with both.

                  • Sex workers may need a certificate for their workplace to state they have been screened for STIs. Work with them to provide them with what they need and acknowledge the positives in what they are doing.

                  • It is useful to know the context of a person’s sex work as risk may vary enormously. A person working from the street, for example, may be at higher risk of personal violence and sexual assault compared to someone working from a well-supported and regulated brothel. A person sex working to support their drug dependence may be more likely to engage in unsafe sex in order to make money more quickly. And a sex worker using drugs with a client together may lead riskier practices and unsafe sex due to disinhibited behaviour.

                  • It is useful to know that sometimes condom use may be how a sex worker distinguishes between their sexual practices at work and at home. So there are many sex workers who would use condoms 100% for work, but not necessarily with their partner/s. It is important when taking a sexual history to determine risk of STIs to ask about both.

                  • Don’t forget about contraception, as well as STI risk.

                  At-risk youth

                  • It is essential to understand mandatory reporting considerations, as legislation may differ in different countries or jurisdictions.

                  • It can be helpful to acknowledge that you may not know the young people’s ‘lingo’. Ask them what they mean if you don’t understand. Most people like to feel helpful and knowledgeable and will be willing to teach you if you ask respectfully.

                  Homeless

                  • On average, people who are homeless and street based die about 20 years earlier, and have a physical ‘age’ of someone 20 years older.

                  • It is important to consider practicalities. They may have nowhere to store any medications, no access to refrigeration, and limited or no access to running water. Depending on the situation and their needs, be prepared to think outside the box. Can you see them each day? Can you store medications for them? Can someone else?

                  Sexual identity and sexual behaviour

                  • Do not assume that how someone identifies in terms of their sexuality (e.g. homosexual, heterosexual, bisexual) necessarily determines their sexual practices. A man who considers himself heterosexual may still have sex with men. A gay woman may have sex with men in the context of sex work. Be clear when asking about specific behaviour, without judgement and without assumptions.

                  • With sexual identify, it can be helpful to simply ask ‘Do you prefer to have sex with men, women, both, or neither?’

                  • And when asking about actual sexual practices, it can be helpful to introduce it by saying ‘In order to work out any risks, I need to ask about all sexual contact you have had, no matter who it was with, when, where, or how. So that includes regular partners, casual partners, paid sex work, and everything in between. Is it OK if I ask about this?’.

                  • And to accurately determine clinical risk of STIs and/or HIV/AIDS, you will need to know details. Among men who have sex with men, for example, you need to ask about anal intercourse, and get the details as to insertive/receptive and with/without condoms or any broken condoms. Be open and ask/acknowledge your own limitations if need be.

                  • If you are embarrassed, they are more likely to be. If you can be matter of a fact, they are more likely to be.

                  People who inject drugs

                  • Remember that their priorities may not be your own. Ask them what it is that you can help with, and focus on what they want/need.

                  • Always ask not only what people are using, but where they are using. Ask to inspect injection sites if they consent.

                  • Are they interested in reducing/stopping? Would they like your help with that? And if they are not ready/willing/able to consider ceasing their drug use, be prepared to offer harm reduction messages instead.

                  • Avoid scaremongering. Instead of ‘You are going to die if you don’t get treatment for that’ consider reframing and focus on solutions. ‘I can hear you’re worried about this, despite everything that is going on for you right now, and I know you would like to get some treatment. How can I best help you with that?’

                  • Know something about filtering, and how/where they may access wheel filters if they are interested.

                  • Remember other practical interventions—hepatitis B vaccination, for example, or take-home naloxone.

                  Substance use in different cultural contexts

                  Cultural issues in clinical practice

                  In many countries, patients with alcohol or substance use disorders have diverse cultural and linguistic backgrounds with differences in practices and beliefs. Socioeconomic factors, living conditions, physical environments, and access to education and healthcare affect people’s use of alcohol and/or other substances and subsequent problems. Effective communication is important in understanding and managing these, and clinicians need to be aware of the specific factors that have an impact on patients and their families.

                  Types of substance used

                  Some substances are only used or popular in particular areas; often these are local plants or herbal mixtures, e.g. kratom (Mitragyna speciosa—a plant with mild narcotic properties), kava, and coca leaves. Some of these substances were used traditionally by local people long before becoming modern substances of abuse. For instance, kratom was used by rural people in southern Thailand as an energizer for hard work and medicine for several illnesses for over a hundred years. It has now become a substance commonly abused by youths in a mixture with other addictive substances, e.g. benzodiazepines and codeine cough syrup. Kava (Piper methysticum) is used in the Pacific in the form of a traditional herbal drink to welcome guests at important sociopolitical events. It has been abused in other places as the kavalactones in it can produce euphoria and relaxation.

                  The use and misuse of drugs have escalated with newly emerging and re-emerging substances coming on to the market. Some substances are used to cause ‘legal highs’ in some countries or states but are illegal in others. A wide range of unregulated products can now be developed quickly; these include herbal mixtures and synthetic designer drugs, frequently with concealed ingredients, often aggressively advertised and marketed over the Internet and sold in specialty shops as incense, room odourizers, plant food, bath salts, or research chemicals.

                  Due to innovative marketing and rapidly changing compositions, suppliers can circumvent regulations. In some jurisdictions these drugs, despite being similar in structure to prohibited drugs, are traded regardless of the drug's legal status; in others they are grey market goods. Examples include ‘Spice’ (herbal mixtures laced with synthetic cannabinoids) and ‘bath salts’ (mephedrone, amphetamines, and cathinones). When there is a scarcity of some drug, a new or modified kind of abuse emerges, such as the use of ‘krokodil’—a ‘flesh-eating’ mixture made by cooking crushed codeine pills with household chemicals, which allegedly has effects like those of heroin. It was first produced in Russia when a scarcity of heroin and abundance of over-the-counter codeine fuelled a pandemic peaking in 2011. Various street names of the substances are known only to people from the same community. Clinicians should be knowledgeable about the common types and patterns of alcohol or substance use in their community and use this information in their assessment of patients.

                  Quantification of alcohol or drug intake

                  Many cultural influences make the quantification of substance intake difficult. People in many countries are unfamiliar with a standard unit of alcohol and may not use a standard-sized container to drink it. In some situations drinkers share a container when they drink together in a closed group. The use of other substances, such as cannabis and heroin, may also be difficult to quantify as users often report the amount they consume in the unit familiar to their community or share the substance from the same container. Some users mix together two or three different substances.

                  To obtain the best estimate of the quantity of substance used, the clinician needs to inquire about the method of administration, size of the container used, street names of the substances and ‘units’, form of the substance—leaf, liquid, pill, or powder—and places or situations where they are used. Asking how many people share the supply (e.g. a bottle of wine), the frequency of drinking (e.g. payday only or daily), how much money the person spends on the substance each day, and number of associates in the drinking group are also helpful in assessing the amount consumed and risk of complications.

                  Social attitudes and norms

                  Substance use is a matter of public concern and debate worldwide because of its negative and often tragic associations and there is high- profile media coverage of substance-related issues. Substance use is a part of normal life and support for legalizing some drugs, e.g. cannabis and Ecstasy, and harm reduction varies between countries and shifts over time. In this digital era where online social networking is a key part of everyday life and transportation systems are good, forms of drug trade and epidemic have changed and cross-border drug-related activities are common. The spread of the ‘drug culture’ and increasingly tolerant attitudes—at least towards cannabis—occur worldwide. They affect how people in a society admit or deny drug use when asked in a clinical or non-clinical setting.

                  Indigenous people may be at increased risk of substance- and alcohol-related problems because they are marginalized and at a social disadvantage. They may also face barriers when accessing mainstream services for help, as a result of which they present late for treatment. This may occur because most services are designed for and by the majority cultural groups or because of unawareness of services available. Thus, active detection of substance-related problems is important to improve access to indigenous-specific and other treatment services. Increased cultural sensitivity in mainstream services is needed. Partnership between these services and indigenous health professionals, services and communities increases the chance of achieving reduction in substance-related problems both at individual and community levels.

                  Beliefs about the causes of substance use

                  The perception of causes or explanatory models of illnesses differ among ethnic groups. In more highly educated societies, people are more likely to understand the bio-psycho-social model of substance use and accept substance dependence as a disorder of the brain. However, some cultures regard alcohol or substance use as a moral issue. Substance dependence is believed to reflect disadvantages associated with people's backgrounds (which include poverty and mental illness) or to result primarily from individual decisions and choice.

                  Failure to control the use of substances may be viewed as moral inadequacy or weakness of mind and modern treatments may be considered inappropriate. As stigmatization is very strong in some cultures the need for treatment, especially long-term treatment, may be interpreted as an index of severity, leading to poor compliance with treatment. Symptoms such as tremor and sweating due to alcohol withdrawal or stimulant-induced psychosis may be thought due to breaking a taboo or being possessed by a spirit.

                  It is helpful for the healthcare team to adopt an educational approach, discussing bio-psycho-social aspects in simple terms and explaining pathological patterns of dependence, including the repeated desire to cut down, the prolonged use of substances and taking larger amounts than intended as behavioural symptoms of a disorder and not as a moral weakness. Pharmacotherapy and psychosocial intervention should be explained as means of relieving troublesome symptoms, but responsibility for change should always remain with the patients, with the success of treatment being largely theirs.

                  Taboo and stigmatization

                  Alcohol and substance use is taboo in some cultures, families, or religions. In many Muslim countries, alcohol consumption is strictly prohibited. In Buddhism, lay people are taught to conform to the Five Precepts, the fifth of which is to refrain from using distilled or fermented intoxicants, including alcohol, tobacco, and other addictive substances, which often lead to undesirable behaviour. In some countries it is thought that alcohol use is acceptable ‘macho’ behaviour, while stigma is attached to drinking by women.

                  Many people believe that substance misuse is a problem of other people or of those from other ethnic communities and cannot accept that it is also their own problem. People may therefore be too embarrassed to report that they or their relatives need help. They may also feel ashamed that they will be judged as a bad person or even a criminal. Responses to questions may depend on social attitudes, and marital or family problems resulting from drinking may be kept secret, with women being taught not to discuss the problems outside the family. Clinicians need to recognize that people from all communities use substances, licit or illicit, and anyone can experience harm due to intoxication, overdose, or dependence. It is important to find the most comfortable way to help people to talk about their alcohol or substance use and related issues.

                  Communication and treatment issues

                  • It is important to assess whether patients’ symptoms are culturally normal or abnormal. Someone may spend a long time in a drinking group in a community where the alcoholic beverage is consumed from the same container until the supply is depleted, yet an individual within the group drinks little. Therefore, when asking if he/she spends a lot of time drinking, gets intoxicated, or has hangovers, he/she may give an affirmative answer leading to a mistake in diagnosis.

                  • Clinicians may have difficulty exploring symptoms which are culturally specific when they are unfamiliar with the patterns of behaviour within a particular social group. In small, closed communities, where people know each other’s business and are unconfident about assurances of confidentiality, patients may not admit to substance use. In addition, people who find it hard to disappoint or hurt others may give over-obliging, favourable responses to therapists or fail to disclose their lack of adherence to medication.

                  • In traditional Asian cultures, families are largely close-knit and extended and the family plays a very important part in daily living and a patient’s decision to seek and/or take treatment as recommended. Information from family members about a patient’s substance use and its consequences may sometimes be more reliable than information from the patient him/herself. Such information may be the sole source, particularly in those intoxicated, having severe withdrawal symptoms, or otherwise disturbed. If clinicians and the treatment team are sensitive to the importance of the family and can communicate with them directly, this will help the patient to remain engaged in treatment and reduce the risk of relapse. However, some may not want their family to know that they use a substance, and their wishes should be ascertained before contacting them.

                  • It is necessary for a clinician to be sensitive to and acknowledge the cultural factors that determine the patient’s disorder, and at the same time understand and respect their right to adhere to their cultural beliefs and practices, in order to assess and treat them effectively.

                  Further reading

                  Center for Substance Abuse Treatment (2009). Substance abuse among specific population groups and settings. In Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. Rockville (MD): Substance Abuse and Mental Health Services Administration (US). Available at: http://www.ncbi.nlm.nih.gov/books/NBK83240/Find this resource:

                    National Institute on Drug Abuse, National Institue of Health (2003). Drug Use Among Racial/Ethnic Minorities – Revised. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse.Find this resource:

                      Indigenous peoples

                      Indigenous peoples are those who have inhabited a land for thousands of years as distinct from those who have lived there only a few hundred years. They typically have a strong concept of unification of people with the natural world. Each has a distinct culture, spirituality, and traditions, and many speak a distinct language or languages.

                      Indigenous peoples include Aboriginal and Torres Strait Islander Australians, Maˉori (or ‘Tangata Whenua’—‘people of the land’) in New Zealand, First Nations in North America and Canada (including Indian, Métis, and Inuit) among many others.

                      Risk factors for substance use disorders

                      In some countries, the indigenous people form the largest population group and hold power (such as in Fiji). However, in many countries indigenous populations have been subject to colonization, and have become economically and socially disadvantaged. In such countries indigenous peoples have typically faced considerable challenges across many generations through loss of individuals’ identification with their culture, disempowerment, loss of land, lack of access to quality education, employment, and wealth, as well as challenges to traditional sense of worth, law and identity. All of these factors predispose to increased risk of both substance use disorders and mental health disorders.

                      Specific factors which contributed to increased risks include:

                      • The introduction of new, stronger, and readily available psychoactive substances at the time of colonization, in the context of threats to community values and authority.

                      • Indigenous peoples were encouraged or forced to leave their traditional land in several countries for a time, e.g. Australia, US and Canada. Instead the peoples lived in defined communities, often in mission settlements.

                      • Enforced removal of children from their parents occurred in some cases, with the intention of hastening assimilation into the mainstream. In some areas this practice occurred as recently as the 1960s.

                      • Childhood separation, loss of sense of identity, and in some cases exposure to physical or sexual abuse within institutions have often left psychological scars that may include anxiety, depression, and post-traumatic stress disorder. These mental health disorders further predispose to substance use disorders.

                      • Some Indigenous adults then face major challenges bringing up their own children, having had limited opportunity to observe parenting skills. This can result in transgenerational transmission of substance use and mental health disorders.

                      • Other historical factors (e.g. payment or rations provided in the form of alcohol or cigarettes) contributed to normalization of episodic heavy drinking or smoking in some communities.

                      • There has been considerable speculation that genetic influences may explain an increased risk of substance use disorders, however for most indigenous peoples (e.g. Aboriginal and Torres Strait Islander Australians) this theory has never been tested, and there are ample social stressors to explain the increased risk.

                      Prevalence and impact of substance use disorders

                      • Data on the prevalence of substance use disorders in Indigenous communities is often limited.

                      • Available studies generally show higher rates of abstinence from alcohol, but among those who do drink, higher rates of unhealthy drinking. For example, Maˉori are more likely to be non-drinkers than are other New Zealanders, but drink 40% more on average per drinking occasion.

                      • Smoking rates in Indigenous communities are typically double that of the non-indigenous population in the same country.

                      • There may be a higher prevalence of cannabis and other illicit substance use. Some Aboriginal and Torres Strait Islander communities, in Northern Australia, report significant problems from cannabis, including high financial outlays, psychiatric complications, and stress or even violence when cannabis is not available.

                      • There may be higher prevalence of solvent misuse, including glue and paint sniffing in urban settings, and petrol sniffing, particularly in rural and remote regions.

                      • Prevalence of injecting drug use and of sharing of injecting equipment can be higher (e.g. among Indigenous Australians), with associated increased risk of blood-borne viruses.

                      Other health disorders and substance use

                      In disadvantaged indigenous communities there can be a high prevalence of physical disease. For example, Aboriginal and Torres Strait Islander communities in Australia often have a high prevalence of diabetes, renal failure, and rheumatic heart disease.

                      • The distress of disease and of recurrent premature deaths in the community may be a trigger to substance use.

                      • Alcohol or drug use may impact significantly on the ability of the individual to manage their own chronic disease.

                      • Alcohol use may complicate the course of a comorbid disease. For example, acute alcohol consumption may precipitate hypoglycaemia in a person taking hypoglycaemic medication, while chronic heavy consumption may increase insulin resistance. Unhealthy alcohol use combined with obesity and/or viral hepatitis can greatly increase the risk of liver disease.

                      • Any experience of alcohol withdrawal may be more severe in persons with multiple medical disorders.

                      • Any pharmacotherapy suggested for alcohol dependence needs to selected with an understanding of the challenges the individual will face with adherence if they are living in a stressful setting or overcrowded housing. For example, once-a-day naltrexone may be more suitable than a three-times-daily acamprosate regimen. In carefully selected and informed individuals, disulfiram may be possible, though chronic disease may make that medication too risky in others.

                      Treatment for indigenous persons with substance misuse

                      The concept of ‘cultural competence’ describes the set of attitudes, knowledge, and skills that allow the healthcare professional to care effectively for a person from another culture (see p. [link] on cross-cultural care). This typically incorporates not only awareness of and respect for the culture of the patient, but also awareness of the clinician’s own culture and how it can affect their approach. The ability to develop relationships that engender trust and respect is critical (see Box 24.12).

                      Communication with indigenous clients can be assisted by the following:

                      • Taking ample time for effective communication

                      • Introducing yourself as a person, and starting to get to know the patient you are talking with as an individual

                      • Bringing no preconceptions with you

                      • Willingness to learn about the patient’s culture and environment

                      • An awareness that one’s own culture influences one’s beliefs and interactions

                      • Indigenous health professionals or clinical aides can typically enhance the quality of communication and engagement, and help ensure a welcoming and culturally comfortable environment

                      • Where language differences impair communication, quality translation is essential.

                      • In a clinical assessment, a less structured conversation which allows the patient to tell their story can be more effective in history taking and engagement than a series of directed questions. This can be followed up by ‘filling in the gaps’ with more structured questions, linking this in with the story you have already heard.

                      • A holistic approach to medical, psychological and social needs is recommended.

                      In providing counselling or support, it is particularly important to consider culturally appropriate forms of communication and the home, family, and community context. Extended family and kinship or community ties, and responsibilities can be particularly strong. These ties can bring both challenges and resources. If close kin are also problem drinkers, it can be challenging for a dependent drinker to avoid cues to drinking. On the other hand, non-drinking relatives may provide great support. The patient may wish to involve family in the treatment process.

                      Traditional or community-controlled treatment approaches

                      Indigenous peoples have their own cultural beliefs regarding health and treating sickness, which must be acknowledged and respected. In some indigenous communities, specific traditional approaches to healing have been utilized in treatment of substance use disorders.

                      Efforts need to be made to ensure that treatment respects the patient’s culture, but also includes access to the full range of modern therapies, including relapse prevention medicines for alcohol dependence, or opioid maintenance pharmacotherapies (see Box 24.13). Explaining the role of modern medicines clearly is important.

                      In many countries health services run by indigenous communities provide a highly accessible alternative to mainstream services or work in collaboration with mainstream services.

                      The patient in the context of the community

                      At times, whole communities may be seriously affected by unhealthy alcohol or drug use. This tends to normalize risky substance use, and also provides a traumatic or difficult environment for children and adults alike. In communities such as these, where an individual seeks to stop substance use they can face immense challenges, with constant cue exposure, e.g. to cigarettes or episodic heavy drinking. Considerable leadership and strength has often been shown by communities which have effectively made changes in these circumstances. Support of community-driven efforts to address substance use is likely to increase the chance of success of any one individual who is seeking to address their substance use.

                      Some remote indigenous communities affected by widespread unhealthy alcohol use have successfully sought out a range of supply controls, including:

                      • regional alcohol bans

                      • restrictions to the amount or time, or location of alcohol sales

                      • restriction of sales to low alcohol beer

                      • a system of individual permits to buy alcohol, where a permit is lost in the case of alcohol-related violence.

                      These measures, which are sometimes opposed by the alcohol industry, have had documented success. They are often combined with opportunities for community development.

                      In efforts to reduce petrol sniffing (volatile substance misuse) in Australia, good results have been obtained by supply control, with the switch of whole regions to non-sniffable fuel. This has been successfully combined with increased opportunities for young people and for general community members.

                      It is important that services and health professionals work in partnership with indigenous communities to ensure that solutions are relevant, appropriate and likely to be successful.

                      Further reading

                      Gray D, Saggers S, Sputore B, et al. (2000). What works? A review of evaluated alcohol misuse interventions among Aboriginal Australians. Addiction 95:11–22.Find this resource:

                      Kirmayer LJ, Brass GM, Tait CL. (2000). The mental health of Aboriginal peoples: transformations of identity and community. Can J Psychiatry 45:607–16.Find this resource:

                      Saggers S, Gray D. (eds) (1998). Dealing with Alcohol: Indigenous Usage in Australia, New Zealand and Canada. Cambridge: Cambridge University Press.Find this resource:

                        Immigrants and refugees

                        The prevalence and patterns of substance use and mental disorders among immigrant and refugee groups is highly variable. Immigrant status, in itself, is not associated with either increased or decreased risk for substance-related or mental health disorders. However, among groups most vulnerable to the development of substance and mental health problems are refugees and asylum seekers.

                        It is the specific circumstances of pre-migration experience, migration, and settlement that are important in influencing risk for mental disorder.

                        Risk factors among immigrants and refugees

                        • Traumatic experiences or prolonged stress prior to or during migration

                        • Being adolescent or elderly at the time of migration

                        • Separation from family

                        • Inability to speak the language of the host country

                        • Prejudice and discrimination in the receiving society

                        • Low socioeconomic status and, particularly, a drop in personal socioeconomic status following migration

                        • Non-recognition of occupational qualifications

                        • Isolation from persons of a similar cultural background

                        • Extent of acculturation.

                        The global picture

                        To longstanding patterns of migration for economic and family reasons have been added mass movements of people because of persecution, civil war, and conflict.

                        Instability in the Middle East, Africa, and Central America has been a primary reason for the shifting flows of the displaced around the world in recent years. Economic reasons are also still motivating those fleeing parts of Central America and Africa.

                        The changing pattern of war means that the nature of displacement is very different from previous eras. It has shifted from pitting countries against each other to warring factions vying for control within countries, often with weapons and gunmen and combatants from abroad (e.g. Syria).

                        This means the likely needs of displaced persons are different.

                        Origins and destinations for migrants and asylum seekers

                        • The biggest group of asylum seekers in recent years has come from Afghanistan, followed by those from Pakistan and Iran, which have hosted large numbers of refugees from a succession of wars in Afghanistan in recent decades.

                        • In 2014, the largest group are Syrians fleeing more than 3 years of civil war (to Egypt, Jordan, and Lebanon mainly).

                        • Other main sources of asylum seekers are Iraq, Eritrea, Sudan, Gaza, Libya, Ukraine, and Somalia.

                        • The most sought-after destinations are Europe (Germany, Sweden, France, and Italy), North America parts of the Asia Pacific, and Turkey, Egypt, Jordan, and Lebanon.

                        • Increasing proportion of asylum seekers applying to the US are from Mexico and Central America, escaping drug cartel and organized crime violence.

                        • China remains a main country of origin for those seeking asylum in the US—as per previous years.

                        • The recent surge of migration from Central America (El Salvador, Honduras, Guatemala) to the US, increasing numbers are women and children. More than 50,000 unaccompanied minors crossed illegally into the US from October 2013 to June 2014—a record.

                        • Of the total number of people forcibly displaced from their own countries, about half are children.

                        Internally displaced groups

                        • There are now many displaced people who live in their own countries.

                        • Syrians today make up the single largest group of internally displaced persons, with 6.5 million displaced within the country by the end of 2013.

                        • In Colombia, although rebellion is waning, 5.4 million remain displaced, and another 3 million in the Democratic Republic of the Congo.

                        Epidemiology

                        Studies of the epidemiology of substance use disorders in immigrant receiving countries show no overall difference in the prevalence of substance use disorders compared with the ‘home’ population. However, there is great variation between immigrant groups, which reflects:

                        • the variation in the demographic, cultural, and migration profiles of the groups being studied

                        • the wide variation in national health service, social support, and legal systems

                        • the significant methodological and practical challenges to carrying out high quality research in immigrant and refugee communities.

                        The patterns of alcohol use tend to reflect patterns in the home countries of immigrants. To a significant extent this is also the situation with injecting drug use, although the rates of drug use in some young immigrant and second-generation groups is of great concern.

                        Socioeconomic position and cultural dislocation are important contributors. Co-morbidity is very common, with causality operating in both directions. The presence of a mental disorder increases the risk of alcohol and other forms of drug abuse and dependence, and the presence of drug use disorder increases the incidence of mental disorder, particularly mood disorders, most commonly depression and anxiety.

                        Accessing treatment and prevention services

                        A consistent finding in English-speaking countries with large immigrant populations is lower levels of utilization of mental health services by immigrant communities, although there is wide variation. It is not known whether this is due to lower prevalence of mental disorder among these communities or whether the lower rates of service use may be explained by factors such as:

                        • conceptions of mental health and illness that do not accord with mainstream views

                        • higher levels of stigma associated with using mental health services, perceptions of inappropriateness of services

                        • a lack of awareness of what services are available.

                        There is little information on whether the quality of treatment outcomes for immigrant and refugee patients is the same or different to that of majority communities. The existence of culturally appropriate treatment and prevention services for mental and substance use disorders is the exception rather than the rule.

                        Where such services do exist they are almost never rigorously evaluated. In most countries, mental health services and drug and alcohol services are separately administered. Given the very high rates of co-morbidity this is generally an unsatisfactory situation. Mental health services are usually not competent to treat drug and alcohol problems, and drug and alcohol services are generally not competent to treat mental disorders. People with both types of problems bounce around between services and, more often than not, receive poor quality care.

                        There is increasing recognition of this system-level problem and attempts to integrate mental health and drug and alcohol services are becoming more common, as is the recognition that mental health clinicians require at least basic training in skills relevant to drugs and alcohol, and drug and alcohol clinicians require basic mental health competencies.

                        All clinicians require additional training in effective cross-cultural clinical practice, and health services require assistance in developing effective models of service delivery to cultural minority groups.

                        Immigrant diversity: a policy challenge

                        In some countries with a long history of permanent immigrant settlement, there is generally a policy framework that recognizes the cultural and linguistic diversity of populations, and the responsibility of services (variably, and never fully, discharged) to respond effectively to this reality of diversity.

                        However, in countries that have become immigrant-receiving countries only in recent decades there is generally both a lack of epidemiological and other necessary information, and little in the way of policy and practical service response to diversity.

                        There is much to be learnt about:

                        • the hundreds of millions of internal, rural to urban, migrants in China, India, Indonesia, Brazil, and other countries

                        • temporary labour migrants, most commonly women and almost entirely from poor countries

                        • the large numbers of trafficked women

                        • tens of millions of international students

                        • huge numbers of illegal migrants living in countries without the benefits of permanent residency or citizenship and in constant danger of imprisonment and deportation.

                        These less visible and under-researched groups are likely to be most at risk of developing mental and substance use disorders, and are least likely to have access to effective services.

                        Prison inmates

                        Introduction and epidemiology

                        The prison environment is unique and challenging. The dominant culture is one of control, and healthcare services often sit uncomfortably within this. There is, furthermore, a nexus of antisocial behaviour, personality disorder, disadvantage, mental health disorders, physical illness, infectious diseases, risky sexual behaviour, and substance use that poses huge health risks to inmates. Box 24.14 offers a snapshot of a sample prison population in New South Wales (NSW), Australia.

                        The rate of incarceration throughout the world varies from 29 per 100,000 adults in Liechtenstein to 750 per 100,000 adults in the US. The variability in incarceration is strongly linked to drug-law policies (the so-called War on Drugs), and to health and social welfare indicators linked to poverty, social dislocation, and disrupted relationships. A high proportion of prisoners have a history of alcohol or drug misuse.

                        Psychiatric comorbidity

                        Individuals who misuse drugs disproportionately suffer from mental disorders. Either condition can precipitate non-compliance with treatment and this, in turn, strongly predicts interaction with the criminal justice system. Some prisoners also have adult ADHD which is often primary to their addiction. The appropriate treatment of this (e.g. methylphenidate) has been shown to be useful among prisoners.

                        Drugs and crime

                        The following crime classification has been developed to provide the criminal justice sector a health paradigm for the interactions between substance misuse and crime:

                        • Psychopharmacological crimes: crimes committed under the influence of a psychoactive substance, as a consequence of its acute or chronic use

                        • Economic-compulsive crimes: crimes committed in order to obtain the means to support drug use

                        • Systemic crimes: crimes committed within illicit drug markets—drug supply, distribution, and abuse

                        • Drug law offences: crimes committed in violation of drug and other related legislations.

                        Avoiding imprisonment

                        Attempts to re-engage clients with substance use disorders with community health and welfare services, through low-level courts, is the subject of a number of diversion programmes being trialled in different jurisdictions. ‘Drug Courts’ are just one example.

                        Prevention of drug and alcohol use in prisons

                        Alcohol

                        Controlled in prison reasonably well, as the quantities required make it difficult to conceal, and easy to detect. Also, because of the disinhibitory effects of alcohol, with consequent disruption to a closed and overcrowded community, tolerance by both custodial authorities and inmates is low, and when tolerated, short-lived.

                        Other drugs

                        Supply is constrained through regulation and physical barriers, but the success of supply reduction has never been supported with evidence. Random urine testing of prisoners confirms that drugs, licit and illicit, available in the community, are being brought through to prisoners— either through corrupt staff or contractors, or by coercion of families and friends.

                        Diversion of prescribed medications is minimized through supervision of medications by health service staff. Custodial staff have an important ancillary role to play, but non-compliance and diversion will always be threats to a prescribing service in the prison.

                        Management of drug and alcohol use in prisoners

                        Incarceration may result in:

                        • catastrophic interruption of substance use (transfer to a coercive, non-therapeutic environment)

                        • continuation of interrupted therapeutic associations

                        • an opportunity to address substance use in a relatively controlled environment (particularly polydrug misuse).

                        Prison-based opioid pharmacotherapy programmes are available in some countries and states but not others. The may include:

                        • maintenance—some systems impose low fixed-dose regimens, while others restrict the particular correctional centres that ‘allow’ opioid pharmacotherapies through the prison classification system

                        • reduction—clients from community programmes are withdrawn from their treatment, in a non-consensual manner

                        • enforced withdrawal—in jurisdictions where no opioid pharmacotherapies are sanctioned.

                        Harm reduction

                        • Harm reduction in the prison environment, despite extreme risks of blood-borne virus transmission often receives inadequate attention.

                        • Undue priority is given to supply reduction (e.g. surveillance, interdiction).

                        • Demand reduction—psychological approaches are favoured by custodial authorities; therapeutic approaches are constrained; limited number of prison-based therapeutic communities; most experience is with methadone, and little with buprenorphine or naltrexone.

                        • Harm reduction is limited to immunization programmes and rarely extends to education about bleach and making bleach available for cleaning injecting equipment. Outside of 11 countries worldwide, there is no access to regulated exchange of injecting equipment.

                        Management of psychiatric comorbidity

                        Imprisonment may provide an opportunity for management of psychiatric co-morbidity including sometimes undiagnosed primary psychiatric conditions.

                        Transition to the community

                        The period immediately after release from prison is a very dangerous one. Often tolerance to drugs such as opioids or benzodiazepines is reduced due to enforced abstinence, but the desire to use a substance is high. Australian male prisoners were nearly four times more likely to die soon after release than their non-incarcerated peers, and women on release from prison were nearly eight times more likely to die. Drug-related causes of death were the most common.

                        Efforts to reduce post-release mortality include education, offering increased doses of opioid maintenance pharmacotherapy just prior to release, and ensuring a smooth transition to community-based treatment and support services.

                        Summary

                        Despite some improvements in recent years, there remains an overwhelming need for enhanced responses to mental health and substance use disorders for people who are or have been in prison. The inconsistencies between prison systems, and sometimes even within the system, make the transition from community to prison and back to community difficult for service providers, and dangerous for clients.

                        Further reading

                        European Monitoring Centre for Drugs and Drug Addiction (2007). Drugs in Focus: Drugs and Crime—a complex relationship. Lisbon: EMCDDA. Available at: http://www.emcdda.europa.eu/attachements.cfm/att_33064_EN_2007_2721_EN_WEB.pdfFind this resource:

                          Larney S, Kopinski H, Beckwith CG, et al. (2013). Incidence and prevalence of hepatitis C in prisons and other closed settings: results of a systematic review and meta-analysis. Hepatology 58:1215–24.Find this resource:

                          Zlodre J, Fazel S. (2012). All-cause and external mortality in released prisoners: systematic review and meta-analysis. Am J Public Health 102:e67–75.Find this resource:

                          The impaired health professional

                          Approximately 10–15% of all healthcare professionals will misuse drugs or alcohol at some time during their career. Though recent studies suggest that the prevalence is similar to the general population, given their level of responsibility, any impairment could potentially place patients at risk. Drug-dependent health professionals represent a specific subtype of drug misuser, given their access to licit drugs, particularly opioids, sedatives, and tranquillizers.

                          While risk factors for substance use disorders are similar to those for the general population, health professionals have additional risk factors related to their chosen profession. These include the relative ease of access to a range of prescription medications, as well as the stressors commonly encountered in clinical practice (Table 24.4).

                          Table 24.4 Risk factors for substance misuse

                          Vulnerable individual

                          • Family history of mental illness, substance misuse

                          • Adverse childhood experiences

                          • History of mental illness, physical illness, pain

                          • Marital discord; poor support networks

                          • Poor coping skills with stress

                          • Personality factors e.g. perfectionistic, obsessional, self-sacrificing, ambitious, rigid, difficulties with emotional expression

                          Drug factors

                          • No treating GP; prone to self-medication

                          • Ready availability e.g. opioids, benzodiazepines, anaesthetic agents, other sedatives

                          Occupational factors

                          • Overwork, sleep deprivation

                          • Impaired work–life balance

                          • Exposure to trauma and death

                          • Treatment failures; medico-legal concerns

                          • Inadequate resources and support

                          • Ethical and diagnostic dilemmas

                          Dealing with an addicted colleague

                          Recognition of warning signs is an important step in dealing with an addicted colleague (see Table 24.5). Once a problem is identified, there are many barriers to receiving treatment. The impaired practitioner will often rationalize, deny, and minimize their problem. They may fear being stigmatized, ostracized, and deregistered. Others are often reluctant to confront or deal with warning signs, fearing unpleasant consequences for their colleague (loss of livelihood and reputation) and themselves (time-consuming investigations, legal repercussions, loss of collegiality). Take the following steps:

                          • Seek advice from senior colleagues/health advisory services

                          • Arrange a time to meet privately with the colleague of concern

                          • Inform them that you are concerned and why

                          • Ask them to consult an appropriate doctor, provide relevant contact information, and follow-up to ensure advice is take.

                          Table 24.5 Warning signs of substance misuse at work

                          Clinical performance

                          Appearance and behaviour

                          • Increased sick days

                          • Reduced efficiency and decisiveness

                          • Patient complaints, e.g. poor analgesia

                          • Inappropriate prescribing

                          • Overt evidence of drug use—ampoules, syringes, pills

                          • Filling patient’s prescriptions

                          • Dishevelled appearance

                          • Change of mood, personality

                          • Unexplained loss of consciousness

                          • Smells of alcohol at work

                          • Evidence of drug use—track marks, drowsy, tremulous, ataxic

                          Notification to regulatory authorities

                          Consideration should be given to making a formal notification to the appropriate regulatory authorities where there are concerns that the health professional:

                          • has practised the profession while intoxicated or otherwise affected by alcohol or drugs

                          • has placed or may place patients at risk of harm during their practice (a) because of a substantial departure from expected professional standards due to substance use (b) because of impairment from substance use.

                          Reporting obligations vary across different jurisdictions, and health practitioners should consult their local regulatory authorities to determine if reporting is mandatory or not. Even without mandatory reporting, health professionals often have an ethical and professional responsibility to report behaviour of concern. Impaired colleagues should also be encouraged to self-notify.

                          Effective health programmes for impaired practitioners have high success rates and provide a combination of structure, treatment, supervision and monitoring (e.g.. thrice weekly urinalysis; urinary EtG; breathalyser testing; testing blood for MCV, LFTs, CDT).

                          When treating an impaired health professional, treat them as you would any other patient. Be aware that over-identification with a colleague and defence mechanisms such as collusion, denial, avoidance, minimization, and rescuing are barriers to treatment.

                          Preventive strategies include more education in training programmes about risk factors and protective factors for substance misuse, and early access to appropriate treatment and rehabilitation programmes.

                          Further reading

                          Baldisseri M. (2007). Impaired healthcare professional. Crit Care Med 35:106–16.Find this resource:

                          Kenna G, Lewis D. (2008). Risk factors for alcohol and other drug use by healthcare professionals. Subst Abuse Treat Prev Policy 3:3.Find this resource:

                          Safety-critical occupations

                          Introduction and epidemiology

                          Certain occupations have a special responsibility for public safety because of the nature of the work. These include airline pilots, air traffic controllers, and some other transport personnel, certain medical and other healthcare practitioners, and emergency services personnel.

                          • Of 1353 US pilots who died in aviation accidents between 2004 and 2008, 507 were found to be taking drugs and 92 had ethanol in excess of 0.04 g/dL.

                          • Many safety critical industries (e.g. airlines, forestry) run comprehensive alcohol and drug programmes to reduce risk; those who don’t, should.

                          Approaches to policy and prevention

                          Best practice considers:

                          • workplace alcohol and drug policies

                          • detecting and monitoring those with intoxicant use problems

                          • employee privacy

                          • staff training

                          • what local resources and specialists are available?

                          • when is an affected employee work safe

                          • management of relapse

                          • continuous programme improvement.

                          An enthusiastic senior staff member should lead the programme together with a governance group of managers, unions, staff, and healthcare professionals. All should debate and agree common goals for the programme.

                          Information

                          Workplace policies may extend to employees’ behaviour outside of the workplace, setting a zero tolerance of workplace alcohol or drug use, discussing alcohol use at company functions, and devoting particular attention to risk. Policies should be publicized and include ongoing staff education.

                          Access

                          This includes voluntary presentation, referral by unions, peers, management, and health services, and pre-entry or reasonable cause drug and alcohol tests. Staff need assurance that participation and compliance with treatment can enable them to continue in employment.

                          Intervention

                          • With trained staff, screening and brief intervention may be possible, but focus should include possible intoxicant-related problems, e.g. antisocial behaviour, accidents and trauma, or apparent intoxication at work.

                          • Programme staff should discuss concerns with the employee and refer them to alcohol and drug practitioners for assessment, treatment, and advice about ongoing monitoring and support.

                          • Monitoring can involve blood and urine tests and regular meetings with health services.

                          • Urine testing can detect drug use. The best biomarker of relapse to heavy drinking is the CDT test. This is not as useful in initial assessment.

                          • Support may involve counsellors, others in recovery, and recovery group attendance.

                          Work

                          After an agreed treatment period an employee who ceases unsafe use of intoxicants and who complies with monitoring and support should return to work. Relapse should trigger re-assessment, decisions about further assistance, and whether the employee remains work safe.

                          Further reading

                          Canfield DV, Dubowski KM, Chaturvedi AK, et al. (2012). Drugs and alcohol found in civil aviation accident pilot fatalities from 2004-2008. Aviat Space Environ Med 83(8):764–70.Find this resource:

                          Csiernik R. (2003). Ideas on best practices for employee assistance program policies. Employee Assistance Quart 18:15–32.Find this resource:

                          Flynn CF, Sturges MS, Swarsen RJ, et al. (1993). Alcoholism and treatment in airline aviators: one company's results. Aviat Space Environ Med 64(4):314–18.Find this resource:

                          SAMHSA Advisory (2012). The Role of Biomarkers in the Treatment of Alcohol Use Disorders, 2012 Revision. Available at: http://store.samhsa.gov/product/The-Role-of-Biomarkers-in-the-Treatment-of-Alcohol-Use-Disorders-2012-Revision/SMA12-4686