Three-part webinar series

Transcription

1 July 20 th :00 a.m. 12:00 p.m. (EDT) Opioids Across the Lifespan Part 2 of a 3 part series: Transitional Aged Youth Dr. Kim Corace The Royal Ottawa Mental Health Centre Lori Naylor & Stephen Chatterton Breakaway Addiction Services Welcome! The webinar will begin shortly! To hear audio for this event, please turn up your computer speakers. Please note this event will be recorded. Three-part webinar series Early Years Maternal/Prenatal Transitional Aged Youth Older Adults June Today August Today s speakers: Dr. Kim Corace The Royal Ottawa Mental Health Centre Stephen Chatterton Breakaway Addiction Services Lori Naylor Breakaway Addiction Services 1

2 Opioids Across the Lifespan: Transitional Aged Youth Dr. Kim Corace, PhD, CPsych Director, Clinical Programming and Research Substance Use and Concurrent Disorders Program The Royal Ottawa Health Care Group Associate Professor, University of Ottawa Clinical Investigator, Institute of Mental Health Research You may only access and use this PowerPoint presentation for educational purposes. You may not post this presentation online or distribute it without the permission of the authors. Learning points Examine the opioid crisis amongst youth Identify signs and symptoms of problematic opioid use and addiction Review screening and assessment strategies Discuss overdose prevention and response Explore harm reduction and other treatment options including services tailored to needs of youth 2

3 Total number of cases 7/20/2017 Total Number of Opioid-Related Deaths in Ontario * Preliminary figures subject to change Ontario Agency for Health Protection and Promotion (Public Health Ontario). Interactive Opioid Tool. Toronto, ON: Queen s Printer for Ontario; Transitional Aged Youth: A critical age group A period of transition from adolescence to adulthood Unique developmental tasks and challenges to navigate A time of great change and adaptation Psychosocial transition, social role change, physical maturation Neurodevelopmental changes Disruption in access to services: aging out, different requirements in the adults system, changes in accessing social and health services Age of vulnerability: Onset of substance use and mental health problems Even more of a difficult transition for this population Table 1. Past Year Drug Use (%) for the Total Sample, and by Sex and Grade, 2015 OSDUHS (CAMH) Total Male Female G7 G8 G9 G10 G11 G12 Alcohol Cannabis Binge Drinking Opioid Pain Relievers (NM) Cigarettes

4 Number of cases 7/20/2017 The Opioid Crisis Among TAY Youth (aged 15-24) have the highest self-reported past-year use of illicit substances compared to any other age group in Canada Youth are 5 times more likely than adults (>25 years) to report harm due to drug use Ontario students in grades 7-12: Over 72% obtain the opioids from home and 6% from friends Opioid Related Morbidity and Mortality Among Youth (15-24) in Ontario Total Male Female Deaths ED Visits Hospitalizations PHO, Interactive Opioid Tool What kinds of opioids are our youth (16-25) using? 60% 50% 40% 30% 20% 10% 14% 18% 32% 32% 50% 43% 0% Corace, Willows, et al (2016) 4

5 A Generation Exposed... Although experimentation with alcohol and other drugs is a natural part of adolescence, experimentation involving opioids is high risk as addiction occurs much more rapidly than with other drugs» National Institute of Drug Addiction (NIDA) Commonly used prescription opioids Oxycodone (Oxycontin, OxyNEO, percocet) Oxycontin formerly most popular opioid Replaced by OxyNEO designed to be more difficult to alter Generic Oxycodone now available but not covered by ODB Generally chewed, snorted or injected Dilaudid, Hydromorph Contin Usually chewed, snorted or injected What is Fentanyl? Fentanyl: times stronger than morphine Patch Fentanyl can be extracted from patches that are designed to be long-acting medication Sucked in mouth (strips), smoked, or injected Powder fentanyl ( illicit fentanyl ) made illegally and sold on the streets as fentanyl, pressed into pills and sold as another opioid (i.e. oxycontin, percocet), or cut into other drugs Fentanyl is the leading cause of opioid deaths in Ontario in

6 Opioid Intoxication: What can you observe? Drowsiness or the Nod Constricted or pinpoint pupils Slurred speech Impairment in attention or memory Opioid Withdrawal: What can you observe? Dilated pupils Anxiety, irritability, anger (drug craving) Agitation & Restlessness (cannot sit still) Appears to be ill: nausea, vomiting, diarrhea, sweats and chills, watery eyes, runny nose Yawning Insomnia ** Can assess using Clinical Opioid Withdrawal Scale (COWS) What are the risks of opioid use in youth? Overdose high risk new users unknown dose or unknown/new source combined with alcohol and/or benzodiazepines after a period of stopping opioids especially after leaving treatment program Death Accidents Addiction Infectious diseases from intravenous use and sharing drug equipment (Hepatitis C, HIV) 6

7 Teaching youth opioid overdose prevention Don t use alone Don t mix drugs Go slow Cannot predict the quality of street drugs Fentanyl is being cut into other drugs (counterfeit oxys or other pills including ecstasy) You cannot smell, taste or see it Know your tolerance Be aware that drugs can be tampered with Carry a naloxone kit An overdose is a medical emergency: Call 911 Naloxone Saves Lives *available for free for those who use drugs or their family/friends WHAT ABOUT ADDICTION? 7

8 Addiction is a developmental disease that starts in adolescence and childhood 1 Are our programs, polices and procedures designed to address this? 1 NESARC, 2003 Risk Factors for Substance Use Problems Vulnerable Host Environment/ Sociocultural Context Repeated substance use ADDICTION Screening and Assessment Screen using validated tools for youth: Global Appraisal of Individual Needs-Short Screener (GAIN-SS) CRAFFT Comprehensive Assessment: including risk, mental health, youth s goals, and readiness to change Be respectful and collaborative: Listen, engage, build alliance, focus on strengths, and integrate harm reduction Youth are the experts in their experience: Meet them where they are at 8

9 Concurrent Disorders are the Norm MH D/O Any Mental Illness Severe Mental Illness Individuals With SUD SUD (lifetime) SUD (past 12 months) % % Adults % Youth 30% 18% 29% 40-60% 23-35% 35% National Comorbidity Survey, 1997; NSDUH, 2015; Rush 2008; Epidemiological Catchment Area study Concurrent Treatment is Key.But In Ontario, 16% of grade 7-12 students have a substance use problem that requires treatment, yet only 0.6% received treatment in the last year Youth with concurrent disorders face even more barriers to treatment Regional Opioid Intervention Service One of the first of it s kind in Ontario: Focus on Care, Capacity Building, and Integration Multidisciplinary team provides outpatient intervention for opioid use an related mental health problems Target youth and young adults (age 16 and up) Partnerships with community and hospital service providers to offer a full spectrum of care close to where our clients live Evaluation: To better understand the unique needs of young people with opioid use problems 9

10 Results: Youth have unique needs Youth have unique needs: A one-size-fits-all approach does not make sense We need to create tailored treatment programs for youth, with a focus on integrated concurrent disorders treatment and harm reduction Treatment Approaches with TAY Developmentally appropriate, safe, low barrier, youthcentred, collaborative, flexible, evidence-based Harm reduction Opioid Agonist Therapy: Suboxone*, Methadone Psychosocial treatments and psychotherapy Integrated mental health treatment Withdrawal Management Risks of abstinence based opioid treatment Relapse Overdose with relapse due to loss of tolerance to opioids after a period of abstinence Stages of Change: Meeting youth where they re at 10

11 Harm reduction is evidence-based Policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption * Research shows that harm reduction: Reduces substance-related harms, risky drug use, overdose Reduces incidence of HIV, Hep B &C, and other STIs Engages clients in the health care system Can promote entry into substance use treatment *International Harm Reduction Association, 2010 We can integrate harm reduction in our work with youth by. Thinking about: What are the risks associated with drug use? What causes these risks? What can I do to help reduce these risks? Engaging Opioid Using Youth Lori Naylor Clinical Lead Breakaway Addictions Stephen Chatterton Youth Opiate Outreach Worker Toronto Opiate Support Team 11

12 According to neurobiological research, adolescent behaviour can be partially explained by their brain s stage of development. BEING TRAUMA INFORMED Adverse Childhood Experiences ACE Study Measured childhood exposure to: psychological, physical, or sexual abuse violence against mother living with household members who are substance users, have mental health challengers, are suicidal or have been imprisoned Of the 17,000 HMO Members: 1 in 4 were exposed to 2 categories 1 in 16 were exposed to 4 categories 22% were sexually abused women were 50% more likely to have experienced 5+ ACEs 12

13 Adverse Childhood Experiences The higher the ACE Score, the greater the likelihood of: Severe and persistent emotional problems Health risk behaviors Serious social problems Adult disease and disability High health, correctional and social service costs Poor life expectancy Childhood exposure to 4 + factors: 4-12 fold increase in risk of alcohol use disorder, drug abuse, depression and suicide attempt in adulthood 10 times more likely to have injected drugs First Stage Trauma Work Build therapeutic alliance Promoting safety Address immediate needs Normalizing and validating client experiences Educating client about PTSD and treatments Address gender issues that make women vulnerable Nurture hope and strengths Generate treatment goals Crucial for young people to prevent further trauma Teach coping skills which target post traumatic adaptations (grounding) Attachment Style and Counselling Disrupted relationships with adults can put a young person in a defensive, mistrustful stance Experience with a trusted adult who is an ally may be limited Counselling may re-create or re-enact a parental dynamic Opportunity to model a nurturing relationship with clear boundaries and respectful interactions 13

14 New to Social Services or Counselling Lay the groundwork for the next steps in their journey Unlikely that you will see them through the full journey set up potential for return to services Stay present and focus on the process Be prepared for testing behaviours Harm Reduction Approach Sporadic, infrequent or intermittent contact with youth clients Take-aways are critical: o Information, skills, supplies which can minimize the harm they encounter between meetings Harm Reduction Approach Retention in the helping relationship Abstinence as a goal may lead to disconnection Long term goals and outcomes are not yet in their capacity I am bulletproof attitude Lack enough lived experience to have learned otherwise 14

15 Counselling Language take a break try it out you can return to it later do an experiment give your body a rest you can change your mind as time goes on Opioid Overdose Prevention Naloxone Try not to use alone Don t make assumptions on what you have o Risk of contaminants and quality Understand tolerance Avoid mixing substances Safety is Crucial! Housing / Shelter Safer drug use Safer relationships - Safer injection practices - Risk of human trafficking Safe Sex & Consent Financial stability - OW or ODSP can prevent high risk means of getting money (e.g.: sex work, stealing) Health care - address preventable diseases and early detection (e.g.: Hep C, HIV, abscesses) 15

16 Stages of Change Where Are They At? How To Help Them Move Along? CASE STUDY Hunter G. 21 year old male Injection Ketamine use OAT on a low dose of Suboxone History of interpersonal trauma and preexisting mental health concerns. Desire for counselling and residential treatment Frequently missed appointments Never followed through on first steps Parents called asking for advice and support and to get him into detox or treatment. 16

17 Potential Risks Overdose Infectious disease Driving while sedated Criminal involvement Alienation from family Engagement Client-centred approach Put the responsibility for change in Hunter s hands Reminders that the door was always open we would work with him when he was ready NOTHING WORKED Hunter stopped making contact. 8 months later... Hunter called! Looking for support Re-engaged with counselling Identified two main goals Reducing use Finishing high school He is currently working toward these goals! 17

18 Lessons Learned Leave the door open! Hunter was contemplative - not ready to make change. Youth can try it out Long term commitment can be a deterrent for youth Honour their social networks Peer groups are very important negative comments apply the same comments about peers to themselves Flexibility is key Be clear about boundaries Don t enforce strict rules 3 missed appointments & you re out Starting Difficult Conversations Be direct o As you might start a conversation about suicide. Ask about the benefits they get from using substances Get their opinion on their substance use what you are saying is making me think... Lots of young people experiment with substances. Do you mind if I ask a few questions? Engagement Protection When youth are using substances in a high risk way our protective instincts kick in we move too quickly try to change the behavior with education or counselling We need to support youth to have agency over their own process, while weaving in information about safety and letting them know that we care. 18