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Nova Scotia Adolescent Withdrawal Management Guidelines
2013
1Adolescent Withdrawal Management Guidelines 2013
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Primary principles of withdrawal management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Identification and management of intoxication and withdrawal states . . . . . . . . . . . . . . . . . . . . . 8
Early recognition of withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Principles of assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Comprehensive assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Engaging Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Connection to Continuum of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Adolescent Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Development changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Substance Abuse and Brain Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Gender Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
The impact of substance use on developmental tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Culturally Effective Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
First Nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
African Nova Scotians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Migrant Youth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Lesbian, Gay, Bisexual, Transgendered, and Questioning Youth . . . . . . . . . . . . . . . . . . . . . . . . . 49
Trauma-Informed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Essence of trauma-informed services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Family Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Youth Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Withdrawal Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Substance Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Nicotine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
PharmacologyofNicotine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
NicotineReplacementTherapy(NRT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Adolescent Withdrawal Management Guidelines 20132
Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Alcoholintoxication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Featuresofalcoholwithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
AlcoholWithdrawalSeizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
AlcoholWithdrawalDeliriumandDeliriumTremens(theDTs) . . . . . . . . . . . . . . . . . . . . . . . 77
ManagingAlcoholWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
AssessmentofwithdrawalsymptomsusingtheCIWA-A . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
PharmacologicalManagementofAlcoholWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Benzodiazepineintoxication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
BenzodiazepineWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
FeaturesofBenzodiazepineWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
ManagingBenzodiazepineWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
PharmacologicalManagementofBenzodiazepineWithdrawal . . . . . . . . . . . . . . . . . . . . . . 87
Cannabis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
CannabisIntoxication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
CannabisCessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
ManagingCannabisWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
PharmacologicalManagementofCannabisWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Typesofopioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Signsandsymptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
ManagingOpioidWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
ClinicalManagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Pharmacologicalmanagementofopioidwithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
3Adolescent Withdrawal Management Guidelines 2013
Stimulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Somecommonstimulants: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
StimulantEffects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 StimulantToxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
Methylenedioxy-methamphetamine(MDMA,Ecstasy) . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
Featuresofstimulantwithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
ManagingStimulantWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108
PharmacologicalManagementofStimulantWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . .109
Volatile substances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
Managingvolatilesubstancewithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113
PharmacologicalManagementofInhalantWithdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . .114
Tattoos, Piercings, and Needle Sharing—Hepatitis C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
Sleep Disturbance in Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
Appendix I: Modified Fagerström Tolerance Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
Appendix II: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) . . . . . . . . . . . . . . . .121
Appendix III: Clinical Opiate Withdrawal Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125
Appendix IV: Adolescent Bio-Psycho-Social-Spiritual Assessment Form . . . . . . . . . . . . . . . . . . .128
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149
Special Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150
Adolescent Withdrawal Management Guidelines 20134
Introduction
NovaScotiahasinvestedinnumerousspecializedaddictionservicesforadolescentsduringthelastdecade.TheDistrictHealthAuthorities(DHAs)haveleveragedprovincialenhanced-servicesfundingforyouthtodevelopavastrangeofmuch-neededsupportsandservicesforadolescentsandconcerned/significantothers.AdolescentworkhasbeenfurtherenhancedthroughfundingmadeavailablethroughHealthCanada’sDrugTreatmentFundingProgram(DTFP).Between2009and2013,NovaScotianyouthandfamilieshavebenefitedfromtargetedfundingforyouthatriskofsubstanceabuse.InaccordancewithDTFPfundingcriteria,projectshaveincludedcapacity-enhancementactivitiesdesignedtoincreasetheabilityofserviceproviderswithinthecommunitytoidentify,refer,andsupportyouthatriskofsubstanceuse.Otheractivitiesfocusedonearlyinterventionforyouthatriskandtheirparents.Targetpopulationshaveincludedrural,street-involved,in-care,andaboriginalyouth.Systemcapacityandstaffcompetenciesrelatedtohealthpromotionandpreventionandtreatmentofsubstanceuseandgamblingamongadolescentscontinuetogrow.Oneofthesystem’sgreatestassetsistheexpertiseattainedbyadolescentaddictionworkers.
Unfortunately,asignificantgapremainsalongthecontinuumofsupportsandservicesforadolescents.Untilrecently,theexpansionofadolescentserviceshasnotincludedacloseexaminationofwithdrawalmanagement.Currently,therearenoyouth-orientedwithdrawalmanagementservicesinNovaScotiathatwhollymeettheneedsofthispopulation.Toaddressthecurrentgapinwithdrawalmanagement,keyprovincialstakeholders/expertshavereviewedbestandpromisingpracticesandapproacheswithrespecttoadolescentwithdrawalmanagementtohelpinformacomprehensivesystemofadolescent-specificwithdrawalmanagementservicesinNovaScotia.
Atpresent,thereisnounityacrossCanadaregardingwhichapproachbestservestheneedsofadolescents.Provincesandterritoriesdifferwidelyintheirapproachestoadolescentwithdrawalmanagementprograms,reflectingdisparateneeds,ideologies,andresources.Aliteraturereviewandreportonyouth-specificwithdrawalmanagementprogramsandstrategiesacrossCanadawascommissionedandreleasedin2007;itwasupdatedin2011tohelpinformtheworkoftheProvincialAdolescentWithdrawalManagementWorkingGroup.
5Adolescent Withdrawal Management Guidelines 2013
TheformalcallforprovincialWithdrawalManagementGuidelinescamefromtheProvincialAdolescentWithdrawalManagementWorkingGroupduringameetingheldJanuary9–10,2012.Thefollowingthemesemergedfromtheprovincialworkinggroup:
• Adolescentclinicaltherapistsandcommunityoutreachworkersshouldplayaroleinadmission,treatment,anddischargeplanningspecifictowithdrawalmanagement.
• AdolescentWithdrawalManagement(AWM)requiresatime-sensitiveresponse.
• Everydooristherightdoor—ifanadolescentisseekingwithdrawalmanagementbutdoesnotmeetadmissioncriteria,he/sheshouldbelinkedtoanotherappropriateservice.
• Adolescentprogramming,evenwithdrawalmanagement,musttakeintoconsiderationdevelopmentalneedsandactivityrequirementsappropriateforthecontext.
• CoreCompetenciesshouldincludeknowledgeofwithdrawalmanagementmedicalprotocolsforadolescents.
• SpecializedStaffCompetenciesshouldincludeknowledgeofadolescentdevelopmentandtheimpactofsubstanceuseonthedevelopingbrain.
• StaffmustbetrainedinCulturalCompetencyandCulturalSafety,toenhancethetreatmentexperienceforFirstNationandotherpopulations.
• Staffmustrecognizethatwithdrawalmanagementisjustonecomponentofthetreatmentexperience.
• Havinglinkageswithotherpartsofthetreatmentsystem,suchasCommunity-BasedServices,iscritical.
• Consistentguidelinesfor“flow”inandoutofwithdrawalmanagementmustbeprovided.
• Treatmentplanningmustconsidertheclient’sreadinessforchange.
• Rolesmustbeclarifiedwithrespecttocaringforadolescentsandhelpingthemnavigatethesystem.
• Standardizedprovincialassessmentisneeded,whilerecognizingthat“over-assessment”canbeabarriertoaccess.
AsubcommitteeoftheProvincialAdolescentWithdrawalManagementWorkingGroupwasformed,andotherexpertsonthesubjectwereconsulted,toadapttheAustraliandocument YSAS Clinical Practice Guidelines: Management of Alcohol and Other Drugs Withdrawal.Carefulconsiderationofthethemeslistedabove,relatedliterature,andresultsfromyouthstakeholdermeetingshelpedtodeterminethestrengthsandlimitationsofAustralianguidelinesfortheNovaScotiacontextandtoshapethisdocumenttobetterfittheneedsofNovaScotia.
Adolescent Withdrawal Management Guidelines 20136
Theguidelinesaremeanttosupportmanagementofsubstance-usewithdrawalfor13-to18-year-oldsinallsettingsthatareexpectedtoprovidewithdrawalmanagementservicestoadolescents.Thismayincludeanadultwithdrawalmanagementunit,apediatricunitorinthefuture,anadolescentspecificwithdrawalmanagementunit.Thedocumentisintendedtosupportandinformallstaffwhohavearoleinassistingadolescentswiththewithdrawalmanagementprocess.Thisincludeshelpingadolescentsaccesswithdrawalmanagementservices,helpingadolescentsstayconnectedtothecontinuumofservicesoncetheycompletewithdrawal,andsupportingfamilyandconcerned/significantothersasrequired.Tofillalong-standinginformationgap,thisdocumentplacesparticularattentiononthemedicalwithdrawalprotocolsforadolescents.Thisdocumentalsotakesintoaccountpsychosocialandspiritualconsiderationsnecessaryfortheprovisionofholisticcare.Usersofthisdocumentmustnotethatthemedicalprotocolsaretobeusedonlyasaguide;decisionsregardingdosagelevelsmustbebasedonathoroughsubstance-usehistoryandcomprehensivemedicalassessmentofeachindividualclient.
Thisdocumentwasdevelopedwiththeintentofaddressingissuesofwithdrawalmanagementforadolescentsaged13-18years.However,muchofthecontentsofthisdocumentwillveryadequatelyapplytoyouth/youngadults,andinsomejurisdictionsreferredtoastransitionalagedyouthwhopresentwithaddictionandwithdrawalmanagementissues,Theneurodevelopmentalissuesfacedbyyoungadults(ages18-25years)areextremelysimilartoadolescents.Accordingly,thepsychosocial,medicalandmentalhealthissuesfacingyoungadultswithalcoholandsubstanceusedisordersarealsosimilartoadolescents.Infact,theneedsofyouthinwithdrawalmanagementsettingsandotheraddictiontreatmentsettingsoftenaremoresimilartothoseofadolescentsthanofadultclients/patients.Thereforethecontentsofthisdocumentmaywellinformclinicalpracticesfortransitionalagedyouthaswellasadolescents.
Usersofthisdocumentmustnotethatthemedicalprotocolsaretobeusedonlyasaguide;decisionsregardingdosagelevelsmustbebasedonathoroughsubstance-usehistoryandcomprehensivemedicalassessmentofeachindividualclient.
TheredevelopmentofthisdocumenthasalsobeenguidedbyprinciplesoutlinedinthedocumentASystemsApproachtoSubstanceUse:RecommendationsforaNationalTreatmentStrategy(NTS,2008).Availabilityandaccessibility,matching,responsiveness,andcollaborationandcoordinationhaveallbeenconsideredandhavebeenincorporatedintothisdocument.Thetieredframeworkrepresentsacontinuumofdifferentlevelsofsupportsandservicesthatcorrespondtotheacuity,chronicity,andcomplexityofrisksandharmsassociatedwithsubstanceuse.WithdrawalmanagementservicesinNovaScotiaarefoundpredominantlyintheuppertwotiers—Tier4orTier5—oftheframeworkasdescribedintheNTS,andinvolvemoreintensive,specializedservicesthanthelowerthreetiers.Clientsseekingservicesintiers4and5areamongthemostharmfullyinvolvedofourclients.Theacuity,complexity,andchronicityofanyadolescent’spresentationofmentalhealthandsubstance-usestatusshoulddeterminetheextentofspecializedservicesrequired.Inallcases,itisessentialthatadolescentsarehelpedtomovebetweentiersand/oraccessmultipletiersaccordingtotheirneed.Forthisreason,itissuggestedthatanavigatororcasemanager
7Adolescent Withdrawal Management Guidelines 2013
functionbeestablishedtoensurethatadolescentsarenotlostbetweenthecracks.Thisfunctionincreasestheprobabilitythatanadolescentwillremainconnectedwiththecontinuumofcarefollowinghis/herinvolvementwithwithdrawalmanagement,therebyincreasingthechanceofrecoveryandenhancedhealth.Thisisparticularlyimportantinlightofthefactthatadolescenceistheprimarylifeperiodforphysical,emotional,andmentaldevelopment.
Thisdocumentalsohelpstoadvancethegoalsofthe2012NovaScotiaMentalHealthandAddictionStrategy,“TogetherWeCan:TheplantoimprovementalhealthandaddictionscareforNovaScotians.”Enhancingthefullspectrumofmentalhealthandaddictionservicesforyouthfiguresprominentlyinthestrategy,aswellasrecognizingourresponsibilitytobettermeettheneedofalldiversegroupsandcommunities.Byplacingemphasisonculturalcompetencyandculturallysafeenvironments,theseguidelinesaredirectingthoseresponsibleforprovidingwithdrawalmanagementservicestoensurethateverypossibleactionistakensothateveryyoungpersonhasthebestchanceoffeelingsafewhileparticipatinginwithdrawalmanagementservices.
Highlyspecializedservicesforadolescentswhorequiremedicalwithdrawalmanagementandtreatmentforamentalhealthdisorder(Tier5)cannotrealisticallybeprovidedinalljurisdictionsthroughouttheprovince.GiventhesmallproportionofadolescentsthatwouldmeetthecriteriaforTier5,provinciallycentralizingthatlevelofserviceisbeingexplored.
Fromapopulationstandpoint,thisprovincemustalsoconsiderthemosteffectivewaytoprovideclient-centred,safe,andefficientwithdrawalmanagementservicesforadolescentswhodon’tmeetthecriteriaforTier5butrequiremedicalwithdrawalmanagement.BeingaccountabletoourentirepopulationandtoAccreditationCanada’squalitydimensionshasforcedtheaddictionservicessystemtoanalyzeallpossibilities.Whileitmaynotbeidealtoco-locateadolescentsandadultsonthesamein-patientwithdrawalmanagementunit,implementationoftheseguidelineswillenhancestaffcompetenciesinaddressingadolescentneeds.Subsequently,itisexpectedthatintegrationoftheseguidelinesintopractice,willimprovethetreatmentexperienceandtreatmentoutcomesforadolescentsreceivingwithdrawalmanagementservices.Aswell,wheneverpossible,localizedinterventionshaveagreaterlikelihoodofprovidingcoordinatedshared-careapproaches.Thus,theunintendedconsequencesofnotprovidingtheseserviceswithinareasonablegeographicareamustbeconsideredagainsttheunintendedconsequencesofprovidingservicesinanenvironmentprimarilyintendedforadults.
Matchingintensitywithneedinvolvesunderstandingcultureandcontextandtheopportunitiesthatexisttherein.Withdrawalmanagementunitsshouldbeinterestedineveryadolescent’scircleofsupportandcircleofcare,bothofwhichinvolvebuildingunderstandingandrelationshipswithinthecontextofcommunityandmakingadolescenttreatmentmoreseamlessalongthecontinuum.Considerationmustalsobegiventourbanvs.ruralculturaldifferences.Unlessthemoveisconsideredessential,adolescentsshouldnotbedisplacedfromtheircommunityofsupports.Furthermore,centralizingalladolescentwithdrawalmanagementservicescarriesariskofbottleneckingaservicetoapopulationthatshouldbeourfirstpriority.
Adolescent Withdrawal Management Guidelines 20138
Managingwithdrawalsymptomsisacomponentofacomprehensivetreatmentstrategy.Awithdrawalsyndromeisthepredictableconstellationofsignsandsymptomsfollowingabruptdiscontinuationorrapiddecreaseinintakeofasubstancethathasbeenusedconsistentlyovertime.Thesignsandsymptomsofwithdrawalareusuallytheoppositeofthedirectpharmacologiceffectsofthesubstance.
Identification and management of intoxication and withdrawal states AsdescribedinthePrinciplesofAddictionMedicine,intoxicationistheresultofbeingundertheinfluenceof,andrespondingto,theacuteeffectsofalcoholoranotherdrugofabuse.Itmayincludefeelingsofpleasure,alteredemotionalresponsiveness,alteredperception,andimpairedjudgmentandperformance(Reis,Feillin,Miller,&Staitz,2009).Recognizingintoxicationstatesisessentialindeterminingacourseoftreatment.Intoxicationstatescanrangefromeuphoriaorsedationtolife-threateningemergencieswhenoverdoseoccurs.Eachsubstancehasasetofsignsandsymptomsthatareseenduringintoxication.Theinitialchallengeisdiagnosis,asintoxicationcanresemblemanymedicalandpsychiatricsymptoms.
Identifyingintoxicationmustcommencewithathoroughassessmentthatincludesclienthistory,physicalexamination,and,inmostcases,laboratoryscreening.Ofimmediateconcernisoverdose.Itiscriticaltoknowwhatsubstanceshavebeentakenandinwhatquantity.Incaseswhereaclientisunabletoprovidetheinformation,afamilymemberorconcernedothermaybeabletoprovideimportantinformation.Whenscreeningforsubstances,urineisoftenusedbecauseoftherelativelyhighconcentrationofdrugsandmetabolitespresentinurineandthestabilityofmetaboliteswhenfrozen.Screeningisespeciallyimportantwhenclienthistoryisvague.Understandingthespecificitiesandcross-reactivitiesoftheparticularurinedrugscreenisvitallyimportanttotheinterpretationofthescreen.Itisalsoimportanttoknowtheusualdurationofdetectabilityofspecificsubstancesandhowthatisaffectedbythequantityingested.Individualfactorssuchasfluidintake,excretion,andratesofmetabolismmustbetakenintoaccount.Substancewithdrawaloccursasaresultofacessationof,orreductionin,heavyandprolongedsubstanceuse.Substancesinagivenpharmacologicalclassproducesimilarwithdrawalsyndromes;however,theonset,duration,andintensityarevariable,dependingontheparticularagentused,thedurationofuse,andthedegreeofneuroadaptation.
Primary principles of withdrawal management
9Adolescent Withdrawal Management Guidelines 2013
Reisetal.(2009)statethatneuroadaptationreferstosensitizationandtolerance.Sensitization—anenhancedresponsetoadrug—occursasaresultofpriorintermittent,ratherthancontinuous,exposuretothedrug.Itistheoppositeoftoleranceandissometimesreferredtoasreversetolerance.Theprecisepharmacologic,neurobiologic,andbehaviouralfactorsthatdeterminesensitizationandtolerancearenotwellunderstood.
TheAmericanSocietyofAddictionMedicine(ASAM)liststhreeimmediategoalsofdetoxification:• toprovideasafewithdrawalfromthedrugofdependenceandenablethepatienttobecome
drug-free;
• toprovideawithdrawalthatishumane,thusprotectingthepatient’sdignity;and
• topreparethepatientforongoingtreatmentofhis/herdrugdependence.
Threeessentialandsequentialstepsinclude:• assessment/medicalevaluationandaccuratediagnosis;
• stabilization;and
• fosteringpatientreadinessforandentryintotreatment.
Withdrawaltreatmentismosteffectivewheninterventionsaretailoredtotheassessedimportanceofeachofthedimensions.
Early recognition of withdrawalAwithdrawalsyndromeorwithdrawalsymptomswillusuallydevelopprogressivelyaftercessationorrapidreductioninsubstanceuse;therefore,earlyrecognitionandongoingmonitoring,alongwithpromptmanagementoftheinitialandmilderwithdrawalstate,canpreventprogressiontomoreseverestagesandcomplications.Itisalsoimportanttodiscusstheoptionsthatyoungpeoplehavewhenitcomestowithdrawal,asnotallyoungpeoplewillrequestorrequireamedicatedwithdrawal.Itisessentialtoconsiderthatsomewithdrawalstatescanbelife-threatening(e.g.,alcoholandbenzodiazepines)andalsothatmanymedicalandpsychiatricconditionscanmimicintoxicationand/orwithdrawalstates.Theassessmentshouldprioritizethesubstancesthatneedpharmacologicwithdrawalsupport.
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Principles of assessmentInassessment,youngpeople’sinsightintotheirsituationandhistoryshouldbeconsideredandvalued,andwithdrawaleducationshouldalwaysbepresentedinthecontextofadolescentdevelopment.Someyoungclientsmayhaveunderdevelopedliteracyskills;therefore,verbalandvisualeducationtoolsaremoreappropriatethanextensivehandoutsofinformation.Takingastrengths-basedapproachlendsitselftoamoreengagingprocessandhelpstofacilitateadiscussionofresourcestobuildon,includingself-esteem,communitysupports,copingskills,pastsuccesses,talents,andmotivationfortreatment.Thegoalistodevelopabetterunderstandingoftheyoungperson;explaintotheyoungpersonhowthisassistsintheformulationofawithdrawalplanaswellassubsequenttreatmentplans.
Thepurposeofassessmentistodetermine,incollaborationwiththeyoungperson,appropriatetreatmentoptions.Assessmentshouldbecomprehensiveandshouldfocusonallaspectsoftheyoungperson,includinghealth,socialsupports,andotherfactorsthatmayimpactonhisorhertreatment.Theassessmentshouldbeconductedinacalmenvironment,andsufficienttimeshouldbeallocatedtoestablishrapport.Interpersonalskillsofstaffwillassistintheestablishmentofasupportiveandcaringenvironment.Theenvironmentshouldhelptheyoungpersonfeelwelcomeandrelaxedduringtheassessment,soitisimportantthatthephysicallayoutoftheroomanditsimpactontheyoungpersonareconsidered.
Assessmentshouldincludeconsultationwithothercareprovidersand/orsignificantothers.
Comprehensive assessment AnassessmenttemplatecanbefoundinAppendixIV.SomeofthefollowinginformationhasbeenadaptedfromtheSAMSHSATreatmentImprovementProtocolaswellasfromexistingprovincialstandards.Inallcases,itisthejointresponsibilityofallprofessionalsinvolvedintheongoingcareoftheadolescenttoensurethatanadequateassessmenthasbeenundertakenbeforeongoingmanagementcommences;thisisespeciallyimportantwhereinterventionswithmedicationsareinvolved.
The aims of assessmentAssumingtriageassessmenthasbeencompleted,theremainingobjectivesoffullneedsassessmentwillbeto:
• detailthecurrentandpasthistoryofsubstancemisuse;
• identifyandassesscomplicationsofsubstancemisuse;
• identifyandassessthepresenceofcomplexneeds;
• confirmactivesubstancemisuseobjectively;
Assessment
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• collectotherinformationnecessarytodeterminetheappropriateimmediate,medium,andlong-termmanagementplan;and
• engagetheclientwithtreatment.
Theassessmentmayinclude,butisnotlimitedto,thefollowing:
Reason for presentationThiswouldincludeidentifyingthereasonforseekingtreatment,whomadethereferral,andhowtheadolescentisfeelingaboutthereferral.Thereasongivenforpresentationmaybeusefulindeterminingmotivationandstageofchange,andforindicatingtheoveralldirectionofthetreatmentplan.Thisshouldincludenotinganyclientambivalenceorexpectationsofthetreatmentexperience.
Current and past substance abuse• Ascertainthesubstances,includingalcohol,tobacco,prescriptiondrugs,andover-the-counter
medication,thatarecurrentlybeingused.Alsodeterminewhethertheadolescentgambles.
• Assesspastuseofsubstances,especiallythosethatwereconsumedonadailybasis.Itiscriticaltogatherinformationregardinghowoldtheadolescentwaswhenhe/shefirstusedandwhatsubstance(s)wasused,aswellasrouteofadministration.
• Thehistoryshouldincludethelengthoftimeusing,thefrequencyandpatternofuseforeachsubstance,andthequantityofthesubstanceused.Thiscanalsogiveanindicationofdevelopingtolerance,whichmaydeterminewhethermedicationwillberequiredforwithdrawal.
• Itcanbehelpfultoaskiftheadolescenthasevergonethroughastagewherehe/shehasdrunkalcoholeveryday,thenexplorefurther.Askaboutthepatternofusethroughoutthisdailyuse,e.g.,bingeingatnightordrinkingthroughouttheday.
• Itisimportanttoascertainwhetherornotthepatternofusehaschangedovertime,andtodeterminewhen/iftheusebecamedailyandifithasbeenheavierinthepast.Donotassumethatthecurrentuseistheheaviest.
• Notethetimeoflastuse,whatwasused,andthequantity.Thismayinformtheneedforimmediatetreatmentplanning.
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• Determinewhethertheadolescenthashadanyperiodsofabstinence.Thisenablesyoutoexploreexperiencesofwithdrawalduringthosetimesandhowhe/shemanaged.Explorethestrategiesusedtoreduceuseandthetriggersthatcausedrelapses.
Medical history• Identifythepresenceofanyconcurrentmedical/physicalillness(es)thatmaymask,mimic,or
exacerbatewithdrawal.Thiswillrequireafullmedicalhistory(pasthospitalization,etc.)andexamination,noting,forexample,previousillnesses,ulcersorothergastrointestinalsymptoms,chronicfatigue,recurringfeverorweightloss,nutritionalstatus,recurrentnosebleeds,infectiousdiseases,medicaltrauma,andpregnancies.Thisinformationshouldbetakenpriortowithdrawal,andanypre-existingmedicalconditionsshouldbemonitoredthroughoutthewithdrawalepisode.Identificationandtreatmentofconcurrentconditionsandcarefulmonitoringofphysicalandmentalhealthduringwithdrawalareimportantintheoveralloutcomeoftheadolescent’swellbeing.
• Womenwhoenterthedetoxificationunitmaybenefitfromacomprehensivephysicalexamination,includingagynecologicalandobstetricalexamination.Staffsensitivitytotheneedsoffemaleclientsiscritical.Itisespeciallyimportantforaphysiciantobeinvolvedbeforeimplementinganyprotocolonpregnantornursingwomen.
• Collectinformationonallprescribeddrugs,includingthereasonsfortakingthem.
Emotional, spiritual, developmental, and mental health • Identifyanyhistoryorcurrentissuesrelatedtoemotionalandmentalwell-being,suchashistoryof
depression,anxiety,and/oranyprevioustreatmentorinterventionsrelatedtotheidentifiedissues.
• Youngpeoplewhohaveahistoryofself-harmmayexpressthisduringanepisodeofwithdrawal.Triggersandinterventionsforself-harmshouldbeexploredpriortowithdrawal,andamanagementplanaroundself-harmmaybenecessary.
• Oftenpsychosocialissuesmayappearinsurmountabletoyoungpeoplewhentheyceasetheirsubstanceuse.Forthisreason,exploringtheuseofcopingstrategiestoreduceanxietyanddepressionduringthistimemaybeuseful.Whileitisnotwithinthescopeoftheseguidelinestodiscussthetreatmentofanxietyordepressionoutsidethecontextofwithdrawal,itmaypresentasanopportunityforreferralandassessmentbystaffwhiletheyoungpersonissubstance-free.
• Acriticalissuetoaddressissuiciderisk,asthereissignificantlyincreasedriskinadolescentswithsubstance-usedisorders,especiallywithco-morbiddepression.
• Collectinformationontheadolescent’ssexualhistory,includingsexualorientation,sexualactivity,sexualabuse,sexuallytransmitteddiseases(STDs),andSTD/HIVriskbehaviorstatus(e.g.,pastorpresentuseofinjectingdrugs,pastorpresentpracticeofunsafesex,sellingsexfordrugsorfood).
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• Identifydevelopmentalissues,includingthepossiblepresenceofattentiondeficitdisordersand/orlearningproblems,andinfluencesoftraumaticevents(suchasphysicalorsexualabuse).
• Exploretheadolescent’sunderstandingofspiritualityandanyformalorinformalreligiousorspiritualaffiliationsorpractices.
Family and social support• Detailasmuchinformationaspossibleregardingcurrentandpastlivingarrangementsand
relationshipstatuswithfamily.Itisimportantthattheadolescentbeaskedtoidentifywhohe/sheconsiderstobetheprimarycaregiver/supportsystem.
• Explorethefamilyhistory,includingtheparents’,guardians’,andextendedfamily’shistoryofsubstanceuse,mentalandphysicalhealthproblemsandtreatment,chronicillnesses,incarcerationorillegalactivity,childmanagementconcerns,andthefamily’sethnicandsocioeconomicbackground.Itishelpfultonotesubstandardhousing,homelessness,proportionoftimetheyoungpersonspendsinsheltersoronthestreets,andanypatternofrunningawayfromhome.Issuesregardingtheyouth’shistoryofchildabuseorneglect,involvementwiththechildwelfareagency,andfostercareplacementsarealsokeyconsiderations.Thefamily’sstrengthsshouldbenoted,astheywillbeimportantininterventionefforts.Thissectionshouldincludeprimaryandotherlanguagesofthehousehold.
School, volunteer and employment• Asschoolengagementisanimportantindicatorofcurrentandfuturewell-being,gatherasmuch
detailaspossibleonpastandcurrentschoolengagement.Thiswouldincludetheadolescent’shistoryofpositiveand/ornegativeencounterswithteachersandotherschoolstaff,curriculum,andextracurricularactivity.Thisshouldalsoincludeanoverviewofacademic,behavioralperformance,orattendanceissues.Iftheadolescenthashadanopportunitytobeemployedorvolunteer,itwillbeimportanttogatheranunderstandingofwhetherornotthishasbeenimpactedbysubstanceuse.
Peer relations and recreation• Identifycurrentandpastpeergroupsandwhetherornotthathaschangedovertime,andthe
motivationforaligningwiththecurrentpeergroup.Gatheranunderstandingofsatisfyingandunsatisfyingaspectsofcurrentrelationships.Noteinterpersonalskills,anyganginvolvementandneighborhooddescription.Thisisanalsoanopportunitytoascertainthedegreeofcommunityengagementand/orcommunitysupports.
• Capturinganadolescent’sskills,talents,hobbies,andinterestswillenableatailored,holistic,andstrengths-basedtreatmentplan.
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Legal• Noteanyinvolvementwiththejusticesystem,includingtypesandincidencesofbehaviorand
attitudestowardthatbehavior.
MotivationTheassessmentofmotivationislargelyamatterofclinicaljudgment.First,itisimportanttoanswerthequestion:Motivatedforwhat?Isthemotivationforabstinenceorstabilization?Isthemotivationforaperiodofintensivetreatmentorforalow-key,“low-threshold”approach?Iftheadolescentisnotimmediatelymotivatedtomakechangesinthesubstancemisusebehaviour,istheremotivationtomakechangesinotheraspectsofbehavioursuchaswork,accommodation,andpersonalrelationships?
Engaging YouthTheinformationinthissectionentitled,“EngagingYouth”,hasbeenextractedfromtheHealthCanadadocumententitledTheBestPractices—EarlyIntervention,OutreachandCommunityLinkagesforYouthwithSubstanceUseProblems,whichpointsoutkeyactionsforworkingwithyouthwhohavesubstance-useproblems:
• Recognizethatthemotivationsforsubstanceusemayvary.
• Conveyunderstandingandacceptance.
• Engageyouthascollaborators.
• Beflexibleandcreativeinmeetingandplanningactivities.
• Incorporateandbuilduponpositivefamilyorcommunityconnections.
• Expressconcernregardingyouths’healthandwell-being.
• Maintainapositiveconnectionduringtheprocessofchange.
• Reachoutusingyouth-focusedmediaformats.
• Selectdevelopmentallyappropriateapproaches.
• Addressfamilyrelationshipconcernsaspartofearlyinterventionefforts.
• Increaseservice-providerawarenessofbarrierstoaccessencounteredbyyouth.
Toengageyouth,youthworkerscanutilizeapproacheslikemotivationalinterviewing(MI),anapproachthathasbeenidentifiedaspromisingforworkingwithadolescents.Thisclient-centredinterventionentailsusingcollaborativedecision-makingprocesses,applyingstrategiestoincreaseawarenessofproblemsubstanceuse,andimplementingmotivationalstrategiestofacilitateclientcommitmenttowardactiontodecreaseandeliminatesubstanceuse.KeytechniquesofMIinclude:
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• reflectivelistening;
• open-endedquestioning;
• summarizingreflection;
• identifyingdiscrepanciesbetweenpersonalgoalsandbehaviours;
• affirmingstrengths;and
• encouragingsmall-stepplansandbehaviours.
Motivationalinterviewinghasbeenseenasparticularlybeneficialforusewithadolescentswhoshowastrongidentificationwithproblemsubstanceoralcoholuseandresistancetoadultswhotrytodirectorinfluencetheirbehaviour(Dunnetal.,2001;Masterman&Kelly,2003).
Whenexaminingcontinuedtreatment,youthworkersneedtobesensitivetotheyouth’sdoubtaboutthevalueofmeetingacounsellororhelper.Concernsshouldbesharedopenly,withtheintentofestablishingacommongoalforthesession.
Characteristicsofeffectiveyouthworkersinclude:• beingcredibletoyouth(Rhodes,1996);
• exhibitinggenuineandacceptingattitudes(CollaborativeCommunityHealthResearchCentre,2002);
• demonstratinganon-judgmentalapproachtodrugusenorms,culture,andbehaviours(CollaborativeCommunityHealthResearchCentre,2002;HealthCanada,1996;Rhodes,1996;Self&Peters,2005);
• havingareal-lifeunderstandingofthesocialcontextofuseforyouth,e.g.,streetsense(Self&Peters,2005);and
• adoptingaflexibleapproachwithrealisticexpectations(CollaborativeCommunityHealthResearchCentre,2002).
Positivecommunitylinkagesareasourceofsocialsupport,beitwithfamily,peers,orschool(Murray&Belenko,2005).Communitylinkagesalsorefertocommunity-basedservicesthatareaccessibleandresponsivetoyouthearlyonintheiraddictionbehaviour(Dembo&Walters,2003).Positivecommunitylinkagesforyouthshouldfocuson:
• strengtheningyouths’attachmenttoprosocialrelationships,activities,agencies,andprograms;
• reducingexposureandattachmentstoantisocialgroupsandnorms;
• enhancingschoolattendanceandacademicperformance;
• increasingopportunitiestolearnandpracticeskillsthatfacilitateachievementofpersonaleducationalandcareergoals;
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• engagingyouthandfamilymembersinplanning;
• encouragingcollaborativeresponsesamonghealthproviders,communitymembers,andpoliceinaddressingspecificsubstance-useproblemsinthecommunity;and
• creatingservicenetworksamongagenciesthateffectivelyaddresstheneedsofyouthatrisk(CollaborativeCommunityHealthResearchCentre,2002;Murray&Belenko,2005).
Effortsarestrengthenedwhenyoutharemeaningfullyconnectedtoavarietyofcommunityactivitiesandrelationships.Withouttheselinkages,effortstoreduceproblematicsubstanceusemaybesignificantlyimpeded(MacLean&d’Abbs,2002).Areasofcommunityconnectednessincludehavingasafeplacetolive,receivingsupportfromfamilyorothercommunitymembers,beinginvolvedinaneducationalorcareer-relatedprogram,andparticipatinginrecreationalservices.
ReassuranceYoungpeoplewhoenterwithdrawalsettingsareinhighlysupportiveenvironmentswith24-hourstaffcare.TheseUnitsaredesignedtoreduceoverallanxietyandsubsequentlycreateapositiveexperienceofwithdrawal.Itisusefultoexplainthebenefitsofadmissiontotheunit,suchas:
• theyoungpersonisnolongerexposedtocuesathome,
• patternsofsubstanceusearebroken,and
• removaltoanotherenvironmentcanautomaticallyreducethelevelofwithdrawalsymptoms.
Connection to the Continuum of ServicesWeknowtheimportanceofyouthconnectednessandengagement.Canadianresearchtellsusthatyouthwhoareconnectedhaveadecreasedlikelihoodofsuicideattempts,lowerratesofsubstanceuse,andlowerlevelsofdepression.Itisthroughengagementthatyouthdeveloptheskillsthatareneededforbettermentalhealthoutcomes,becomeempowered,andmakeconnectionstocommunity(Dyer,2011).Thus,whentalkingaboutin-patientyouthsubstance-useservices,acorecomponentofcareisaboutyouthengagementandconnectedness,astheseprocessespromotebetterhealthoutcomes.Clientretentionandengagementareissuesforhealth-relatedservices,anditiscommonlyacceptedthatserviceuserswhodropoutoftreatmenthaveagreaterlikelihoodofreturningtoproblematicsubstanceuse.Thereislittleresearchavailablethatprimarilyfocusesonyouth-orientedtreatmentretention;however,retentionisoftenaddressedwhenconsideringeffectivetreatmentapproachesandmethods(HealthCanada,2001).
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Toensurethatyouthengagewithin-patientprogramming,staffmustfirstmaketheyouthfeelwelcome,supported,andsafe.Thefirst72hourswillbethemostdifficultforyouth;duringthistimespecialcareshouldbetakentoensurethattheyoutharereceivingenoughsupport.Forsomethismaybemoretimealone;othersmayneedmoreintensecontactfromserviceproviders.Fromthebeginning,afocusonengagingyouthintheprogramfostersasenseofbelonging,whichencouragespositivepeerandstaffalliances(BritishColumbiaMinistryofHealth,2011).
Effectivetreatmentandsupportssetthetoneforyouthtoengageintheirowntreatment.Therearemanyelementsthatcontributetoeffectivein-patienttreatment.Successfulapproachestosubstance-usetreatmentandsupportforyouthinvolveprogramsandservicesthatrespondtothediversityofyouthandseethewholeperson,notjustthesubstanceuse.Thereisconsensusintheliteraturethattreatmentoutcomesforpeoplewithproblematicsubstanceusearemoresuccessfulwhenthetherapeuticalliancebetweenclientandcounsellorisflexible,warm,affirming,andhonest.Itisvitalthatprogramstaffshowrespectandtrusttowardseachprogramparticipant,asyouthrespondbettertonon-hierarchicalstructureandphilosophy.Furthermore,researchindicatesthatyouthrespondbettertoexperimentalstylesoflearning,withatreatmentfocusonstrengths(BritishColumbiaMinistryofHealth,2011).
In2001HealthCanadapublishedBestPracticeTreatmentandRehabilitationforYouthwithSubstanceUseProblems.Section2.10highlightstheimportanceofclientretentionintreatmentandprovidesperspectivesfromkeyexperts,whoidentifiedbestpracticesrelatedtoretentionintheareasofassessmentandintake,programphilosophyandapproach,outreachtofamilies,andprogramcontent.
Assessment and intake: • tryingtomatchclientreadinesswithtreatmentobjectivesandmethods;and
• makingdetailedinformationavailableforbothclientandfamily.
Program philosophy and approach:• consideringyouthrelapsenotasafailurebutasapartofrecoveryandanopportunitytolearn;
• takingaharm-reductionapproach;
• focusingonclientlifegoalsandtheimpactofsubstanceuseonthese,ratherthanprimarilyfocusingonsubstanceuse;
• formingasupportiveserviceuser–serviceprovideralliance,withtheserviceuserdirectinggoalandtreatmentplanning;
• providingtreatmentthatconsidersyouthwithinasystem—family,peers,school,community;and
• consideringyouths’spiritual,mental,emotional,andphysicalneeds.
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Outreach to families:• activelyinvolvingandengagingfamilyandotherswhomtheclientdeemstobeofimportance.
• Programcontent:
• utilizingabroadpsycho-educationalapproach;
• providingatreatmentenvironmentthatincorporatesarangeofrecreationalactivitiesandissafeandfun;and
• ensuringthatlearningandprogrammingareexperientialwheneverpossible.
Ensuringthatyouthcontinuetoengageoverthecontinuumofcarerequireseffectivetransitionplansforeachyouthreturningtothecommunity.Inordertobeeffective,transitionplanningshouldbeacollaborativeprocessbetweenyouth,servicesprovider,andthosewhomtheyouthhasidentifiedasimportant.Evidence-andpractice-basedliteratureidentifieskeyelementstoincludeintransitionplanning:waystoreceiveongoingtreatment;relapsepreventiontips;accesstoappropriatecommunityservices;andstrengtheningofpersonalandsocialsupports.Transitionbackintoandengagementwiththecommunityaremostsuccessfulwhenthereareeffectivepartnershipsbetweencommunity-basedservicesandinpatientprograms.Tomaintainandbuilduponprogressthatyouthhavemadewhilein-patients,itisessentialthatappropriatesupportsinthecommunitybeengagedintheyouths’careaswell,suchasCommunityServices,andEducation(BritishColumbiaMinistryofHealth,2011).
Adolescent DevelopmentAdolescenceisaperiodofsignificantchangeandtransition—theperiodbetweenchildhoodandadulthoodthatismarkedwithaseriesofchallengesanddevelopmentalgoals.Itisaperiodofrapidphysical,mental,andsocialgrowth.Youngpeoplebegintoexperienceagreaterawarenessoftheworldtheylivein,andoftenbegintoformnewandmeaningfulrelationships.Identificationofselfintermsoffeelings,beliefs,values,attitudes,andself-perceptionsbecomesintegralinayoungperson’slife.Itisimportanttorememberthatalthoughweareabletoidentifyspecificdevelopmentalstages,adolescentsarenotahomogeneousgroup.
Adolescencecanbedefinedastheperiodoftransitionfromchildhoodtoadulthood,characterizedby:• effortstoachievegoalsrelatedtotheexpectationsofthemainstreamculture;
• spurtsofphysical,mental,emotional,andsocialdevelopment(WHO,1984).
Chronologically,adolescenceoccursbetween12and18yearsofage.
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Development changesAdolescentdevelopmentcanbecategorizedintofourareasofchange:physical,emotional,sexual,andcognitive.Developmentalchangeswithintheseareasareinterconnected,andtheyhaveanimpactonayoungperson’swell-being.Withineacharea,certaindevelopmentaltasksmustbemasteredinorderfortheadolescenttomoveintoadulthood.
Physical developmentThemarkedgrowthanddevelopmentinadolescenceissignificantlydifferentfromotherlifestages.Theonsetofpubertybeginswhencertainphysicalandsexualchangesstarttotakeplace,suchasthedevelopmentofsecondarysexualcharacteristics(e.g.pubicandunderarmhair)and,ingirls,breastdevelopmentandtheonsetofmenstruation.Asurgeinbodysizeandshapetakesplaceandotherphysiologicalchanges,suchastherapidgrowthofthedigestiveandcirculatorysystems,alsooccur.
• Whilebiologicalchangesaregenerallythoughttobecompletewiththeattainmentofpuberty,thereiscontinueddevelopmentthroughoutadolescenceasthebodymaturesinshapeandsize.(Peterson&Taylor,1980)
• Theageofonsetofpubertydiffersbetweenboysandgirls,andvariesforindividualswithineachgender.Pubertyingirlsmaybeginbetweentheagesof10and14years,andinboysbetween10and16years.
Cognitive developmentAyoungperson’swayofthinking,orcognition,transformsfromthe“concrete/operational”stagebetween7and11yearsofagetoa“formaloperational”stage(Piaget,1969),whichischaracterizedbythedevelopmentofabstractthought,theabilitytosolveproblemsandconsiderwider,inter-relatedissues,andtheemergenceofidealismregardingissuesrelatedtothemselvesandtheirenvironment.
Moralreasoningadvancesduringadolescenceastheyoungpersonstartstobecomeconcernedaboutsocialorderandjustice.AccordingtoKohlberg(1973;citedinFrydenburg,1997),“postconventionalmoralreasoning”(thatis,theeffortbyadolescentstodefinetheirownmoralrulesratherthanacceptthemfromthegrouporanindividual),isdistinguishedfrom“pre-adolescentreasoning”byanimplicit,reciprocalcontractbetweentheindividualandsociety.Throughthisphaseofmoralreasoningandabstractthought,youngpeopledeveloptheirownvalues,beliefs,moraljudgments,andconscience,andbegintorecognizecertainbenefitsincomplyingwiththerulesdeterminedbysociety.
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Summarizing normative developmental tasksItisimportantforyoungindividualstoachievecertainnormaldevelopmentaltasksinordertobecomepositiveandhealthyyoungadults.Insummary,theseare:
• acceptanceofphysicalchanges/bodyimage;
• gainingofindependence(Theadolescentbecomesemotionallyindependentofparentsandotheradults.Thedesireforautonomyfromparentsandtheirauthoritycanleadtooutburstsofangeraswellasfeelingsoflossastheymoveawayfromchildhoodsecurity);
• developmentofnewrelationshipswithpeersofbothsexesandthejoiningofpeergroups(Theseareimportantstepsfortheyoungperson’spsychologicaldevelopment);
• establishmentofself-identity(Youngpeopledeveloptheirownopinionsbasedontheirownvalues,morals,andideals,independentoftheirfamily.Adolescentsoftenwilltakerisksandbeextremeintheirviews,astheyexercisetheirbeliefofrightandwrong.Wovenintothisfabricishowtheirpeersviewthem—acceptancebypeersisvital);
• acceptanceofsexualidentity(Theadolescentacceptshimselforherselfasasexualbeingandadoptsasexroleinlinewithhis/herownself-conceptandbodyimage);and
• preparationforandselectionofacareerchoicethatcorrespondswiththeirability,attitudes,self-image,andvalues.
Developmental sub-stages of adolescenceThetablebelow,outliningthedevelopmentalsub-stagesofadolescence,isadaptedfromanarticleonadolescentpsychiatry.Eachstagerepresentsdifferentdevelopmentaltasksandbehaviours.Whenworkingwithyoungpeopleitisimportanttounderstandthatthestagesofadolescencearetransitional.
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Psychological/Emotional DevelopmentPsychological/emotionaldevelopmentstakeplaceasadolescentsseparatefromtheirparentsandmovetowardsformingtheirownidentities.Thisprocessusuallyinvolvesrisk-takingbehavioursandactsofrebellioninordertodefineseparationandindependencefromtheparents.Examplesofthismayincludeexperimentingwithsubstanceuseandavoidingsetcommitmentsandresponsibilities.
Inadolescence,peersplayanimportantroleinpsychologicaldevelopmentasyoungpeoplespendmoretimewiththeir“group.”Thisinvolvementdevelopssocialskills,broadensinterestsandvalues,andteachescompetition,co-operationandcommunicationskills.Peersprovideyouthwithsupportandasenseofbelongingasadolescencebringsphysicalandsocialchange,withtheassociatedchallengesofidentityformationandunderstandingtheirplaceinthefamilyandthecommunity.
Emotionalmaturationoccursduringadolescence.Intensefeelingsofloveandotheremotionsconnectedtonewlyformedrelationshipsaswellaschangestotheparent/childrelationshipcancauseanxietyandstress.Fluctuatingemotionsandmoodswingsmayalsooccurduetothehormonalactivity.Developmentally,itisimportantfortheyoungpersontoexperiencethesefeelingsandemotions,andtogainunderstandingandinsightbylearningwaystocope.
Table 1:Developmentalsub-stagesofadolescence
Determinants Tasks BehavioursEarly adolescence 12–14years
Biologicalchanges Initialseparation–individuationfromparents
Preoccupationwithselfandself-image,moodswings,strongerconnectiontosame-sexpeergroup
Middle Adolescence15–17years
Cognitivedevelopment,upsurgeofsexualdrive,emotionaldevelopment
Peerattachments,awarenessofownsexuality,considerationofvocationalchoice
Idealism,risk-taking,challengingstructures,rebelliousness,identifyingwithpeers,omnipotence,romanticattachments
Late Adolescence18–21years
Preparationforadultlife
Completionofseparation–individuationfromparents,understandingandintegrationofself-identity,acquisitionofgoals,ideals,values
Careerchoiceconsolidation,developmentofrelationshipsthatarebasedoncareandequality
Source:Bashir,M.andSchwarz,M.,,AdolescentPsychiatry.TakenfromP.J.V.BeumontandR.B.Hampshire(Eds.),TextBookofPsychiatry(1989)
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Sexual identityAdolescenceisthetimewhensexualneedsandsexualidentitycometoprominence.Asaresultofpuberty,youngpeoplebecomesexualbeingsandstarttobeexposedtoissuesrelatedtotheirownsexuality.
Inmovingawayfromtheprimaryinfluenceofthefamily,theadolescentmovestowardsidentifyingwithandseekingsupportfromthesame-sexgroupwithwhomtheysharesimilarinterests.Middleadolescenceseesthemovetowardsmixed-sexgroups.Withthiscomefeelingsofattractiontoandintimacywithmembersoftheoppositeorsamesex.Confusioniscommon,asadolescentsnegotiatethediverse,andattimesconflicting,messagesandinformationfromfamily,media,society,andtheirpeers.
Forayoungpersontoformapositivesexualidentity,manylevelsofsexualityneedtobeconsideredwithinthecontextofhisorherownidentity.Self-conceptandself-esteem,bodyimage,emotions,feelings,culture,relationships,peerpressure,andgenderconstruction,aswellasethicalandmoralvaluesandopinions,needtobeexploredinorderforsexualidentitytodevelop.
Brain DevelopmentThefollowinginformationhasbeenincludedintheguidelinesinanattempttomakeaconnectionbetweenadolescentpsychosocialdevelopmentstagesdiscussedinthepreviouschapterandtheeffectsofadolescentsubstanceabuseinthecontextofourgrowingawarenessofage-relatedbrainchanges.
Adolescentdevelopmentisusuallydiscussedinbehaviouralterms,ascharacterizedbyashiftinorientationfromanacceptanceofthe“parentalworldview”toamore“personalizedview.”Otheraspectsofthisdevelopmentalperiodinclude:
• restructuringtheself-concept;
• redefiningtheconceptofothersandtheirinfluenceonself;
• reappraisingsocialstandardsandvalues;and
• redefiningtherolesofparentsandadultsas“guides”and“decisionmakers”toequals,andmovingfromdependencetoindependenceinthoughtandaction.
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Thebigquestionhereis“WhoAmI?”Suchself-examinationinevitablyentails:
• tryingoutvariousadultroles;
• evaluatingtheresponseofotherstotheseexperiments;
• adjustingtosexualmaturity;
• adaptingtothedemandsofnewsocialrelationships;
• changingthenatureofpeerrelationships;and
• exploringvocationalchoices.
Researchisconstantlychangingscientists’understandingofthehumanbrainanditsgrowth;therefore,thereisanincreasingappreciationofdevelopmentalbiologyintheseprocesses.Braindevelopment(orlearning)isaprocessofcreating,strengthening,anddiscardingsynapses.Synapsesorganizethebrainbyformingneuralpathwaysthatconnectdifferentpartsofthebrain.Exposingthebraintocomplexenvironmentswillencouragesynapticgrowth.
Theteenageyearsturnouttobeacomplicatedtimeinthebrain,withcellsfightingitoutforsurvivalandtheconnectionsbetweendifferentregionsbeingrewiredandupgraded.Someabilities,suchasquashingoffensivebehaviourandempathizingwithothers,keepmaturingwellintothetwenties.Thepassagefromchildhoodtoadulthoodisnotstraightforward.Someresearchersnowseetheteenageremodellingasanalogoustothe“developmentalwindow”thatallowsthebraintobemoldedbyexperienceininfancy.Therearewaysinwhichteenagebrainsperformquitedifferentlyfromeitherchildishoradultones.
Grey MatterHumansachievetheirmaximumbrain-celldensitybetweenthethirdandsixthmonthofgestation.Duringthefinalmonthsbeforebirth,pruningeliminatesunnecessarybraincells.Bythetimeachildis6yearsold,hisorherbrainis90–95%ofitsadultsize.Betweentheagesof6and12,neuronsgrow“bushier,”makingconnectionstootherneuronsandcreatingnewpathwaysfornervesignals.Thethickeningofneuronsandtheirdendritespeakswhenfemalesareabout11andmales12½,atwhichpointaseriousroundofpruning(discardingofsynapses)commences.Thefinal,criticalpartofthissecondwaveoccursinthelateteens.Unliketheprenatalchanges,thisneuralwaxingandwaningaltersnotthenumberofnervecellsbutthenumberofconnections,orsynapses,betweenthem.
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Frombirthtoearlychildhoodthereisanexcessiveproductionofneurons.Wheneverneuronsareengagedinatasktheyenteranexcitatoryphaseinwhichtheyfire.Whenonecellfires,ittendstoreducethelevelofexcitationrequiredfortheothercellsinthesamenetworktofire.Thephrase“cellsthatfiretogether,wiretogether”characterizesthisprocess.Afteracertainperiodoftimethesecircuitsbecomehard-wiredandallthecellsinagivennetworkwillfireinconcert.Thisprocess,inwhichthebrain’sgreymatterthinswhilethewhitematterthickens,formsthebiologicalsubstrateoflearning,andissometimesreferredtoas“NeuralDarwinism.”Graymatteristhinnedoutatarateofabout0.7%ayear,taperingoffintheearly20s.
Thosecellsthatfailtoformsignificantconnectionswithothersdonotthrive—the“useitorloseit”principle.Forexample,themorethatsportisplayedatthisage,themorepathwaysinvolvedin,forinstance,hand/eyecoordinationarestrengthened,whileiftheindividualisatthesametimelessinvolvedinpainting,thebrainareasspecializinginthosefunctionsgetpruned.Soourbrainsaresculptedbyourinteractionswithourenvironment,whichsuggeststhatNature’sconcernisincreasedefficiency.
Anotherconsequenceofcellsfiringtogetheristheretrogradeexchangeofneurotrophicfactors(neurotrophicfactorspromotecellulargrowth)fromthepostsynaptictothepresynapticcells.Untilaroundtheageof12neuronsgrowbushier,thenthepruningprocesscommenceswiththesensoryfunctionsfirst,thencoordination,andlastlyexecutivefunctions.
Thereisaninstinctiveneedtostimulatethebrainandengageinexploratorybehaviour,whichgivesrisetoadolescentsactivelyseekingoutintensefeelingsandgrowingeagertoleavethenesttofollowtheirownpaths.Thisprocessistraditionallyseenasthrill-andnovelty-seekingbyadults,whoviewthisbehaviourasproblematic.
Itappearsthatnoveltyisthekey,asnewexperiencesfosterandpromotebraindevelopment.Importantly,accordingtoVolkow(NIDA),impoverishedenvironmentsleaddirectlytoalackofreceptors,whichisassociatedwithaddiction.
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White MatterAsstatedabove,atthistimethebrain’swhitematter(composedoffattymyelinsheathsthatencaseaxonsandmakenerve-signaltransmissionsfasterandmoreefficient)thickens.Inotherwords,duringadolescencefewerbutfasterconnectionsaredevelopedinthebrain.Thisdevelopmentproceedsinstagesfromtheoccipitalregiontothefrontalregion.Braincentresthatmediatedirectcontactwiththeenvironmentbycontrollingsuchsensoryfunctionsasvision,hearing,touch,andspatialprocessingreachmaturity(throughproliferationandpruning)earliest.Nextareareasthatcoordinatethosefunctions,suchasthepartofthebrainthathelpsyouknowwherethelightswitchisinyourbathroomevenifyoucan’tseeitinthemiddleofthenight.
Theverylastpartofthebraintobeprunedandshapedtoitsadultdimensionsistheprefrontalcortex,homeoftheexecutivefunctions:planning,settingpriorities,organizingthoughts,suppressingimpulses,weighingtheconsequencesofone’sactions.
Hormonal ChangesHormonesremainanimportantpartoftheadolescentbrainstory.Atthesametimeasthebrainswitchesfromproliferatingtopruning,thebodycomesunderthehormonalassaultofpuberty.Thesetwoeventsarenotcloselylinked,however,asbraindevelopmentproceedsonscheduleregardlessofwhetherthechildexperiencesearlyorlatepuberty.
Duringadolescencetheadrenalsexhormonesestrogenandtestosteroneareextremelyactiveinthebrain,attachingtoreceptorsthroughoutthebrainandexertingadirectinfluenceonserotoninandotherneurotransmittersthatregulatemoodandexcitability.
Testosteronesurgesduringpubertymakeanalmond-shapedpartofthelimbicsystem—calledtheamygdala—swell.Thelimbicsystemgeneratesemotionssuchasfearandanger,andtheswellingoftheamygdalacanintensifyfeelingsofaggressionorfear,sofeelingsreachflashpointmoreeasilyandadolescentsactivelyseekoutsituationswheretheycanallowtheiremotionsandpassionstorunwild.
Thereisahormone–brainrelationshipcontributingtotheappetiteforthrills,strongsensations,andexcitement.Thisthrill-seekingevolvestopromoteexploration—aneagernesstoleavethenestandseekone’sownpathandpartner.
Intaskssuchasidentifyingemotionsdisplayedonfaces,bothchildrenandyoungadolescentsrelyheavilyontheamygdala,whileadultsrelymoreonthefrontallobe,aregionassociatedwithplanningandjudgment.Duringresearch,adultsmakefewererrorsinassessingphotosofpeople,whileunder-14stendtomakemistakes.Inparticular,theunder-14sidentifyfearfulexpressionsasangry,confused,orsad.Thisdevelopmentalphysiologymayexplainwhyadolescentssofrequentlymisreademotionalsignals,seeingangerandhostilitywherenoneexists.Teenageranting(“Thatteacherhatesme!”)canbebetterunderstoodinthislight.
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Risk vs. OpportunityExperimentsinvolvingdrivingsimulatorshavebeenusedtoobserveteensandadultsastheydecidewhethertorunayellowlight.Theresultsshowthatbothsetsofsubjectsmakesafechoiceswhenplayingalone,butingroupplayteenagersstarttotakemorerisksinthepresenceoftheirfriends.Thisusuallyceasesinthoseoverage20,soagedifferenceisarelevantfactorindecisionmakingandjudgmentunderconditionsthatareemotionallyarousingorhavehighsocialimpact.Interestingly,mostteencrimesarecommittedingroups.Researchshowsthatthenucleusaccumbens(theregioninthefrontalcortexthatdirectsmotivationtoseekrewards)inadolescentsrespondsdifferentlythaninchildrenoradults.Instudieswhereadolescentsaregivenamediumorlargerewardforperformingcorrectly,thenucleusaccumbensreactsmorestronglythaninchildrenandadults.Whengivenasmallreward,theteenagenucleusaccumbensresponseisdecreasedbelowthatofchildrenandadults,asifthesmallrewardrepresentednorewardatallintheteen’sview.
Arewardcentreonoverdrivecoupledwithplanningregionsnotyetfullyfunctionalcouldmakeanadolescentanentirelydifferentcreaturefromanadultwhenitcomestoseekingpleasure.Thismaycontributetothefactthatadolescentsarepronetoengaginginbehavioursthathaveareallyhighexcitementfactor,areallyloweffortfactor,oracombinationofboth.
Theadolescentbrain’sdevelopmentalchangesmaycontributetotheoccasionalemotionalturmoilthatteenagersexperience.Thefactthatjudgmentisstilldevelopingmayalsoexplainadolescents’tendencytotakerisks.Whennew,excitingactivitiescauseneuronstoreleaseneurotransmitters,suchasdopamine,thatmakeyoufeelgood,riskybehaviourmayproduceemotionalrewards,too.
Adolescents and StressResearchconductedonfemaleadolescentmiceshowsthattheirbrainsrespondtostressdifferentlythanthoseofadultsandprepubescentindividuals.Anxietyisregulatedbythebrain’sprincipalinhibitoryneurotransmitter,GABA(gamma-amino-butyric-acid),whichcounteractstheeffectofglutamate,anexcitatoryneurotransmitterinthebrain’slimbicsystem.StresscausesthereleaseofasteroidknownasTHP(allopregnanolone),whichinadultandprepubescentindividualsincreasesthecalmingeffectofGABAinthelimbicsystem.However,intheabove-mentionedresearch,itwasshownthatTHPhadtheoppositeeffectinadolescentmice.ItappearsthatTHPhastworoles:oneinthelimbicsystemwhereitiscalming,andanotherinthehippocampuswhere,inadolescents,itstimulates.Thehippocampusisimportantforemotionregulation,andthisparadoxicalroleofTHPisthereasonfortheadolescentbrainbehavingdifferently.Theunderlyingmechanismappearstobedifferentlevelsofexpressionofatypeofreceptor(the“alpha-4-beta-delta”GABAreceptor)inthehippocampalbrainregionknownasCA1.Inadultsandpreadolescents,thereceptorsareinlownumberssotheoveralleffectofTHPisacalmingone.However,inadolescents,theexpressionofthesereceptorsishigh,sofortheseindividualstheanxiety-raisingeffectofTHPinthehippocampusoutweighsthecalmingeffectithasinthelimbicsystem.Researcherswereabletoreversethepubertyeffectinthemicebygeneticallyalteringthenumberofreceptors.
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Theneteffectisthatwhatevertheadolescent’sreactiontostressislikelytobe—whethertocryortobeangry—itwillbeamplified.Theresearchersindicatethat,thoughtoadultsitmayseemlikeanoverreaction,it’stheonlythingtheteenagercando.Thisstudyisthoughttobethefirsttosuggestanunderlyingphysiological,asopposedtoabehavioural–psychological,explanationforteenagemoodswings.
Sleep PatternsThepinealgland,situatedatthebaseofthebrain,producesmelatonin(achemicalthatsignalsthebodytobeginshuttingdownforsleep)asnighttimeapproachesanddaylightrecedes.Ittakeslongerformelatoninlevelstoriseinteenagersthaninyoungerchildrenoradults,regardlessofexposuretolightorstimulatingactivities.Thismaycontributetothechangeinsleeppatternsoftenassociatedwithteenageyears,resultinginteenagersstayinguplateandsleepinguntillunchtimethenextday.
Chemical MessengersWhenaneuron’sdendritesbecomestimulated,itsendsanelectricalsignalthroughthecellbodyanddownalongaxon.Attheendoftheaxontheneuronthenreleasesneurotransmitters,whichsendsignalstonearbyneuronsacrosssynapses.
Thebrainreliesonabout50differentneurotransmitters.Examplesinclude:• acetylcholine(ACTH)—affectsbrainactivityrelatedtoattention,learning,andmemory;
• dopamine—stimulatesfeelingsofpleasureandaffectsarousallevels;
• endorphinsandenkephalins—reducestressandeasepain;
• glutamate—playsavitalroleinlearningandlong-termmemory;
• noradrenaline—stimulatesmentalandphysicalarousalandheightensmood;and
• serotonin—affectsmoodlevels,sleep,appetite,andotherfunctions.
Afteraneurotransmitterstimulatesanearbyneuronbyattachingtoreceptorsonitsdendrites,thepresynapticneuron’sterminalabsorbsitthroughaprocesscalled“reuptake.”Reuptakekeepsneuronsfromconstantlybeingfired.
Substanceabuseinterfereswiththebody’snormalreleaseanduptakeofneurotransmitters.Forexample,nicotineactslikeACTHanddopamine,methamphetaminemimicsdopamine,PCPinterfereswithglutamatereceptors,andMDMAmimicsserotonin.Inmostcases,thebrain’sresponsesreinforcetheuseofthesubstance.Overtime,thebodydemandsmoreofituntilthepersonbecomesaddicted.
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Substance Abuse and Brain DevelopmentWithrecentdevelopmentalneuroscienceresearchindicatingthatadolescenceisakeyperiodofneuromaturation,thereisgrowingsupportfortheideathattheadolescentbrainmaybemorevulnerabletotheeffectsofaddictivesubstancesthantheadultbrain.
Insummary,theremodelingofthebrainthattakesplacefromchildhoodthroughtotheearly20sisthoughttoensuremoreefficientcommunicationbetweencorticalandsubcorticalbrainregions,facilitatingoptimalfunctioningwithincognitive,emotional,motivational,andsensorimotorsystems.However,itappearsthatthebraindoesnotmatureuniformlyacrossthisdevelopmentalphaseoflife.Instead,thereisagradedprogressionofcorticalmaturationwithinthemedialandlateralfrontalareas(regionsresponsibleforhighercognitivefunctions)thatcontinuesintolateadolescence,whereasthedeeperandmoreposteriorbrainstructures(regionsresponsibleformoreprimitivefunctions)maturemuchearlier.
Althoughrelativelyfewerstudieshaveexamineddevelopmentalchangesinbrainfunction(asopposedtostructure),differencesinaffective,motivational,andcognitivecapacityduringadolescenceappeartobeconsistentwithreportedmaturationalneuro-anatomicalfindings.Forexample,earlyadolescenceischaracterizedbyincreasesinaffectivereactivity,peer-directedsocialinteractions,risktaking,andsensationseeking,whiledecisionmakingandself-regulatoryskills(i.e.frontalexecutivefunctions)donotfullymatureuntilearlyadulthood.
Growingliteraturefromanimalstudiessuggeststhatadolescentsubstanceusedisruptsneuro-endocrinefunctioning,andcaninducegreatereffectsonneuralplasticityandcognitionthaninadults.Substanceuseduringadolescencecanalsoelicitalteredsensitivitytolaterdrugexposure,impairadultcognitivefunctioning,andeveninducecorticaldamage.Substantiallylessworkhasbeenconductedinadolescenthumans,althoughthereisincreasingevidenceofdevelopmentalharms.
Anumberofstudieshavereportedsmallerhippocampalvolumesamongadolescentsandyoungadultswithalcoholusedisorderscomparedtohealthymatchedcontrols.Inoneofthesestudies,hippocampalvolumeswerepositivelycorrelatedwithageoffirstuseandnegativelycorrelatedwithdurationofuse.
Adolescentswithalcohol-usedisordershavealsobeenreportedtohavesmallerprefrontalcorticesandwhite-mattervolumes,withsignificantcorrelationsnotedbetweenprefrontalcorticalvolumesandmeasuresofalcoholconsumption.Suchstructuralabnormalitiesareinkeepingwithreportedalcohol-relatedneurocognitiveimpairmentsamongadolescentdrinkers,aswellasrecentfindingsinfunctionalimaging.
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Whilemostresearchtodatehasbeenconductedamongadolescentdrinkers,youngdrugusershavealsobeenfoundtodemonstrateneurocognitiveimpairments.Youngpeoplewhobeginusingcannabisbeforetheageof17seemtobemorevulnerabletocognitiveimpairmentsandshowreducedbraingreymatter.Chronicinhalantmisusehasalsobeenassociatedwithcognitiveimpairment,sometimesresultinginpermanentandirreversiblecognitivedeficitsandstructuralbrainabnormalities.
Inonestudyof55chronicusers(meanageof30years,withthemajoritycommencinguseinadolescence),almost44%hadstructuralbrainchanges.Theextentofthesestructuralbrainchangeswasrelatedtocumulativedose.Therewasalsoastrongcorrelationbetweenwhite-matterabnormalitiesandgreatercognitiveimpairment.
Anotherstudyrecentlyreportedthatchroniccocaineusesubstantiallyinterfereswithnormalwhite-mattermaturation,particularlyinfrontalandtemporalbrainregions.Enhancedwhitematterconnectivity(especiallywithinthesestructures)isoneofthekeymaturationalprocessestooccurduringadolescence,suggestingthatearly-onsetsubstanceusemayaffectthedevelopmentoffronto-temporalwhite-mattercircuits,potentiallyresultingindisturbedmemoryandexecutiveandaffectivefunctioning.
Studiesofhigh-riskpopulations(e.g.,familyhistoryofalcohol-usedisorders)suggestthatimpairmentsinfrontalfunctioningareapparentpriortodruguseexposureandcanpredictlatersubstanceuse.High-riskyoungpeoplealsofailtodemonstrateappropriateage-relateddecreasesingrey-mattervolume.Suchstudies,however,reportnodifferencesinhippocampalvolume,suggestingthatanyobservedstructuralfindingsmostlikelyrelatetosubstanceexposureratherthanpremorbidvulnerability.
Thelimitedresearchontheneurobiologicaleffectsofalcohol,tobacco,inhalants,andcannabisuseduringadolescenceisatoddswiththeirhighratesofuseduringthisimportantdevelopmentalperiod;animalevidencesuggestssubstantiallyincreasedrisks.Accordingly,itshouldbearesearchprioritytoconductstudiesthatexaminechangesinbrainstructureandfunctionduringearlyadolescence.
Suchresearchisessentialifwearetoassesstheneurobiologicalimpactofsubstanceuseduringadolescence(includingtheextentofrecoveryfollowingabstinence),andidentifyrobustneurobiologicalmarkersofrisk.Thisresearchisalsoessentialinordertoassesstheimpactofexposuretospecificdrugs,aswellaspossiblesynergisticeffectswithpolydruguse.
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Gender DifferencesTogether,theCanadianCentreonSubstanceAbuseandtheBritishColumbiaCentreofExcellenceforWomen’sHealthhighlighthowsubstanceabuseandaddictionvarybetweenmalesandfemales.Commonpatternsofuseforgirlsandwomenhavebeenwidelyacknowledged.ArecentstudyinBritishColumbiashowsagenderedrelationshipwithbenzodiazepineuse,wherefemalesaretwiceaslikelyasmalestobeprescribedbenzodiazepinestohelpcopewithdifficultlifesituations,suchasgriefandstress.HealthCanadaalsohighlightsthatfemaleyouthoftenhavealowertolerancethanmalestotheeffectsofalcohol.Inaddition,femaleyouthtendtoexperiencesymptomsofdependencemorequicklyandareoftenmoresusceptiblethanmalestohealthproblemsrelatedtoalcoholanddrugconsumption.Researchindicatesthatformostsubstancesmaleyoutharemorelikelythanfemaleyouthtousesubstancesatproblematiclevels(HealthCanada,2001).
Researchhasshownthatmentalhealthproblemsandsubstanceabuseareinterconnected,andareworsenedbyafemale’sexperienceofvictimization,trauma,andviolence(CanadianCentreonSubstanceAbuseandBCCentreofExcellenceforWomen’sHealth,2005).Historiesofsexualandphysicalabusearepositivelyassociatedwithincreasedsubstanceuseandaremorefrequentamongfemalethanmaleyouth.Researchsuggeststhatsomefemaleyouthusesubstancestoamelioratemood,increaseconfidence,copewithproblems,looseninhibitions,loseweight,orenhancesexualexperiences(HealthCanada,2001).
Researchshowsthatsocialattitudeswithregardtosubstanceuseandaddictionalsohaveanimpactongirlsandwomen,asthereisgreaterstigmaattachedtoafemalewithasubstance-abuseproblemthantoamale.Girlsandwomenalsoexperiencemoreoppositionfromfriendsandfamilymembersthanmalesdotoenterintotreatment(Poole&Dell,2005).
Itisdifficulttoascertaintheextenttowhichfemalesusealcoholandotherdrugsduringpregnancy,giventhestigmathatisassociatedwithmaternaluse(Poole&Dell,2005).However,servicesforpregnantyouthareseenascriticalfordecreasingthepsychosocialandphysiologicaleffectsofproblemsubstanceuseforboththeyouthandthedevelopingfetus/child.Pregnancyprovidesanopportunitytoreachouttotheyouth,giventheyouth’sconcernforthehealthandwell-beingoftheunbornchild(HealthCanada,2001).Itisnecessarytokeepinmindthatpregnantyouthfacemanychallengesassociatedwiththeirowntreatmentneedsaswellasaccessingprenatalservices;concernsrelatedtofamilycareandresponsibilitiesdecreasethelikelihoodofenteringintoatreatmentprogram(Poole&Dell,2005).
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The impact of substance use on developmental tasksItisoftendifficulttoseparatetheadaptiveaspectsofadolescentsubstanceusefromthemaladaptive.Adolescentsfindthemselvesinaconstantstateoftransition,andsubstanceusemaygivemeaningtothechangesoccurringorblockunwantedfeelingsandemotions,suchasdepressionandanxiety.Substanceusemaybecome“immenselyattractivetotheadolescentinthethroesofdevelopmentaltransformation”(Trad,1993).
Substanceusecanbemaladaptivetotheadolescentwhenitstartstobecomeproblematicandblocksthenormativedevelopmentaltasksfrombeingachievedbytheyoungperson.Whenayoungpersonengagesinproblematicsubstanceuse,theachievementofdevelopmentaltaskscanbeimpeded.Weneedtounderstandthatdifferingpatternsofsubstanceuse,aswellasconsequencesofuse,willexistforeachindividualadolescent,andthatthesewillvarydependingontheyoungperson’sstageofdevelopment.
Factorssuchassocial,ethnic,andculturalissuesmayinfluencedruguse.Sensitivitytodifferentculturalandlinguisticgroupvaluesandattitudeswillallowtheworkertobemoreresponsivetoadditionalcomplexitiesfacedbyyoungpeoplefromvariousbackgrounds.Workersalsoneedtokeepuptodatewithcurrenttrendsindruguse.
Mostdruguseengagedinbyyoungpeopleandadultsisnotproblematic.Itisusefultounderstandthatyoungpeople,ingeneral,useavarietyofdrugsinavarietyofways,foravarietyofreasons.Nodrugisinstantlyaddictive.Howmuchpeopleuse,andhowoften,dependsmuchmoreontheirpersonalityandlifestylethanitdoesontheparticulardrugsbeingtaken.
Thereisafinelinebetweensubstanceusebeingconstructiveandadaptiveordestructiveandproblematic.Thedefinitionofproblematicsubstanceusewilldependonthevaluesandattitudesofthepersonprovidingthedefinition.Ausefulquestiontoaskis:
• Forwhomisthesubstanceuseaproblem(ornotaproblem)andforwhatreason?
Thetablebelowhighlightshowtypicaladultperspectivesondrugusemaydifferfromthoseoftheadolescent.
Table 2: DifferencesinPerspective
Adult Perspective Adolescent PerspectiveStupid/foolish Exciting/funEasilyinfluenced ProofofbelongingActingwithoutregardforconsequence Testinglimits/notcaringDangerous Thrilling/exhilarating
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Thedegreetowhichsubstanceuseisproblematicorfunctionalforyoungpeoplewillvaryaccordingtothedevelopmentalsubgrouptowhichtheybelongandamyriadoffactors,uniquetothecircumstancesofeachindividual.Thefollowingisausefuldefinition:
• Substanceusethatputsayoungpersonatriskofseriousharmand/orimpingesonthatyoungperson’songoingsuccessfuldevelopmentcanbedefinedasproblematic.
• Focusingonimmediateriskaswellaslonger-termdevelopmentalriskhelpstoavoidthenarrowdefinitionofentrenchedandhabitualdruguseastheonlytypesofproblematicdruguse.Forexample,atwelve-year-oldwhoseuseisexperimentalorsocial/recreationalmay,throughsheerlackofinformationandexperience,beatriskofseriousharm.
Quiteoften,problematicsubstanceusedoeshavetheeffectofmarginalizingtheyoungperson,limitingthedevelopmentofalternativestrategiesforcoping,andfurtherentrenchingsubstance-usingbehaviour.Inthesecircumstances,theworkermaybecalledtomanageayoungpersonwhoisusinginahabitualordependentfashion.(Thetypeofdrugstaken,thestyleandpatternsofuse,andthemeaningattributedtouseisoftendifferentfromthatofadultsubstanceusers.)
Whendruguseanditsconsequencesbecomeproblematicforayoungperson,heorshemaycometotheattentionofserviceproviders.Thisismostlikelytooccurwhentheyoungperson’slifecircumstancesbecomeoverwhelming;heorshefeelsunabletocopeandwouldlikepracticalassistancetosortthingsout.Seekingassistancedoesnotautomaticallycomewithagoaltostopdruguse,oreventochangebehaviour.Thisisparticularlysoifthepersonfeelscoerced(e.g.,byfamilyorotherssuchaspolice)toattendtreatment.
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Introduction Whilementalhealthandaddictionsservicesareintendedandassumedtobesafeandrepresentativeofculturesofcareandindividualsupport,thisisnotalwaysthecase.ThissectionoftheAdolescentWithdrawalManagementGuidelineDocumentbuildsuponinitiativesalreadyundertakenwiththeDepartmentofHealthandWellnesstoensurethatNovaScotiansreceiveculturallycompetentpatient-centredcare.CulturalCompetencerequiresthat:(1)health-careprovidershaveeffectiveskills,knowledge,andattitudes,(2)organizationshaveinclusiveproceduresandguidelines,and(3)healthsystemshaveadequatefunding,interpretationservices,adiverseworkforce,soundpolicies,andsupportiveleadersandchampions.
ToolssuchastheCulturalCompetenceGuidelinesfortheDeliveryofPrimaryHealthCareinNovaScotia(foundathttp://www.healthteamnovascotia.ca/cultural_competence/CulturalCompetenceGuidelines_Summer08.pdf )areatremendousresourceandshouldbeutilizedalongwiththeinformationinthisdocument.Inaddition,ACulturalCompetenceGuideforPrimaryHealthCareProfessionalsinNovaScotiacanbefoundathttp://www.healthteamnovascotia.ca/cultural_competence/Cultural_Competence_guide_for_Primary_Health_Care_Professionals.pdf
ThefollowinglinkprovidesguidanceonintegratingCulturalCompetenceandHealthLiteracysothatNovaScotia’sdiversepopulationscanbereflectedinpictures,writteninformation,advertisementsandpostedsignage,andwrittenmaterialforallliteracylevelsinthelanguagescommonlyspokenintheirserviceareas.http://www.gov.ns.ca/health/primaryhealthcare/documents/Messages%20for%20All%20Voices-%20Full%20Length%20Tool.pdf
Thissectiongivesabriefoverviewofspecificdemographicsthatareunderservedandvulnerabletomistreatmentbyapproachestocarethatrepresentcolonialism,racism,homophobia,xenophobia,andsexisminNovaScotia.ThecomplexstrugglesandintersectingidentitiesofAboriginalpeoples,BlackNovaScotians,immigrants,refugees,andLGBTQindividualsrequirementalhealthandaddictionspractitionerstobeawareofthehistoricalcausesofmarginalization.Practitionersshouldalsobeawareofexistingagencyandhealingculturescurrentlybuildingconsensusonindividualandcommunitywell-beinginaglobalizedworldofdiverselanguages,lifeways,andsexualities.
Asweworkwithyoungpeopleinareflectiveandinformedpractice,wecanunderstandthecontextofyouth’scontemporarystrugglesforself-determinationastheydemandreflexivityandtransparencyfrominstitutionsofcaretoensureethicalandeffectiveinteractionsbetweenprofessionalcareworkersandcommunities.
Socialdeterminantsarecrucialfactorsinthehealthandwell-beingofCanadians.Ifwecanunderstandhowandwhytheywork—andhowourservicesandinstitutionscanbestrengthenedandourresourcesmoreequitablydistributed—wewillalsobeabletounderstandandacttoimprovethefactorsthatallowustolivelongerandhealthierlives(Raphael,2010).
Culturally Effective Services
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BeingabletorespondtoandunderstandthediversepopulationsofNovaScotianyouthinawithdrawalmanagementsettingwillbekeyinretainingyouthinthecontinuumofservicesandsupports.Ifyouthfeelthattheyareunderstoodandthateveryattemptismadetomatchservicestotheiruniqueneeds,theyaremorelikelytoestablishapositiveattitudeaboutaddictionservicesandwillbemoreopentofurtherexplorationoftheirharmfuluseofsubstancesand/orgambling.WhiteandKleber(2008)havedocumentedhistoricalandcurrentexamplesofiatrogenicinjuryintraditionaladdictiontreatmentandhaveproducedaguideofferingsuggestionsonhowtopreventsuchharm.Theyurgemedicalprofessionalstoexamineandreflectonthevulnerabilityofmarginalizedpopulationsaccessingaddictiontreatment:
Harmfuleffectsofaddictiontreatmentareoftenwrittenoffassymptomsoftheclient’saddictionpathologyorasproductsofmedicalpsychiatriccomorbidities.Ifweattributepositivechangeinclientstothepotencyofkeytreatmentingredients,wemustalsoconsiderthatnegativechangeinsomeclientsmayflowfromthesesamepotentforces.Membersofhistoricallydisempoweredgroupsareparticularlyvulnerabletoiatrogenicinjury,e.g.,women,children,elderly,ethnicminorities,prisoners,andpersonsexperiencingstigmatizedconditions,e.g.,mentalillness,addiction.(p.9)
Whetherhe/sheisAfricanNovaScotian,FirstNations,immigrant,gay,lesbian,bisexual,ortransgendered,ayoungperson’smotivationwillbeverymuchimpactedbythedegreetowhichhe/shefeelsaccepted,understood,andsafe.Whenworkingfromaculturalcompetencymodel,itisimportanttoensurethatallpeopleareincludedinthedefinition.Oftencultureisseenasencompassingracialorethnicgroupsbut,historically,peoplewithdisabilities,LGBTQpopulations,faithcommunities,orwomenexperiencingstigmatizationininstitutionalpracticeshavebeenleftout.
Therearesomedifferencesinthesegroupsintermsofhowcultureisdefined,buttherearealsosimilarities.WhileLGBTQpeoplesharesimilarexperiencesthatshapetheiridentities,theLGBTQcultureisoftenhiddeninresponsetoheterosexiststigma.LGBTQyouthmaynotidentifywiththecultureoftheirfamilyoforiginorgeographiccommunity.Similarly,intergenerationaldisruptionanddisplacementofindigenousfamilieshasimpactedthecomplexityoftheculturalidentitiesofindigenousyouthraisedinstatecare.Oneoftheeffectsofthismultifacetedoppressionisagenerallevelofself-protectionanddistrustofothersandofofficialsystems,especiallyeducationandhealth-caresystems.Asaresult,youthoftendonotaccesshealthservicesexceptinemergencies,ortheyaccessservicesbutareuncooperativeordonotdisclosetheiridentitiestohealthservicespersonnel.Thefearofexperiencinghomophobiaandtransphobiaorthefearofhavingtodiscloseone’smarginalizedidentityisalargebarriertoaccessingservices(Eliason,2010;Lombardi&vanServellen,2000).Alcoholandsubstance-abuseprogramsandservicesarenoexception.Inonestudy,resultsshowedthat50%oftransgenderindividualsreportedtheydidnotseektreatmentforanaddictionissuebecauseoffearofananticipatedtransphobia.Anothersignificantpercentagestatedtheydidseektreatmentbutdidnotdisclosetheiridentity(Nuttbrock,2012).
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Thereisnotextensiveliteratureavailableonsubstanceusepatternsamongethno-culturalminorityyouth.Substance-useproblemsamongminoritygroupsmaynotbereportedduetoculturalfactors,asthereisasetofbeliefswithinmanyethno-culturalminorityculturesthatdiscouragestheacknowledgementandexplorationofalcohol-anddrug-relatedproblems.Manyculturaltraditionssupportyouthreceivinghelpfrominformalnetworksratherthanfromformalcommunitystructures.Lowreportingnumbersmayalsobearesultofalackofsensitivityandcross-culturaltrainingforserviceproviders,thepresenceofracisminmainstreamservices,andalackofculturallyappropriateservices(HealthCanada,2001).
Inher2007studyofraceandnationinCanada,“ExaltedSubjects,”Dr.SuneraThobanihighlightspluralconceptsofsovereigntyasanuancedwaytounderstandthealienationandagencyofmarginalizedpeoplesinCanada.ShecitesBlacktheoristDr.AchilleMbembetoconveytheongoingpresenceofhistoricalcontrolandviolenceinthelivesofracializedpeoplelivinginCanada:
Blacksubjectivityandalienationwereconstitutedintheracialviolencethattypifiedtheencounterofthe‘native’withmodernityanddefinedtheformofsovereignpowerimposedontheirlives…Insteaditrecognizesthatthecolonizedsubject/objectwasformed—andlives—withinthesouldestroyingbrutalitythatwas/isthecolonialorder.(p.12)
WhilemanysimilaritiescanbedrawnbetweentheimpactofcolonialismonFirstNationscommunitiesandBlackcommunitiesinNovaScotia,therearehistoricallydifferentfactorsthatareimportanttoconsiderinrelationtomanagingwithdrawalservicesforAfricanNovaScotianyouth.Specifically,serviceprovidersshouldbeawareofthehistoryofslaveryofAfricanNovaScotians(Robertson,1996;Rommel-Ruiz,2006;Whitfield,2010)andthedisplacementofindigenousBlackcommunitiessuchasAfricville(Vincer,2008;Sehatzadeh,2008).AfricvillewasavibrantAfrican-CanadiancommunityinHalifaxthatcanbetracedbackto1838whendescendantsofAmericanslavessettledontheshoreofHalifaxHarbour.Inthe1960sracismintensifiedwhenAfricvilleland,increasinglyvaluedforitslocationonaHalifaxwaterfront,wasexpropriatedbythecityofHalifax.Theentirecommunitywasrelocated,andmanyresidentsweremovedingarbagetrucks.Alltheirlandwastaken,theirhomesdestroyed(McGibbon&Etowa,2009).
FirstNationspopulationsexperiencepoverty,violence,andincarcerationdisproportionatelytotheirCanadiancounterparts.TherearemoreFirstNationschildreninstatecarenowthanattheheightoftheresidentialschoolsystem(Blackstock,2007),andintergenerationaltraumaamongFirstNationsyouthisaconsequenceofthecoloniallegacyoftheresidentialschoolsystem(NativeWomen’sAssociationofCanada,2011).Investigationshaveconfirmedrampantinstitutionalabusethatoccurredinresidentialschools,grouphomes,orphanages,andcustodialcentres.ThisinstitutionalizedviolenceagainstFirstNationscommunitiesincludesphysical,sexual,verbal,andemotionalabuse,aswellastheontologicalviolenceofdenyingpolitical,legal,linguistic,religious,family,andeconomicsovereignty.
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Ignoringthecontextinwhichtraumaoccursandisnamedresultsintheindividualbeingheldinherentlyresponsibleforhis/herresponsetohighlydistressingcircumstances,andevenfortheexperienceitself.Asaresult,thepotentialforstigmatizationisfurtherheightened(Feinstein&Dolan,1991).Returningtoathemeofself-determinationinacolonialcontext,“culturalsafety”isagoalforpractitionersandrequiresaparticipatoryapproachthatinvolvestheclientsindefiningtheirneeds,struggles,andagency.AsdescribedbyMikkonenandRaphael(2010),
culturalsafetysupportsself-determination,wheresafetyisdeterminedbytheuserofthehealthsystem,notthesystemitself.Culturalsafetymovesbeyondculturalsensitivitytoanalyzingpowerimbalances,institutionaldiscrimination,colonizationandrelationshipswithcolonizers,astheyapplytohealthcare.(p.17)
Practicingculturaleffectivenessincludesoperatingfromagender-basedanalysis,recognizinghowgenderaffectsindividualexperienceswithaddiction.Forexample,female,male,andtransgenderyouthareindifferentandunequalsocialpositionsand,therefore,willhaveuniqueneedsinawithdrawalmanagementsetting.Transgenderpeoplemaydevelopaddictionsduetothestigmaimposedonthemthrougharigidbinary-gendermodel.Womenmayneedwithdrawalmanagementtoreplaceunhealthycopingmechanismslikebingedrinkingtonumbthepainandtraumaofmaleviolence.Theseexamplesarenotmeanttoessentializebuttorecognizethatthesedifferingrootcausesrequiredifferentsolutions(StatusofWomen,2009).Astransgenderpeopleandwomenareoppressedinourcurrentculture,genderconsequentlydeterminesunequalaccesstoresources,materialsupport,andrecovery.Itisthereforeimportanttoemployagender-basedanalysisandapproachtosupportpositivehealthoutcomeswhilerecognizingandhonouringdifference.
First Nations InthearrangementofCanada’ssocialaffairs,onlytheassimilatedIndianhasbeenofferedeventheprospectofwellness.Forthosewhoresistedorrefusedthebenefitsofassimilation,governmentpoliciesassuredalifeofcertainindignity.Thatistheessenceoflifeinthecolony:assimilateandbelikeusorsuffertheconsequences.(Kirmayer&Valaskakis,2009,p.xi)
Historical Context of Turtle IslandThecolonially-generatedculturaldisruptionaffectingFirstNations…compoundstheeffectsofdispossessiontocreateneartotalpsychological,physicalandfinancialdependencyonthestate.ThecumulativeandongoingeffectsofthiscrisisofdependencyformthelivingcontextofmostFirstNationsexistencestoday.Thiscomplexrelationshipbetweentheeffectsofsocialsuffering,unresolvedpsychophysicalharmsofhistoricaltraumaandculturaldislocationhavecreatedasituationinwhichtheopportunitiesforaself-sufficient,healthyandautonomouslifeforFirstNationspeopleonindividualandcollectivebasesareextremelylimited.(Alfred,2009,p.42)
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UnderstandingappropriateapproachestoaddictionsandmentalhealthworkwithAboriginalcommunities,families,andyouthrequiresperspectiveonpasttreatmentofindigenouschildreninCanada.Aboriginalchildren,particularlyFirstNationschildren,becamethecentraltargetforassimilationstrategiesthroughtheirforcedattendanceatresidentialschoolsandout-of-communityadoptionintonon-Aboriginalfamilies.TheseeffortswerepartofanorchestratedplanofforcedassimilationthatemergedatroughlythesametimeinCanada,Australia,andNewZealandinaccordancewithBritishcolonialpolicy(Armitage,1995).
TheCanadiangovernmentinformallyrecognizedindigenouscommunitiesofCanadaaspeoplesornations,buttheywereviewedasuncivilizedandhenceunabletoexerciserightsascitizensinademocraticpolity.TheBagotCommissionReport(1844)arguedthatreservesinCanadawereoperatingina“half-civilizedstate”andthatinordertoprogresstowardcivilization,Aboriginalpeoplesneededtobeimbuedwiththeprinciplesofindustryandknowledgethroughformaleducation.ThisreportbeganashiftinIndianpolicyinCanada,awayfromtheprincipleofprotectionandtowardactiveassimilation.ThisshiftwasreinforcedbytheDavinReport(1879),whichrecommendedapolicyof“aggressivecivilization.”AboriginaladultsandEldersweredescribedbythissecondreportashaving“thehelplessmindofachild.”Tobeintegratedintotheemergingnation,therefore,Aboriginalchildrenhadtobeseparatedfromtheirparentsand“civilized”throughaprogramofeducationthatwouldmakethemtalk,think,andactlikematureBritishCanadians.
From1879to1973,theCanadiangovernmentmandatedchurch-runboardingschoolstoprovideeducationforAboriginalchildren(Miller,1996).FollowingtherecommendationsoftheDavinReport,residentialeducationforAboriginalchildreninCanadawasmodelledafterthesystemofboardingschoolsforNativeAmericanchildrenintheUnitedStates(Miller,1996;Milloy,1999).Althoughportrayedasplacesofeducationandenlightenment,mostoftheresidentialschoolsinfactfunctionedas“totalinstitutions”(Goffman,1961)or“carceralspaces”(Foucault,1977)—enclosedplacesofconfinementwithahighlyregimentedsocialorderapartfromeverydaylife.Theschoolswerelocatedinisolatedareas,andthechildrenwereallowedlittleornocontactwiththeirfamiliesandcommunities.
Therewasaregimeofstrictdisciplineandconstantsurveillanceofeveryaspectoftheirlives,andculturalexpressionthroughlanguage,dress,food,andbeliefswasvigorouslysuppressed.
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Overthespanof100years,about100,000Aboriginalchildren,mainlyFirstNations,weretakenfromtheirhomesandsubjectedtoaninstitutionalregimethatfiercelydenigratedandsuppressedtheirheritage.Attheirheight,therewere80residentialschoolsoperatingacrossCanada,withapeakenrolmentin1953ofover11,000students.Althoughsomefamilieswelcomedtheopportunityforformaleducationoftheirchildren,othersdesperatelytriedtoavoidsendingtheirchildrentotheschools(Johnston,1988).Theextentofthephysical,emotional,andsexualabuseperpetratedinmanyoftheresidentialschoolshasonlyrecentlybeenacknowledged(Haig-Brown,1988;Knockwood&Thomas,1992;Lomawaima,1993;Milloy,1999).Beyondtheimpactonchildrenofabruptseparationfromtheirfamilies,multiplelosses,deprivation,andfrankbrutality,theresidentialschoolsystemdeniedAboriginalcommunitiesthebasichumanrighttotransmittheirtraditionsandmaintaintheirculturalidentity(Chrisjohn,Young,&Maraun,1997).
IntensivesurveillanceandcontrolofthelivesofAboriginalpeoplesinCanadawentfarbeyondtheresidentialschoolsystem.AssimilationofAboriginalpeopleswastheexplicitmotivationfortheremovalofAboriginalchildrentoresidentialschools.Aboriginalparentswerenotnecessarilyseenas“unacceptable”parents,onlyasincapableofeducatingtheirchildrenandpassingon“proper”Europeanvalues(Fournier&Crey,1997;Johnston,1983).
Beginninginthe1960s,thefederalgovernmenteffectivelyhandedovertheresponsibilityforAboriginalhealth,welfare,andeducationalservicestotheprovinces,despiteremainingfinanciallyresponsibleforstatusIndians.Provincialchildandwelfareservicesfocusedonthepreventionof“childneglect,”whichemphasizedthemoralattributesofindividualparents,especiallymothers,andonenforcingandimprovingcareofchildrenwithinthefamily(Swift,1995).InthecaseofAboriginalfamilies,“neglect”wasmainlylinkedtoendemicpovertyandothersocialproblems,whichweredealtwithunderwhatsocialworkersreferredtoas“theneedforadequatecare.”However,improvingcarewithinthefamilywasnotgivenpriority,andprovincialchild-welfarepoliciesdidnotincludepreventivecounsellingservicesforfamilies,astheydidinthecaseofnon-Aboriginalfamilies.SincetherewerenofamilyreunificationservicesforAboriginalfamilies,socialworkersusuallychoseadoptionorlong-termfostercarefortheAboriginalchildrentheytookintocare,resultinginAboriginalchildrenexperiencingmuchlongerperiodsoffostercarethantheirnon-Aboriginalcounterparts(MacDonald,1995).
Asaresultofheightenedsurveillanceandconcernsaboutchildwelfare,largenumbersofAboriginalchildrenweretakenfromtheirfamiliesandcommunitiesandplacedinfostercare.Bytheendofthe1960s,between30%and40%ofthechildrenwhowerelegalwardsofthestatewereAboriginal,instarkcontrasttotherateof1%in1959(Fournier&Crey,1997).Bythe1970saboutoneinfourstatusIndianscouldexpecttobeseparatedfromhisorherparents;roughestimatesontheratesofnon-statusandMétischildrenapprehendedfromtheirfamiliesshowthatoneinthreecouldexpecttospendhisorherchildhoodasalegalwardofthestate.Eventually,manyofthesechildrenwereadoptedintonon-AboriginalfamiliesinCanadaandtheUnitedStates.Termedthe“SixtiesScoop,”thispracticelastedalmostthreedecades—andstatisticsindicatethatthereisstillanoverrepresentationofAboriginalchildreninthecareofnon-Aboriginalinstitutionsandfosterfamilies(Goughetal.,2005).
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Thelarge-scaleremovalofAboriginalchildrenfromtheirfamilies,communities,andculturalcontextsthroughtheresidentialschoolsystemandthe“SixtiesScoop”haddamagingconsequencesforindividuals,families,andwholecommunities.Muchlikeformerresidentialschoolstudents,whooftenreturnedtotheircommunitiesinaculturally“betwixtandbetween”state,Aboriginalchildrenrelegatedtothecareofthestateornon-Aboriginalfamilieshaveexperiencedproblemsofidentityandself-esteemasaresultofgrowingupatthemarginsoftwoworlds.Physicalandsexualabuse,emotionalneglect,internalizedracism,languageloss,substanceabuse,andsuicidearecommonintheirstories(Fournier&Crey,1997;York,1990).
First Nations’ Mental Health and Substance Abuse StatisticsSuicideisthemostdramaticindicatorofdistressintheAboriginalpopulations.Inmanycommunities,FirstNations,Inuit,andMétishaveelevatedratesofsuicide,particularlyamongyouth;however,ratesareinfacthighlyvariable(Kirmayer,1994;Kirmayeretal.,2007).InQuebec,forexample,theInuit,Attikamekw,andseveralothernationshaveveryhighratesofsuicide,whiletheCreehavearatecomparabletothatofthegeneralpopulationoftheprovince(Petawabanoetal.,1994).Thisvariationhasmuchtoteachusaboutthecommunity-levelfactorsthataffectsuiciderisk.
Comparedtothegeneralpopulation,asmallerproportionofAboriginalpeopleconsumealcohol—79%versus66%,respectively(FirstNationsInformationGovernanceCommittee,2007).However,therateofproblemdrinkingishigherintheAboriginalpopulation,with16%ofFirstNationsindividualsreportingheavydrinkingonaweeklybasis,comparedto6%inthegeneralpopulation.TheNorthwestTerritoriesHealthPromotionSurveyfoundthat33%oftheterritories’Aboriginalpersonswereconsideredheavydrinkers,comparedto17%inthenon-Aboriginalpopulation(NorthwestTerritoriesBureauofStatistics,1996).Inthesamesurvey,useofcannabiswasalsogreaterforAboriginalpersons(27%)thanfornon-Aboriginalpersons(11%).ThesurveyalsoaskedaboutthehistoryofsolventuseandfoundthatthepercentageofAboriginalpeoplewhohadusedsolventswasparticularlyhigh(19%),comparedto2%amongnon-Aboriginalpeople.
AsurveyofdruguseinManitobaassessedAboriginal(IndianandMétisresidentsoff-reserve)andnon-Aboriginaladolescentsoverfourconsecutiveyearsfrom1990to1993(Gfellner&Hundleby,1995).TheAboriginalgroupshadconsistentlyhigherratesofuseofmarijuana,non-medicaltranquilizers,non-medicalbarbiturates,LSD,PCP,otherhallucinogens,andcrack.ForbothLSDandmarijuana,theaveragerateofuseforAboriginaladolescentswasoverthreetimesthecorrespondingnon-Aboriginalrate.Inthesamesurvey,glue-sniffingwasmorefrequentamongtheAboriginalgroupthanamongthenon-Aboriginalgroups.
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Inhalantuse(e.g.,gas,glue,solvents)isanincreasingproblemamongyoungpeopleworldwidebutismuchmorecommoninsomeAboriginalcommunitiesthaninthegeneralpopulation(Howardetal.,1999;Neumark,Delva,&Anthony,1998;Weir,2001).InasurveyofInuityouthinonecommunityinQuebec,21%reportedhavingusedsolventsatonetime,and5%hadusedthemwithinthepastmonth(Kirmayer,Malus,&Boothroyd,1996).Individualswhohadusedsolventswereeighttimesmorelikelytohavemadeasuicideattempt.The2004NunavikHealthSurveyfoundthat6%ofrespondentshadusedsolventsintheprevious12months;forthose15to19yearsofage,theratewas13.5%(Muckleetal.,2007).
Narrativesandlifehistoriessuggestthattheresidentialschoolexperiencehashadenduringpsychological,social,andeconomiceffectsonsurvivors(Haig-Brown,1988;Milloy,1999;York,1990).Thelinksbetweeneventsandoutcomesmadebyindividualsintheirnarrativesgiveaclearpictureofhowsufferingisunderstoodandexperienced,andcanidentifyplausibleconnectionsformoresystematicstudy.
Transgenerationaleffectsoftheresidentialschoolsincludethestructuraleffectsofdisruptingfamiliesandcommunities;thetransmissionofexplicitmodelsandideologiesofparentingbasedonexperiencesinpunitiveinstitutionalsettings;patternsofemotionalrespondingthatreflectthelackofwarmthandintimacyinchildhood;repetitionofphysicalandsexualabuse;lossofknowledge,language,andtradition;systematicdevaluingofAboriginalidentity;and,paradoxically,individualizingandessentializingAboriginalidentitybytreatingitassomethingintrinsictothepersonandthusstaticandincapableofchange.Thesefactorspointtoalossofindividualandcollectiveself-esteem,toindividualandcollectivedisempowerment,andthedestructionofcommunities.TheRedRoadProjectisoneexampleofaFirstNation–ledprojectinMi’kma’kiintendedtostrengthentheconnectionbetweenindigenousculturaltraditionsandyouthresiliencerelatedtoaddictions.
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The Red Road ProjectConceivedinearly2012bycommunitychiefs,theRedRoadProjectaimstoeducateFirstNationsyouthaboutthedangersofusingillegalsubstances.
Theprojectencouragesyouthtosaynotothepeerpressuresforsubstanceabuse,andraisesawarenessofthedamagingeffectsofsubstanceabusenotonlytothepersonusing,butalsototheirfamily,friends,andlargercommunity.Theproject’sname,“RedRoad,”stemsfromtheNativeAmericanconceptofbeingontherightpathinlifeinharmonywithourCreator.
“Apositivelifestyleiswhenyou’redoingwhatmakesyoufeelgood,notdoingwhateveryoneelseisdoing.”
Ourvision:Believe.Conceive.Achieve.RESPECT:OurHomes.OurElders.OurSelves.“Respectyourbodyandyourbodywillrespectyou.”—EskasoniChiefLeroyDenny
Indigenous Youth in Nova ScotiaMi’kma’kiisthehomelandoftheMi’kmaq.TheMi’kmawNationhaslivedintheareanowknownastheAtlanticProvincesandthesouthernGaspéPeninsulasincetimebeyondthereachofmemory,record,ortradition.ThetraditionalhomelandandarchaeologicalfindingsfromboththeDebertsiteinColchesterCountyandtheRedBridgePondsiteinDartmouthhavegivenevidenceofMi’kmawpresenceinandaroundtheareaformorethan10,500years.Mi’kmawpeopledependedonthelandfortheirsustenanceandassuchwereanomadicpeoplewholivedandtravelledthroughoutMi’kma’kiaccordingtothetimeofyearandtheseasonalpattern.Mi’kma’kiwasdividedintosevendistricts:Kespukwitk,Sipekni’katik,Eskikewa’kik,Unama’kik,EpekwitkaqPiktuk,Siknikt,andKespek.Consequently,inanefforttomaintainorderlyconductandgoodrelationshipsbetweenfamilies,travelthroughoutMi’kma’kiwasbasedonrespectforthosewhosehuntingterritoryonemaybetravellingthrough.
Source:http://www.danielnpaul.com
KespekLast Land
EpekwitkLying in the Water
Unama'kikLand of Fog
Eskikewa'kikSkin Dressers Territory
Aqq PiktukThe Explosive Place
Sipekne'katikWild Potato Area
KespukwitkLand Ends
SikniktDrainage Area
The Land of the Micmac
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L’nu (pluralLnu’k)istheself-recognizedtermfortheMi’kmaqofNewBrunswick,Newfoundland,NovaScotia,Quebec,andMaine,meaning“humanbeing.”
First Nation(s) isatermthatcameintouseinthe1970storeplacetheword“Indian,”atermthatmanypeoplefoundoffensive.FirstNationsreferstopeoplewhoarethedescendantsoftheoriginalinhabitantsofCanada.
Aboriginal means“existingfromthebeginning.”AboriginalpeopleincludeMétis,Inuit,andFirstNations,regardlessofwhethertheyliveinCanadaandregardlessofwhethertheyareregisteredundertheIndianActofCanada.
Indigenous PeoplesAccordingtoacommondefinition,theyarethedescendantsofthosewhoinhabitedacountryorageographicalregionatthetimewhenpeopleofdifferentculturesorethnicoriginsarrived.Itisestimatedthattherearemorethan370millionindigenouspeoplespreadacross70countriesworldwide,fromtheArctictotheSouthPacific.Practicinguniquetraditions,theyretainsocial,cultural,economic,andpoliticalcharacteristicsthataredistinctfromthoseofthedominantsocietiesinwhichtheylive.Thenewarrivalslaterbecamedominantthroughconquest,occupation,settlement,orothermeans(UNFactsheetonIndigenousPeoples).
Thereare13Mi’kmaqFirstNationsinNovaScotia,withcommunitypopulationsrangingfromabout240intheAnnapolisValleyFirstNationtoabout4,000intheEskasoniFirstNation.Intotal,thereareabout13,500registeredIndiansinNovaScotiaandofthese,around4,700liveoff-reserve.TheFirstNationpopulationismuchyoungerthanthegeneralpopulation,withamedianageof25.4versus41.6forthetotalpopulation.TheRegisteredIndianpopulationinNovaScotiaisrepresentedthroughaseriesof13bandcouncilsandtwotribalcouncils,theConfederacyofMainlandMi’kmaq,andtheUnionofNovaScotiaIndians.TheUnionofNovaScotiaIndianstribalcouncilrepresentsthefiveFirstNationcommunitieswithinCapeBreton(We’koqma’q,Wagmatcook,Membertou,Eskasoni,andChapelIslandFirstNations)alongwithtwoFirstNationslocatedinmainlandNovaScotia(IndianBrookandAcadiaFirstNations).Theremainingsixcommunities(BearRiver,AnnapolisValley,Glooscap,Millbrook,Paq’tnkek,andPictouLandingFirstNations)arerepresentedbytheConfederacyofMainlandMi’kmaq(N.S.OfficeofAboriginalAffairs,2011).
FirstNationspeopleinNovaScotia,includingyouthwhoareinneedofwithdrawalmanagementservices,relyoncommunityinitiatives,suchastherecentlyfoundedRedRoadProject,andprovinciallyfundedwithdrawalmanagementservicesofferedthroughtheDistrictHealthAuthorities.Asahealthservice,AddictionServiceshastheresponsibilitytodoalltheycantoensureaculturallyrelevantexperienceforallwhoentertheirprograms.Culturalsafetycanonlybedeterminedbytheclient,andachievingculturalsafetycomesastheresultofanongoingreflectiveprocess,notfroma
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singletrainingevent.Alllevelsofasystemmustbefullyengagedandopen.Culturalsafetyextendsbeyondculturalawarenessandsensitivitywithinservices.Itincludesreflectinguponcultural,historical,andstructuraldifferencesandpowerrelationshipswithinthecarethatisprovided.Itinvolvesaprocessofongoingself-reflectionandorganizationalgrowthforserviceprovidersandthesystemasawholetorespondeffectivelytoFirstNationspeople(NationalNativeAddictionsPartnershipFoundation,2011).
Cultural SafetyTheNationalNativeAddictionsPartnershipFoundation(NNAPF)hasproducedadocument,“WorkingwithFirstNation’sPeople:CulturallySafeToolkitforMentalHealthandAddictionsWorkersLiteratureReview.”Thistoolkitisgroundedina“CulturalHumility”framework(Eisenbruch&Volich,2005).In1998,MelanieTervalonandJannMurray-Garciacameupwiththeconceptofculturalhumility,whichisdefinedas:
alifelongcommitmenttoself-evaluationandself-critique,toredressingthepowerimbalancesinthepatient-physiciandynamic,andtodevelopingmutuallybeneficialandnon-paternalisticclinicalandadvocacypartnershipswithcommunitiesonbehalfofindividualsanddefinedpopulations.(p.117)
Sixsteppingstonesdescribeaprocesstowardsculturalsafetyandbuildupononeanotherwithafoundationofculturalhumility.
• ThefirststepisCriticalReflection,asocialtheorythatemphasizesself-reflectionandispertinentinculturalsafetybecauseunderstandingwhatonebringstotheenvironmentwilldevelopacriticalmindset(Pockett&Giles,2008).
• ThesecondstepisCulturalAwareness,whichaddressesthediversitywithineachclientandassistswithintegratingAboriginalandWesterntherapeuticpractices(Papps,2005).
• ThethirdstepisCulturalSensitivity,whichconstitutesarecognitionthattherearedifferencesbetweencultures(Chandler,2002).
• ThefourthstepisCulturalCompetence,whichisaprocessthatthehealth-careworkergoesthroughtoachieveaculturallysafeenvironmentfortheclient(IPAC-RCPSC,2009).
• ThefifthstepisReciprocity,amoraltheorythatFirstNationspeoplevalue.Itis“theoutlineofournon-voluntarysocialobligations—theobligationsweacquireinthecourseofsociallife...examplesincludesomeofourobligationstoourfamilies,tofuturegenerations,andtoobeythelaw”(Becker,1990).
• ThesixthstepisCulturalSafety.Itisimportanttolocateculturalsafetywithinthecontextofcross-culturalrelationships,betweenAboriginalservicereceiversandnon-Aboriginalservicedeliverers,andtoconsiderhowtheconceptsaffectrelationships,powerstructures,andtrust.Culturalsafetycanbeviewedasanoutcomedeterminedbytheclient,whereculturalcompetenceisonecomponentachievingculturalsafety(Brascoupé,2009).Culturalsafetyisalsocreatedby
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environmentalfactorssuchashealth-careenvironmentsthatpromotehealthwithculturallyspecificattention—healthenvironmentsthatmakespaceforculturalformsofprayer,includingtheuseofsmudging,theroleofelders,orroundroomsforculturalpractices,ordisplaynative-specificartworkthatpromoteshealth.Anothercontributingfactorincreatingculturalsafetyishavinghealth-carepoliciesthatfacilitatethedeliveryofhealth-careservices,e.g.,policiesthatincludetheroleofeldersandculturalspiritualpracticesaspartofamulti-disciplinaryapproach(IPAC-RCPSC,2009).
TheNNAPFCulturallySafeToolkitsummarizeswhatisnecessarytobeskilledinpracticesofculturalrespectandworkeffectivelywithFirstNationscommunities.Ahealth-careprovidermust:acknowledgeone’sculturalpractices,individualbehaviours,andinstitutionalaffiliations,andtheimpactthattheymayhaveonFirstNationspeople;
• understandandacknowledgetheimpactofcolonialismonFirstNationspeople;
• learnaboutFirstNationspeople’sdiverseculturesandtheirvaluesandbeliefs;
• actdifferentlyfromourusualculturalpreferredwaysinordertorespondtotheissueswehavelearnedabout;
• takeinitiativetocreateculturalsafety;and
• continuouslyreviewandbeopentodirectandindirectfeedback.
African Nova ScotiansThissectionusesterminologyinformedbythesocialworkresearchpublishedinRaceandWellbeing(Benjaminetal.,2010).Theterm“AfricanCanadian”isusedtorefertoallpeopleofAfricandescentlivinginCanada,regardlessoftheirplaceofbirth.Thistermisusedinterchangeablywith“BlackCanadians”and“Blackpeople”;somecomparisonsaremadetocircumstancesinAfrican-Americancommunitiesaswell.In2001,Canadian-bornBlacksmadeup90%ofallBlacksinHalifax,comparedto45%inCalgaryand40%inToronto.Anestimated20,000BlackpeopleliveinNovaScotia,withabout13,000ofthemlivingintheHalifaxCensusMetropolitanArea(CMA).BlacksalsoconstitutedthelargestracialminoritygroupinHalifax.While7%ofthepopulationidentifiedasaracialminority,52%ofracialminoritiesidentifiedasBlack(Benjaminetal.,2010).ThepopulationgrowthofAfricanNovaScotiansbetweenthe1996and2002censuses(8.6%)indicatesanincreaseintheyoungerpopulationprofile.(McNiven,CanmacEconomics,JozsaManagementandEconomics,&DavidSableandAssociates,2006).
Liketheirurbancounterparts,AfricanNovaScotianslivinginruralandremoteregionsencounterseriousculturalbarrierstoappropriatehealthcare,butincontrasttourbanpeopleofAfricandescent,theirsituationiscompoundedbygeographicisolation.Evenwhentheyhavethefinancial
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andsocialresourcestoaccesshealthservices,theymaynotfindculturallysensitiveproviders,programs,orfacilitiesavailablewithinareasonabledistance(Lawrence,2000;Etowa,Bernard,Oyinsan,&Clow,2007).
Forcedrelocation,politicaldisenfranchisement,inadequateaccesstoeducation,andtheapprehensionofracializedchildrenbyWhitechildwelfareauthoritiesarehistoricalsourcesofstressandcommunitytraumathatcontinuetoimpactBlackcommunitiesandtheirexperiencesofassessmentandtreatmentbyaEuropeancolonialhealth-caresystem.
TheseexperiencesaredocumentedashistoricallyimpactingBlackcommunitiesinNovaScotia.IntergenerationalimpactsaretracedwithinAfricanNovaScotiancommunities,whoseresidentsaredescendedfromslaves,freepeoples,BlackLoyalists,andhistoricalmigrationsofBlackpeoplefromJamaicaandtheUnitedStates.ThesefamilieshavebeeninNovaScotiaforover400yearsandexpressarangeofregionalandnationalaffinity,identifyingas“BlackNovaScotians,”“African-Canadians,”“indigenousBlacks,”and“peopleofAfricandescent.”Thispopulationhasuniqueintergenerationalexperiencesofsettlementand“citizenship”thatdiffersfromBlackpopulationsmigratingmorerecentlyfromAfricaandtheCaribbeanwhomayalsoidentifyasAfricanCanadians.
FortheseAfricanCanadianyouths,theprocessofgrowingupinaWhite-dominatedsocietycanbeseenasaprocessofbeing“othered”—ofbeingputoutsidethedominantgroup.AfricanCanadianyouthstestifythatevenwhentheyareCanadian-born,theyarerepresentedbythedominantcultureasnot“belonging,”asnot“really”Canadian(Kelly,1998).Inhereducationalmonograph“UndertheGaze,”JenniferKelly(1998)refersto“racialization”as“givingracedmeaningstosocialsituations.”Kelly’sworkfocusesonhowracializedCanadianyouthformconceptsofBlackidentityinpredominatelyWhitesecondaryschools.HerworkisrelevanttothehistoricallyinfluencedmeaningsgeneratedininteractionsbetweenAfricanNovaScotianyouthandstate-runadolescentwithdrawalmanagementservices.
Approaches to TreatmentAcriticalexaminationofblackculturaltraditionsandtherealitiesofinnercitylivingareimportanttoconsiderinforminganunderstandingofsubstanceabuseinthispopulation.Researchandtreatmentthatlacksthisperspectiveislesslikelytoidentifykeyinterventionsforprimary,secondary,andtertiaryprevention.(Britt,2004,para19)
Specificdominant-culturestereotypesaboutBlackyouthhavehistoricallydefinedethnocentricandclassprivilegedapproachestakenbyEuropeanhealth-careprofessionalsinthecolonialcontextofCanada(Capell,Dean,&Veenstra,2008).Theseracistcategorizationsareimportanttonameandchallengeastheyimpactclinicalpractice.Orientaliststereotypesaboutwild,primitive,risky,andruthlessbehaviourbeingexpectedinBlackyouth(Bass&Kane-Williams,1993)representaformofjudgementalvictim-blamingreproducedbyconcernedyetinsensitivehealth-careprofessionals.Discriminatory,culturallyinadequatehealth-carepractices,drugenforcementpolicy,andracializedpolicing(Comack,2012)combinetomarginalizeBlackcommunities,andtheyarefactorsindeterminingwhenandifBlackyouthaccessaddictionsandmentalhealthservices.
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HistoricalimpactsofmistreatmentwithinWhite-dominatedinstitutionalsettingsisafactorinBlackcommunityhealthpractices,whichmaypursueformal“care”onlyasafinaloptionwhenalternativeinformalapproacheshavebeenexhaustedandahealthchallengehasreachedanacutestage.Thisself-determinedapproachtocaremaybeviewedasirresponsiblebyhealth-careprofessionalswhodonotunderstandthehistoricalforcesandalternativeagencythatresultsinprevalenceoflate-stageinterventionsinhealthconcernsofmarginalizedpopulations(Etowaetal.,2007).
Drugandalcoholaddictions,manifestingasself-medicationforintergenerationalpost-traumaticstress,intersectwithundergroundeconomiesofdrugtrafficking,sexualexploitation,andcrime(Duran&Duran,1995).
ManyAfricanAmericanshavebeensubjectedtoviolenceasaprimaryoppressor,whichrobsthecommunityoftheresourcesneededtosolvedrugproblems.Violencedoesnotonlypresentintheformofcrimeordomesticdisputesbutalsointhecontextofracialdiscrimination,lackofaccesstofoodandclothing,homelessness,overcrowdedlivingconditions,lackofhealthinsurance,andrestrictedsocialwelfarepolicy.Blackwomenhaveexperiencedotherformsofviolence,suchassexualharassment,genderdiscrimination,andalackofprotectionfromdomesticviolence(Britt,2004,para9).
Thisinheritedpresenceofcriminalizedpoverty,policebrutality,childprotectionintervention,genderedviolence,anddrug-relatedviolenceinthelivesofAfricanNovaScotianyouthmustberecognizedbyhealthpractitionersasanaffectivefactorandasocialdeterminantofhealth.Whensocialserviceandcareworkerspresumesecurityofperson,securityofidentity,andsecurityofcollectiveaffinity,theyriskimposingameritocraticworldviewthatrendersracialinequalityinvisible.Acriticalviolence-informedapproachcancontextualizeobservedtraumaincolonialsettings.PovertyanditsaccompanyingdeterminantsofhealtharenotinherentoressentialelementsofAfricanNovaScotianyouthexperience;however,acknowledgingtheclass,national,religious,gender,sexual,andculturaldiversitiesofAfricanNovaScotiansisacriticalpartofapplyingatransculturalapproachthatresistsrestrictivedefinitionsofracializedgroups.
Intermsofidentity,community,spirituality,andpersonaltransformation,spiritualityplaysanimportantroleincommunitylifethatimpactsyoungpeople’savenuesforsupportandmotivation.Spiritualityisoften,butnotnecessarily,affiliatedwithreligiousinstitutionsandisawell-documentedfactorinrecovery:
Researchhasshownthatintegrationofculturallyspecificfactorssuchasspiritualityintotreatmentofsubstanceabuseisconsistentlyassociatedwithbetteroutcomesandlowerratesofrelapse.Itcanhelpnegatethehardshipsinthelivesofsubstanceabusers,which
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oftenareprecursorstoaddictionandcausesrelapseforpatientsinrecovery.Inaddition,spiritualitycanhelptreatculturalpain,whichisanemotionthatisexperiencedbyapersonwhoisamemberofaracial,ethnic,orreligiousgroup,particularlyonethathassufferedoppression.(Britt,2004,para.20)
AclearcommitmentofsupporttoindividualandcollectivesovereigntyforBlackpeople,aswellassensitivitytopastandpresentmanifestationsofracistcolonialviolence,arekeyprioritiesforhealthpractitionersworkingwithBlackyouth.
SocioeconomicconsiderationsareeminentdeterminantsofAfrican-Americandruguse.ExpertsonsubstanceabusedisordersagreethatpovertyandothersocioeconomicfactorshaveagreatimpactontheprevalenceofsubstanceabuseintheAfrican-Americancommunity.A1992studyidentifiedpoverty,illiteracy,limitedjobopportunities,pooreducation,highavailabilityofdrugs,andstressesoftheurbanlifestyleasunderpinningsofsubstanceabuseintheblackcommunity.Otherresearchershavefoundthatenvironmentalfactors,suchasthelargenumberofliquorstoresinAfrican-Americancommunities,influencetheheavyuseofalcoholamongBlackAmericans.(Britt,2004,para.8)
Therangeofconnectionsbetweenpersonal,collective,professionalized,andspirituallytranscendentapproachestohealingculturallysensitiveresearchperspectivesandtreatmentoptionsisthekeytoclosingthegapofsubstance-abusedisparitiesintheBlackcommunity.
Migrant YouthImmigrants,refugees,anddisplacedpeoplesmigratetoNovaScotiafromavarietyofcountriesaroundtheworld.Thedemographicsandregionalsourcesofnewcomersareconstantlyinfluxandareconnectedtodisplacingfactorssuchashumanrightsabuses,aswellasgeopoliticalforcessuchaswar,naturaldisasters,andeconomiccrises.Asthesourcecountriesofimmigrantsshiftwithglobaleventsandtrends,addictionsandmentalhealth-careworkersmustcontinuallycultivateatransculturalpracticethatvalidatestheexperiencesandstrugglesofimmigrantsandrefugees.Furthermore,establishedpreviouswavesofimmigrantswillhaveadifferentsetofcareneedsthanrecentnewcomers.
Whencaringforimmigrantpatientsofminoritylanguageandculturalbackgrounds,theriskofmakingamistakecanbecompoundedininstanceswhere,becauseoflanguageandculturalbarriersbetweentheprovidersandtherecipientsofhealthcare,criticalinformationaboutapatientisnotobtained.Ethnicstereotyping,ethnocentrism,bias,anddiscriminationcanalsocontributetounsafepatientcare.(Johnstone&Kanitsaki,2012,p.1314)
Theselectivesettlementofaparticulardemographicofimmigrants,refugees,andnon-statuspeoples,determinedmainlybythepoliciesofthefederalgovernment,createsacomplexwebofculture,bureaucracy,andhealth-caresituations.NewyouthandfamiliescomingtoCanadafacemanyculturaldifferences,languagebarriers,andnewsystemsandpoliticalstructures(Garza,2007;McCrearyCentreSociety,2011).ChuiandRing’s(1998)researchstatesthat:
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programsaimedatimmigrantyouthshouldtakeaccountofwhetheryouthareinthecountryintentionallyorasaresultofbeingforcedtoleavetheircountryoforigin(e.g.duetowarorfamine).Refugeeyouthhaveoftenhadlittleornopreparationforlifeintheirnewcountry,whereasimmigrantswhohaveplannedtheirarrivaloftenhaveaccesstoestablishedfriendsorfamilyandmoreEnglishlanguageskills.(p.20)
Iffamiliesorindividualshavesettledinaregionwheretheyareconnectedtoanestablishedcommunityofsimilarlanguageandculture,thereisarangeofsupportsandfactorsthatarebestunderstoodthroughthelanguageofthecommunity.Addictionsservicesstaffmustacknowledgeandvalidatethelanguageanditsassociatedculturalconnectionforthecommunity;translationservices,includingtele-translatingservices,arevaluabletoaccess,asusingcommunitymembersorchildrenasdefactotranslatorscompromisestheclient’srighttoconfidentialitywithintheirnewcommunity.
Incontextsinvolvingthehealthcareofimmigrantpatientsofminoritylanguageandculturalbackgrounds,theriskofthingsgoingwrongcanbedisproportionatelyhighcomparedtopatientswhoselanguageandculturearecongruentwiththemajoritypopulationandhealth-serviceproviders.Despitethisimbalance,immigrantdisparitiesinpatientsafety(morecommonlyreferredtoas“ethnicdisparitiesinpatientsafety”)havereceivedrelativelylittleattentionintheinternationalpatientsafetyliterature.(Johnstone&Kanitsaki,2012,p.1313)Khadka,Yan,McGaw,andAube(2011)alsohighlightthat,whilerefugeesmakeupabout10%ofCanada’snewcomers,theyfacethemostbarrierswhensettlinginCanadaduetotheirpreviouslifeexperiences.Thisprocessisparticularlychallengingtoyouth,astheymayhavelefttheirfamiliesandexperiencedseveretraumainthemigrationprocess.MetropolisBritishColumbiamakesreferencetoHyman,Vu,andBeiser’s(2000)studyonSoutheastAsiannewcomeryouthtoCanada,wheretheydiscloseddifficultyadjustingtotheirnewschool,feelingsofbeingmarginalized,andinternalconflictwithopposingvalues.Similarly,AnisefandKillbride(2009)foundthatnewcomeryouthinCanadahaddifficultyfollowingnewrulesandauthority;lowlanguageproficiencyresultedinloweracademiclevelsandfrustration;andbothmalesandfemales“feltpressuretodressfashionablyasdefinedbytheirCanadianpeers”(p.14).Thispeerpressure,alackofinclusivenessinmainstreampeerculture,andtheaccumulatedstressesofsettlementgenerateuniquevulnerabilitiestoaddictions.Itisacknowledgedthatsubstanceuseproblemsamongminoritygroupsmaynotbereportedduetoculturalfactors,asthereisasetofbeliefswithinmanyethno-culturalminorityculturesthatdiscouragestheacknowledgementandexplorationofalcohol-anddrug-relatedproblems.Manyculturaltraditionsfavouryouthreceivinghelpfrominformalnetworksratherthanfromformalcommunitystructures.Lowreportingnumbersmayalsobearesultofalackofsensitivityandcross-culturaltrainingforserviceproviders,thepresenceofracisminmainstreamservices,andalackofculturallyappropriateservices(HealthCanada,2001).ThedominantculturesofCanadianyouthprogrammingmaybeunfamiliartonewcomerfamilies,andcanresultinalackofinterest,andevendistrustandfearofparticipating,inyouthprogramming(Garza,2007).TheMcCrearyCentreSociety
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(2011)highlightsworkbyKeleher&Armstrong(2005),inwhichtheysuggestthatanyprogramthataimstoworkwithimmigrantyouthneedsto:
• identifypopulationgroupsofinterest;
• workinpartnershipwithlocalrefugeeorculturalcentresandcommunityleaders;
• ensurehighlevelsofcommunityengagementwithallstakeholders;
• establishsocialarenasthatbuildconnectionandtrustinmulticulturalcontexts;and
• becomesustainablebyensuringprocessesforskillsdevelopment,establishingongoingsupportmechanisms,changingcommunityattitudes,andcreatingconnectionsthatdidnotpreviouslyexist.
Garza(2007)highlightssomekeypointsforstaffmemberswhowillbeworkingwithimmigrantyouth:
• Beawareofthedemographicsofthechangingpopulationsintheirlocalcommunity.
• Knowaboutspecificcircumstancesandconditionsofthehomecountriesofimmigrantyouth.
• Understandandrespectculturalnormsoflocalimmigrantyouth.
• Remainopen-minded,empathic,andresourceful.
• Supportyouth,whilemaintainingstrongconnectionstofamilyandlocalcommunity.
Lesbian, Gay, Bisexual, Transgendered, and Questioning YouthLesbian,gay,bisexual,transgenderandqueer(LGBTQ)youthexperiencealltheusualchallengesofadolescencecombinedwiththeaddedchallengesofholdinganidentitythatrelegatesthemtoapositionofminorityinasocietythatvaluesconventionality.Asaresult,LGBTQyouthoftensuffertheeffectsofdiscrimination,ignorance,andhateastheytrytoaccept,assert,andintegratetheiridentities.WorkingeffectivelywithLGBTQyouthrequiresanawarenessofLGBTQyouth,comfortwiththelanguageofidentity,andknowledgeoftheiruniqueissuesandchallenges.
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Homophobia, Transphobia, and HeterosexismLGBTQyouthareasociallymarginalizedgroup,susceptibletohigherlevelsofaddictionandmentalhealthchallengesduetothenegativeanddamagingeffectsofdiscriminationandisolation.Thisoftencomesintheformofhomophobia,transphobia,andheterosexism.MostLGBTQyouthwillexperiencevaryinglevelsofthese,notonlyastheygrowupbutthroughouttheirlives.Itisbecauseofthedamagingeffectsofhomophobia,transphobia,andheterosexismthatLGBTQyouthfindthemselvesoverrepresentedinratesofsuicide,self-harm,homelessness,andsubstanceuseandabuse.Homophobiaandtransphobiaarethemoreovertanddiscriminatorybehavioursthatoftencomefromfear,hatred,andignorance.LGBTQyouthexperiencehomophobiaandtransphobiathroughviolence,name-calling,rumours,harassment,andrejection.Thiscanoccurintheirschools,theircommunities,andtheirownhomes.
Heterosexismistheunderlyingsocietalassumptionthatheterosexualityissuperiorandcelebratedandthatanythingelseisinferior,wrong,ornon-existent.Itisingrainedinoursystemsandinstitutionsandcanbemoresubtleandhardertoidentifythanhomophobiaandtransphobiabecauseitisaboutassumptions.LGBTQyouthexperiencetheeffectsofheterosexismthroughabsencefromcurriculum,limitedidentityoptionsonforms,andassumptionsaboutfamilyandrelationships.Understandingtherolethathomophobia,transphobia,andheterosexismplayinthelivesofLGBTQyouthisvitaltoprovidingqualityandcompetentcare.
InthreerecentCanadianreports,LGBTQyouthshowedhigher-than-averagechallengesinfeelingacceptedandsafe.Inanationalschoolclimatesurvey(Tayloretal.,2008),threequartersofLGBTQstudentsreportedfeelingunsafeatschool,with95%oftransgenderyouthreportingfeelingunsafe.OverhalfofLGBTQstudentsfeltthattheywerenotacceptedatschoolandcouldnotbethemselves.TheNovaScotiaTaskForceonBullyingandCyberbullyinglistedLGBTQyouthasthemost-targetedgroup(MacKay,2012).TheNovaScotiaStrategicFrameworktoAddressSuicidelistsLGBTQyouthasoneofthetopthreegroupsatriskforsuicideinNovaScotia(ProvincialStrategicFrameworkDevelopmentCommittee,2006).Thesefiguresjoinpreviousandcurrentresearchpapersthatdocumenthighlevelsofhomelessness,schoolabsenteeism,self-harm,andsubstanceabuseamongLGBTQyouth(Darwich,Hymel&Waterhouse,2012;Eliason,2010;Green&Feinstein,2012;Lombard&vanServellen,2000;Marshaletal.,2008).
Sexual Orientation versus Gender IdentitySexualorientationandgenderidentityareoftenconfusedorcombined.However,theyaretwoseparateaspectsofouridentity.Oursexualorientationisaboutourattractionsandaffections;ourgenderidentityisabouthowweseeourselves—asmale,female,both,neither,orsomewhereinbetween.Eachoneofushasagenderidentitythatisseparatefromoursexualorientation.Onedoesnotrelyontheother.ItisimportanttounderstandthedifferenceinordertoensurethatLGBTQyouthgettheinformation,support,andunderstandingthatisrelativetotheiridentities.OftenmythsandstereotypesthatsurroundLGBTQpeople(e.g.,themythsthatgaymenwanttobewomenor
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thatmostaremorefeminine)causeconfusion.Thissetsupanexpectationthatsexualorientationhassomethingtodowithone’sconceptofgender,andoftentransgenderyoutharemistakenforlesbianorgayyouth.However,transgenderyouthmayormaynotbelesbian,gay,bisexual,orqueer,justasLGBQyouthmayormaynotalsobetransgender.TransgenderyouthandLGBQyouthhavesomesimilarexperiencesbutalsoverydifferentones.Itisimportanttoaddressbothpopulationsandnotassumethataddressingonewilladdresstheother.
LGBTQ Youth and AlcoholThereislittleresearchavailableonLGBTQyouthandalcohol,andpracticallynoresearchavailableontransgenderyouthonanyissue.Withregardtotheresearchthatisavailable,therearesomeproblemsthatstemfromthechallengeofidentifyingandreachingthispopulation,theinconsistentwaythatalcoholuseandabuseisdefined,andthesmallsamplesizes(CenterforSubstanceAbuseTreatment,2001).SomestudiesshowthatthereisagreaterprevalenceofalcoholuseamongLGBTQyouththantheirheterosexualpeers;othersshowthatuseisonparwithheterosexualpeers(CenterforSubstanceAbuseTreatment,2001;Green&Feinstein,2012;Marshaletal.,2008;Rosario,Scrimshaw,&Hunter,2009).However,thereissomesupportforthehypothesisthatregardlessofhigherlevelsofuse,LGBTQyouthusealcoholfordifferentreasons.LGBTQyouthoftenusealcoholbecauseofpersonalshameorstigma,todenytheirsame-sexfeelings(LGBQ)orgenderconflict(T),orasawayofcopingwiththenegativeeffectsofhomophobia,transphobia,andheterosexism(CenterforSubstanceAbuseTreatment,2001;Darwichetal.,2012;Marshaletal.,2008).
LGBTQ Youth and Health CareOneoftheeffectsofhomophobia,transphobia,andheterosexismonLGBTQyouthisagenerallevelofself-protectionanddistrustinothersandinoursystems,especiallyoureducationandhealth-caresystems.Asaresult,LGBTQyouthoftendonotaccesshealthservicesexceptinemergencies,ortheyaccessservicesbutareuncooperativeordonotdisclosetheiridentitiestohealthservicespersonnel.Thefearofexperiencinghomophobiaandtransphobiaorthefearofhavingtodiscloseone’sidentityisalargebarriertoaccessingservices(Lombardi&vanServellen,2000).Alcohol-andsubstance-abuseprogramsandservicesarenoexception.Inonestudy,resultsshowedthat50%oftransgenderindividualsreportedtheydidnotseektreatmentforanaddictionissuebecauseoffearofananticipatedtransphobia.Anothersignificantpercentagestatedtheydidseektreatmentbutdidnotdisclosetheiridentity(Nuttbrock,2012).
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Disclosure/Coming OutOneoftheexperiencesuniquetoLGBTQyouthistheprocessofcomingout—disclosingone’ssexualorientationand/orgenderidentitytoothers.Thisisoftenasignificantseriesofeventsthatcanbemarkedbybothanincreaseandadecreaseinanxietyandfear.FormanyLGBTQyouth,comingoutcanbeareliefandanopportunitytogainsupport,betruetothemselves,andbefreefromthechallengesandnegativeeffectsofhiding.Forothers,comingoutcanleadtorejection,anintroductionoforincreaseinvictimization,andsocialisolation.ComingoutcanbebothariskandarewardforLGBTQyouth,anditissomethingtheyoftencontrolveryclosely.Inanenvironmentthatseemshomophobic,transphobic,orheterosexist,youtharelesslikelytodisclosetheiridentities.InordertoprovidesensitiveservicestoLGBTQyouthitisimportanttounderstandthesignificanceandchallengesofthecoming-outprocessandhowthataffectstheLGBTQindividual.Itisalsoimportanttounderstandthechallengesofnotcomingoutandthereasonsbehindit(Rosario,Scrimshaw,&Hunter,2009;Tayloretal.,2008).
Oneofthebarriersorfearsregardingcomingoutistheworrythattheinformationwillbespreadbeyondthecontroloftheindividual.Confidentialityisoftheutmostimportanceinordertogainandmaintaintrust.Youthwhohavebeen“outed”areoftenatagreaterriskforsuicide,anxiety,andotherriskfactors(Bakker&Cavender,2003;Rosario,Hunter,&Scrimshaw,2009;Tayloretal.,2008).ManyLGBTQyouthwilltrytocontrolwhoknowstheiridentity,sotheymaybeouttofriendsbutnotfamily,orvice-versa.ItisimportantnottoassumethatbecauseanLGBTQyouthisoutinoneaspectoftheirlivesthattheyareoutinallaspectsoftheirlives.Understandingwheresomeoneisinthecoming-outprocesswillgivehealth-careprovidersabetterpositionwithwhichtoofferservices.
InvisibilityOneofthemostcommon,yetofteneasilymended,barrierstoaccessinghealthcareisinvisibility.Thisisoftentheresultofuncheckedheterosexism,suchastheabsenceofmorethantwochoicesforgenderonforms;intakequestionsthatassumeheterosexuality;pamphlets,magazines,orpostersinwaitingareasthatdonotpresentimagesofLGBTQpeople;andpoliciesthatexcludesexualorientationorgenderidentity,tonameafew.
Havingwell-trained,supportivestaffandinclusivepoliciesmaynotbeenoughifLGBTQyoutharen’tawareofit.LGBTQyouthwhodon’tseethemselvesrepresentedwillmostlikelydefaulttoapositionwheretheybelievetheyarenotwelcome.SomeLGBTQyouthmaybeinaplacewheretheyaretooafraidtodisclosedespitethemessagesofacceptancearoundthem.Thisisaresultofthepervasiveandpowerfuleffectsofhomophobia,transphobia,andheterosexismthathaveshapedtheirlives.
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Transgender YouthTransgenderyouthsharesomesimilaritieswithLGBQyouthbuthavemanyuniqueissues.WhileLGBQyouthcanmoreeasilyhidetheiridentitiesevenaftertheyhavedisclosed,transgenderyouthcanbeidentifiedthroughtheirnameorpronounchangeorthewaytheydress.Thiscanoftenmakethemtargetsfortransphobia.Transgenderyouthmayalsobeinthementalhealthsysteminotherwaysiftheywishtoaccesshormonesorsurgery.Theirexperienceswiththehealth-caresystem,whethergoodorbad,willshapeanyfutureexperience.InNovaScotia,transgenderyouthhavelimitedaccesstohormonesandsurgeryoptions.Asaresulttheyrelyonthethingstheycancontrolinordertoexpresstheirgenderidentity:clothes,hair,accessories,pronouns,andnames.Tuckingandbindingaretwowaysthattransgenderyouthshapetheirbodiestomatchtheiridentities.Eachcanbeharmfulifnotdoneproperlybutareoftenessentialtotheirbodyimage.Itisimportanttolearnmoreabouthowtransgenderyouthexpresstheiridentitiesinordertoproviderespectful,relevant,andcompetentcare.
Cultural Competency and LGBTQ YouthWhenworkingfromaculturalcompetencymodel,itisimportanttoensurethatLGBTQpeopleareincludedinthedefinition.Oftencultureisseenasencompassingreligious,racial,orethnicgroupsbutnotpeoplewithdisabilitiesorLGBTQpopulations.Therearesomedifferencesinthesegroupswithregardtohowcultureisdefined,buttherearealsosimilarities.WhileLGBTQpeoplesharesimilarexperiencesthatshapetheiridentities,theLGBTQcultureisoftenhidden.LGBTQyoutharenotbornintoaculturethatislinkedtotheirfamilyoforiginorgeographiccommunity.Thismakesitchallengingtothosewhodon’tknoworhaveaccesstootherLGBTQpeople.Thestigmaandmarginalizationthatisbroughtonbyhomophobiaandtransphobiaisoftennotsharedbyothersintheirfamily(Bakker&Cavender,2003;CenterforSubstanceAbuseTreatment,2001).
Things to consider in a cultural competency model for LGBTQ youth:
Accessibility• AcknowledgethatLGBTQyouthexistandmayneedtreatmentforalcohol-relatedissues.
• ProvidevisibilitytoLGBTQyouththroughlanguage,posters,writtenmaterials,andpolicy.
• EnsurethatstaffaretrainedandknowledgeableonLGBTQyouthissues.
• BefamiliarwiththelanguageyouthareusingaroundLGBTQidentities.
• Understandtherolethathomophobia,transphobia,andheterosexismplayinthelivesofLGBTQyouth.
• Createsafeandwelcomingenvironmentsthatarefreefromharassmentandjudgment.
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Modalities• Considerthecomfortlevelanddisclosureinanygroupprograms.
• EducateotherclientsaboutLGBTQissues,andchallengehomophobiaandtransphobia.
• Challengelanguageandstereotypes.
• Ensurethatconfidentialityismaintainedandrespected.
• ConsiderthelevelofdisclosurethatanLGBTQyouthmighthavewiththeirfamilies.
• ConsiderthatfamiliesmaynotbesupportiveofLGBTQidentities.
Continuum of care• Beknowledgeableofcommunityresources.
• Knowwhatsupportisavailableforhelpwithidentitydevelopment,comingout,ordealingwithhomophobiaortransphobia.
• RecognizethatLGBTQyouthmayhavelimitedsupportsystems,andworktostrengthenthem.
• Recognizethevalueofrolemodels.
Coming out• Recognizeandunderstandthesignificanceofcomingout.
• DeterminewhereLGBTQyouthareinthecoming-outprocess.
• Beawareofboththerisksandrewardsofcomingout.
• KnowwhattodoifanLGBTQyouthcomesouttoyou.
Gendered programs and spaces• Ensurethatprogramsthatseparateclientsbygenderallowtransgenderyouthtoaccessthe
programoftheiridentifiedgender.
• Ensure,inresidentialprograms,thattransgenderyouthhaveaccesstowashrooms,showers,andsleepingarrangementsthatcorrespondtotheiridentifiedgender,orareotherwisesafe.
• Ensurethatstaffandotherclientsrespectaccesstothosespacesfortransgenderclientswithoutdisclosingatransgenderclient’sstatus.
• Ensurethatthereisapolicyinplacetoprotecttransgenderyouth.
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Hormones • Ensurethattransgenderyouthonhormonesareabletoaccesstheirmedicationwhenneeded.
• Considertheconsequencesofalcoholwithdrawalandtreatmentforthoseonhormones.
• Understandthetransitionprocessfortransgenderyouth,anddeterminewheretheymaybeinthatprocess.
Dress codes• Ensurethattransgenderyouthcandressandpresentthemselvesasthegendertheyidentify.
• Ensurethatstaffdresscodesallowtransgenderstafftodressastheyidentify.
• Pronounsandnames
• Respecttransgenderyouthbyusingthepronounandnamepreferencetheyidentify.
• Ensurethatthereisapolicyinplacetoaddressnamesandpronounswhennolegalchangehasbeenmade.
• Checkwithtransgenderyouthonwhentousetheirpreferrednameandpronounandwhennotto.
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GlossaryComing Outwhenapersonwhoislesbian,gay,bisexual,ortransgenderbeginstotellotherpeople,suchasfriends,family,co-workers,etc.Itisalife-longprocessandbeginswiththeacknowledgementtooneselfthatoneislesbian,gay,bisexual,ortransgender.
Bisexualapersonwhoisemotionallyandphysicallyattractedtobothmenandwomen.Thisdoesn’thavetobeanequalfeeling.Someonecouldbemoreattractedtomenormoreattractedtowomen,butfeelshe/shecanhaverelationshipswitheither.
Gaymenwhoareemotionallyandphysicallyattractedtoothermen.Oftengayisusedasablankettermtorefertogayandlesbianpeople.
Gender Identityourdeeplyfelt,internalsenseofbeingmaleorfemale,neither,both,orsomewhereinbetween.Thiscouldbebiological,emotional,andsociological.Homophobiathefear,hatred,andignoranceofpeoplewhoarelesbian,gayorbisexual.Homophobiaislinkedtoattributesandbehaviours.
Heterosexismthebeliefthatbeingheterosexualistheonlynormalandnaturalwaytobeandanythingelseisabnormal,unnaturalornon-existent.Heterosexismisinstitutional,andisaboutassumptionsandinvisibility.
Lesbianawomanwhoisemotionallyandphysicallyattractedtootherwomen.
Queerpeoplewhoarelesbian,gay,andbisexual.Althoughhistoricallyusedasanegativeterm,queeriscommonlyusedbythecommunity,theacademicworld,andthemediaasaninclusiveterm.Somepeoplewillalsoidentifyasqueer,preferringitoverotherlabels(LGBTQ),andwilluseitinapositiveway.
Sexual Orientationwhereourattractionslie.Whetherweareattractedtomen,women,orboth.Everyonehasasexualorientation.
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Trauma-Informed CareTrauma-informedservicesembedanunderstandingoftraumainallaspectsofservicedelivery(Poole,2012).Theyplacepriorityontraumasurvivors’safety,choice,andcontrol,andtheycreateatreatmentcultureofnon-violence,learning,andcollaboration.Incontrast,trauma-specificservicesdirectlyaddresstheimpactoftraumaandfacilitatetraumarecoveryandhealing.Trauma-informedpracticeaimstohelpindividualsmakeconnectionsbetweentheirexperienceoftraumaandsubstanceuseormentalhealthconcerns.Clientengagement,retention,andoutcomesimprovewhenservicesareemotionallyandphysicallysafe,providestrength-basedopportunitiesforlearningandbuildingcopingskills,andprovideclientswithchoiceandcontrol.
Researchfoundthattrauma-relatedsymptomsareelevatedamongyouthwithhistoriesofpotentiallytraumaticevents,andthatmanyoftheseyouthbelievedtheiruseofsubstanceswasconnectedtotheirhistoriesoftraumaticexperiences(Rosenkranz&Henderson,2009).Ithasalsobeensuggestedthattraumahistorymayaffectthedegreeandsourceofmotivationforaccessingtreatment,withpotentialimplicationsfortreatmentengagement(Rosenkranzetal.,2011).Knowingthatshamemaymotivatepeopletoenter,thoughnotnecessarilystayin,treatment,itwillbeimportanttoenhanceother,morepositiveformsofmotivationtoencouragepeopletocontinuetoattend.Thesefindingspointtotheimportanceofusingatrauma-informedperspectiveintreatmentservices.Inordertoberesponsivetoclients’needs,assessmentandtreatmentplanningmustbeconductedinatrauma-informedway.Theoverarchingprinciplesthatguideourassessmentandtreatmentplanning—creatingsafetyandempoweringyouth—reflectthistrauma-informedapproach,butalsorespondtotheneedsofyouthwhodonotreporttraumahistories.
TransgenderIndividualswhoarenotcomfortablewiththesexandgenderassignedtothematbirth(thiscanoftenbeproblematicforsomeone,andrangefromphysicaldiscomforttoseriousmentalhealthissueslikedepressionandanxiety).Torecognizethisspecificexperience,manywillself-identifyastransgender.Many(butnotall)transgenderpeoplewillundergomedicaltransitiontobringtheirbodiesintoalignmentwiththeirgenderidentity.
Transitionprocessthattransgenderpeoplegothroughtobecomemorecomfortableintermsoftheirgender.Transitionmayormaynotincludethingslikechangingone’snameandpronoun,takinghormones,havingsurgery,changinglegaldocumentstoreflectone’sgenderidentity,comingouttolovedones,dressingasonechooses,andacceptingoneselfamongmanyotherthings.Transitionisanindividualprocess.
Transphobia—thefear,hatred,andignoranceoftransgenderpeopleoranygendervariationandexpressionthatisseenasunconventional.
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Essence of trauma-informed servicesTrauma-informedservicesaresuccessfulwhentheyareembeddedintotreatmentservices,regardlessofthepopulationforwhomtheservicesareprovided(Rosenkranzetal.,2012).Whenworkingwithyouthinwithdrawalmanagementsettings,thefollowingcomponentsforacomprehensiveandtrauma-informedserviceshouldbeconsidered:
Empowerment in treatment planningTreatmentplanningisacollaborativeprocessbetweenclientandclinician,guidedbytheassessmentresultsandgivingconsiderationtotheclient’sinterestsandpreferences.Withinaharm-reductionframework,treatmentplansaimtocreatesafetyinthelivesofyouthandtoempowerthemtomakepositivechanges.
Involvement and control in goal-settingYouthareoftentold“whatisgoodforthem,”whatchangesthey“need”tomake,whattheirgoalsshouldbe,whattheirtreatmentplanshouldlooklike,andwhoshouldbeinvolvedintheirtreatment.Inrecognizingthatasignificantaspectofhealthydevelopmentforyouthwhoaretransitioningfromadolescenceintoadulthoodisincreasedautonomy,staffwillempoweryouthtocontributetothedevelopmentoftheirowntreatmentplans.Thisalsoallowsforthosewhohavehadlittlecontroloverpreviousexperiences(e.g.,trauma)tohavenewexperiencesinwhichthecontrolforthedirectiontheirliveswilltakeisplacedbackintheirhands.
Harm reductionHarmreductionandminimizingriskarecrucialinaddressingtheneedsofyouth.Choiceaboutfamilyinvolvement—Aspartoftreatmentplanning,youthareencouragedtoconsidertheextenttowhichtheywantfamilytobeinvolvedintheirtreatment.Includingfamilyintreatmentusuallyincreasesretentionandimprovestreatmentoutcomes,butforsomeyouthfamilymaybeasourceoftrauma.Itisimportanttoempoweryouthtomakedecisionsregardingfamilyinvolvementintheirtreatment,and,underguidanceoftreatmentstaff,todecidewhoisimportanttothemandwhomtheywouldliketoengageinthetreatmentprocesswiththem.
Choice in treatment optionsNon-traditionaltreatmentoptions,suchasmusic,art,recreation,andcookinggroups,shouldbeincludedinthechoicesavailabletoyouth.
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Making connections between trauma and current coping strategiesYouthwithtraumahistoriesoftenengageinriskybehaviours,includingexcessivesubstanceuse,self-harming,unhealthyeating,andinvolvementinemotionallyorphysicallydangerousinterpersonalinteractionsandrelationships.Assistanceinconnectingthecurrentbehavioursandfeelingsoftheseyouthtotheirpastexperiencescanhelpthemdevelopalternativeself-understandingthatisnotladenwithnegativejudgments.Thiscanhelpyouthtobeginmakingchoicesthatwillreducetheircurrentrisksandharms.Afocusonpractisingalternativecopingskillscanbeveryeffectiveinreducingrisksandharms.
Creating safetyCreatingasenseofemotionalandphysicalsafetyiscentraltotrauma-informedserviceprovision.Creatingasafeenvironmentisessential,asitwillconsiderfactorsthatmaybeuncomfortableordistressingforyouthandmitigatethepotentialfortreatmenttobetraumatizingorre-traumatizing.Considerationsincludeusingrespectfullanguage,clarifyingyouthrightsandresponsibilities,payingattentiontoself-endangeringbehaviours,assessingeachclient’sreadinesstoengageingrouptreatment,consideringaspectsofthephysicalenvironment,andattendingtostaffsafety.
Levelling off power imbalancesToensurethatyoutharewell-informedaboutwhattheyareentitledtoandwhattheymayexpect,youthrightsandresponsibilitiesarediscussedwhenyouthentertheprogramandagainattheoutsetofthevarioustreatmentcomponents.Afocusonyouthrightsandresponsibilitiesacknowledgesandattemptstoaddressthepotentialimpactofpowerimbalanceanddynamicsinherentinatherapeuticenvironment.Attentionmustbepaidtoconfidentiality,language,respect,andotherstrategiesformaintainingsafety.
Expressing distress safelyThroughouttreatment,staffmustmakeitaprioritytoattendtoyouthdistressandself-endangeringbehavioursandtocheckinwithclientsregularlyregardingsafety.Safetyplansaredevelopedproactivelywithallyouthwhoareidentifiedtobeathighriskforsuicideorotherself-harmingbehaviour.
Treatmentplanningalsomustconsiderthevaryingbackgroundsandpresentationsofyouthandoffermodificationtocontentasappropriate.Groupcontentcanbeofferedindividuallyforyouthwhoarenotyetableorwillingtoparticipateingroups.Considerationsarealsomaderegardinggroupcompositionandtherapistgender-matching.
Lastly,inordertoprovidetrauma-informedandsensitiveservices,staffmembersrequireasafespacetoaddresstheirownissuesrelatedtoworkingwithachallengingpopulationwithcomplexneeds.
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Familiesareoftenthemostimportantresourcethatadolescentshaveintheirjourneythroughtreatment.Familycanplayakeyroleinsupportingandhelpingayouthachievehisorhergoals.Despitethisknowledge,familyengagementcontinuestobeachallengeinmanyadolescenttreatmentsettings.Someofthebarrierstofamilyengagementincludetheassumptionthatfamiliesare“theproblem”orthattheyarejustlookingforsomeoneelsetofindasolution.Someprogramswillindicatethattheydon’thavethestaff,time,orexpertisetoworkwithfamilies.Someprogramswillsaythatclientconfidentialitypreventsthemfrominvolvingfamily.Finally,anadditionalbarrierhasbeenthelimiteddefinitionandunderstandingofwhoconstitutesfamily.Familyshouldbedefinedbytheyouth,andmayormaynotincludetheyouth’sbiologicalfamily.Whomevertheyouthdefinesasfamilywillinfluencetreatmentplanningandtheroleoffamilyinthatplan.Further,whomevertheyouthdefinesasfamilywillaffectthekindofinvolvementthatfamilyhasinthetreatment.Itisimportanttounderstandthateachfamilysituationisdifferent;therefore,thewayinwhichafamilyisapproachedwillvarydependingonspecificcircumstances.
Theage,maturity,readinessforchange,andfamilyhistoryoftheadolescentwillalsoinfluencehowfamilyinvolvementtakesshape.Theseissuesmightnotbereadilyapparentthroughanearlyassessmentbutwillbecomesoastrustdevelops,astheadolescentbecomesmorestablethroughthewithdrawalprocess,andasstaffhavetheopportunitytodirectlyobservetheadolescent.Theexamplesdescribedbelowillustrateasmallsampleoffamilyscenarios.Onecannotmakeassumptionsaboutfamily;thereforeitiscrucialtoconductongoingassessmentstodeterminethemannerinwhichfamilyorconcernedsignificantothersneedtobeinvolved.
• 15-year-oldLuke:Heinitiallyrejectsinvolvinghisparentsbecauseheviewstheirattempttosetboundariesasbeingoverlyintrusiveandsaystheydon’ttrusthim.Hesayshehasthings“undercontrol.”
• 16-year-oldEmma:Herparentsfeeloverwhelmed,betrayed,andexhaustedfromtryingtodealwiththeirdaughter’ssubstance-abusingbehaviour—suspensionfromschool,triptoemergencyroomforaccidentaloverdose,andbrusheswiththelaw.TheyseeEmma’stimeinwithdrawalmanagementasanopportunityforrespite.
• 18-year-oldpregnantHolly:Holly,whoisaboriginal,hasbeenestrangedfromhermotherandhasspentthepastcoupleofyearscouch-surfing.Herpregnancyhasmotivatedhertoseekhelpforheraddictionandhasgotherthinkingaboutreconnectingwithhermotherbutshedoesn’tknowhowtogoaboutit.
• 17-year-oldJenna:Jennahasbeeninaseriousrelationshipwithapersonofthesamegenderandage.Thisindividualhasbeensubstance-freeforseveralmonthsandisinterestedinsupportingJennathroughthetreatmentprocess.
Family Involvement
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AddictionServicesprogramsmustrecognizefamiliesaspartofthesolutiontoadolescentsubstance-abusetreatmentandrecovery.Involvingfamilyandcreatingaparent-professionalcollaborativepartnershipwillimproveoutcomesfortheadolescent.
Programstaffsometimesthinkthatfamilyworkissynonymouswithfamilytherapy,butthatisnotthecase.Familyworkislikelytooccurinalltiersofaddictionsupportsandservices,whilefamilytherapyismorelikelytooccurasacomponentofStructuredTreatmentorintensiveCommunityBasedServices.Familytherapycallsforahighlyspecializedskillsetthatrequiresmuchclinicaltraining,experience,andongoingsupervision.Familyworkcanincludeawholerangeofactivities,fromrecognizingtheroleoffamilyintreatmenttoprovidinginformationtofamiliestoreferringthemtootherservices.Staffmustbeassessedforcompetency,comfort,andtrainingwithrespecttotheabilitytoprovidefamilyworkandfamilytherapy,andprogramsmustnotofferservicesbeyondtheskilllevelofstaff.
Withinthecontextofwithdrawalmanagement,alotcanbedonetoengagefamiliesinaneffectiveandappropriatemanner.Informationandeducationarekey.Itiscrucialthatfamiliesunderstandthetreatmentprocessandtherealityofrecovery.Withoutinformation,familiesmaynotunderstandtheimportanceofatreatmentandrecoveryplanfortheiradolescent,thepotentialadverseconsequences,andtheimpactofsubstance-abuseproblemsonotherfamilymembers.Familiesneedtobeawareofthecontinuumofservicesandsupportsavailable,andunderstandhowfamilyparticipationimprovestreatmentoutcomesandstrengthenstherecoveryprocess.Familyinvolvementshouldbeanessentialpartofintake,treatment,andrecoveryplanning,aswellasthefoundationforeffectiveparent-professionalpartnerships.
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Inthecontextofwithdrawalmanagement,thefollowingguidelinesshouldhelptodeterminetheleveloffamilyinvolvementandcorrespondingactivities:
• Involvingfamilyistheclinicalnorm.Letitbeknownupfrontthattheprogramisclient-andfamily-centred.
• Viatheclinicalframework,acknowledgethestrengthsthatfamilycanbringtothetherapeuticprocess.
• Workinginteamscanbeinstrumentalindeterminingthedegreetowhichfamiliesareinvolved.
• Asearlyaspossible,asktheadolescenttoidentifywhohe/sheperceivesastheirfamilyorsupportsystem.
• Whenfamilyinvolvementisnotindicated,clearlydocumentthereasonsintheclient’sfile.
• Explainatthestartthelimitationstofamilycontact/visitationduringthewithdrawalperiod.
• ConnectclientandfamilywithCommunityBasedServicesasearlyaspossible.
• Ensurethatallwithdrawalmanagementstaffhavecompetenciesthatenablethemtoworkwithfamilies—includingeducationandbasicsupportivecounselling.
• Addressfamilymembers’feelingsandprovidethemwithsupport.
• Makeanefforttomatchclinicalstaffandclients,basedonskillsandleveloffamilyinterventionrequired.
• Ensurethatprogramsandclinicalinterventionscreativelyengagefamilyintheyouth’streatmentprocess.Forexample,ifafamilycannotbepresentthenatelephonemeetingmightbeanappropriateoption.
• Incircumstanceswherefamilymembersarenotinitiallyinvolved,lookforfurtheropportunitiestoinvitefamilytoparticipateinthetreatmentprocess,e.g.,otheraffectedgroups,educationsessions.
• WorkcloselywithCommunityBasedServicestoensurethatwithdrawalmanagementstaffarenothavingtoworkbeyondtheirscopeandmeansinsupportingfamilies.
• Bewellacquaintedwithotherformalorinformalfamily-centredcommunityprograms,andbepreparedtoreferasnecessary.
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Fordecades,theconceptofresiliencehasbeenprovidingawaytounderstandyouth’spositivedevelopmentunderadversityandthefactorsandprocessesthathelpyouthavoidharmful,self-destructive,orantisocialbehaviours,mentaldisorders,andthreatstotheirphysicalwell-being.Resiliencehaslongbeenviewedbyserviceprovidersasakeyfactortohelpyouthwithsubstanceabuseandaddictionsdisordersrecoverfromandceasefutureuseandabuseofdrugsandalcohol(Dicksonetal.,2002;Hawkinsetal.,2002;Willsetal.,2008).Resilienceisviewedasacomplexsetofrelationshipsbetweentheyouth,family,community,andserviceproviderswhocometogethertohelpyouthnavigatesafelythroughtimesofadversityandtonegotiateforservicesthatmeetthespecificculturalandcontextualneedsoftheyouth.Resiliencehasbeendefinedthus:
Inthecontextofexposuretosignificantadversity,resilienceisboththecapacityofindividualstonavigatetheirwaytothepsychological,social,cultural,andphysicalresourcesthatsustaintheirwell-being,andtheircapacityindividuallyandcollectivelytonegotiatefortheseresourcestobeprovidedinculturallymeaningfulways.(Ungaretal.,2008,p.225)
Inordertofacilitateresilienceinyouth,theInternationalResilienceProject(aninternationalresilience-basedresearchproject,whichconductedextensiveresearchinAtlanticCanada),hasshownresiliencetobereliantonthefollowing:accesstomaterialresources;accesstosupportiverelationships;developmentofadesirablepersonalidentity;experiencesofpowerandcontrol;adherencetoculturaltraditions;experiencesofsocialjustice;andexperiencesofsocialcohesionwithothers(Ungaretal.,2008).Thesesevenfactorsofresilience(describedbelow)createasocialenvironmentthatprovidesmeaningfulculturalandcontextuallyspecificinterventionstoyouth,whichhelpsthemsuccessfullynavigatetheirwaythroughtimesofsignificantadversity(Ungaretal.,2008).
Access to resourcesAccesstomaterialresources,asUngaretal.(2008)defineit,istheyouth’saccessto“financialassistance,education,food,shelterandclothing,medicalcare,andemployment”(p.7).Numerousstudieshaveshownthatyouthwhohaveaccesstobasicnecessitiestypicallydemonstratemoreresiliencethanthosewhohavelimitedaccesstotheseresources(Beauvais&Oetting,1999;Nettles,Mucherah,&Jones,2000).Inawithdrawalcontext,Curryetal.(2007)haveshownthat,asexpected,youthwhohaveaccesstosmokingcessationprogramsarebetterabletoquitsmokingthanyouthwhodonotaccesstheseprograms.Santistebanetal.(2011)haveshownthatyouthwhohaveaccesstotherapyandcounsellingsessionsfordruguseand/orabusewereshowntohavehigherratesofdrugcessationthanyouthwhodidnothaveaccesstotherapyandcounsellingsessions.
Youth Resilience
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Access to support relationshipsUngaretal.(2008)statethatformingsupportiverelationshipswithothersoffersasenseofbelonging,emotionalsupport,andfeelingsoflove,compassion,andtrusttoyouthwhohaveexperienced,orarecurrentlyexperiencing,trauma.Theserelationshipsarenotlimitedtoayouth’sfamilyandfriendsbutalsoincludefront-lineworkers,teachers,andcommunitymemberswhoprovidesupportstoyouthduringtimesofstress.Formingandmaintainingtrustingrelationshipswithotherpeoplehasbeenshowntobecentralintheresilienceliteraturefordecades(Kumpfer,1999;Walsh,2006).InNovaScotia,Ungar,Liebenberg,Dudding,Armstrong,andvanderVijer(inpress)haveshownthatyouthwhoreceivedqualityserviceinterventionandwhoalsoestablishedmeaningfulrelationshipswithfront-linestaff,suchasmentalhealthandaddictionsworkers,becomemoreresilientandbetterabletonavigateadversitythanyouthwhodonot.
Development of a desirable personal identityThethirdfactorisconcernedwithhowyouththinkofthemselvesandtheirpersonalbeliefs,futuregoals,values,andstrengths(Ungaretal.,2008).Hinesetal.(2005)haveshownthatyouthwhoadoptpositiveidentities,whohavefuturegoals,andwhohavehighself-esteemarebetterabletonavigatetimesofsignificantadversitythanyouthwhopossessnegativeidentities,whodonothaveanyfuturegoals,andwhohavelowself-esteem.Animportantpartofidentityconstructionandmaintenancealsoreferstotheyouth’sracial,ethnic,gender,and/orsexualidentities,whichhavebeenshowntobeimportantinnumerousstudiesofresilience(Costigan,Su,&Hua,2009;Evansetal.,2012;Settlesetal.,2010).
Experience of power and controlThefourthfactorreferstowhetherchildrenbelievetheycancontrolandchangetheirlives(Ungaretal.,2008).Ungar,Liebenberg,Landry,andIkeda(2012)haveshownthatyouthwhoaccessmultipleservices(addictions,justice,socialservices,etc.)aremostlikelytoengageininterventionplanswhenrelationshipsbetweenfront-linestaffandtheyouthandtheirfamiliesarebuiltuponempowerment.Otherinterventionstyles,suchaswhereserviceproviderstakeresponsibilityawayfromayouth’sparent(s)/caregiver(s)tofacilitatetheyouth’swell-being,orwhereserviceprovidersexpecttheyouthandtheirfamiliestotakesoleresponsibilityfortheirowncare,havebeenfoundtocreatetensionandconflictbetweentheserviceprovidersandtheyouthand/ortheirfamilies(ibid.)Thiscausestheyouthtoresistandavoidtakingpartininterventionstrategies(ibid.).
Adherence to cultural traditionsAdherencetoculturaltraditionreferstohowyouthconnecttotheircultureandhowwellserviceinterventionsengagewiththeirculturalidentity(Ungaretal.,2008).Previousstudieshaveshownthatyouthwhoadoptpositiveculturalidentitiesdobetterinschool(Byrd&Chavous,2009),refrainfromengaginginillegalorhigh-riskbehaviours(Caldwelletal.,2004),anddemonstratebettercopingskillsthanyouthwhodonotpossessstrongconnectionstotheirculture(Evansetal.,2012;Settlesetal.,2010).
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Experiences with social justiceExperiencewithsocialjusticereferstohowyouthinterpretandreacttoformsofdiscriminationandprejudice(Ungaretal.,2008).Caldwelletal.(2004),Lee(2005),andSellersetal.(2006)haveshownthatpossessingastrongracialandethnicidentityallowsethno-racialyouthtobebetterabletocopewhentheyexperienceracism.Astrongracialorethnicidentityisassociatedwithethno-racialyouthwhoaremoreawareoftheirrights,personalstrengths,andcapacitytoresistracism.Forethno-racialminorities,theseskillsareassociatedwithhigherlevelsofacademicachievement(Lee,2005),engaginginlessviolentbehaviours(Caldwelletal.,2004)andhighlevelsofpsychologicalwell-being(Sellersetal.,2006).Likewise,youthwhodonotpossessskillsandsupportstohelpthemnavigateexperiencesofdiscriminationhavebeenshowntousedrugsandalcoholasameansofcoping(Brodyetal.,2012).
Experiences with social cohesionThefinalfactorthatfacilitatesresilience,asidentifiedbyUngaretal.(2008),istheyouth’sexperiencesofsocialcohesion.Socialcohesionreferstoyouth’sbeliefthattheyareconnectedtosomethinglargerthanthemselves—thefeelingthattheirliveshavemeaning,theirpresencematters,andtheirinvolvementisnoticed.Thissectionreferstothesocialecologyorenvironmentinwhichtheyouthareoperating(e.g.,school,treatment,etc.)andwhethertheyfeelanattachmenttothatenvironmentandthepeoplewhooperateinit.Ungar,Liebenberg,Dudding,Armstrong,andvanderVijer(inpress)haveshownthatyouthwhoreceivetreatmentincohesiveenvironmentsaremoreresilientthanyouthwhoareadministeredtreatmentinsettingsthatdonottrytoestablishacohesiveandsupportiverelationshipwithyouth.
Itshouldbenotedthatthesevenaspectsofresilienceareinterrelated,meaningthataffectingchangeinoneaspectwilllikelytoinfluenceayouth’ssuccessinanother.ResearchconductedbyUngaretal.(2008)showsthat,whileresiliencemaynotbederivedfromallsevenfactorsatonetime,internationalresearchhasshownthatresilienceisdependentonseveralfactorsactingsimultaneously.Involvementintreatment,forexample,maynotjustprovideyouthwithaccesstointerventionservices,italsoprovidesyouthwiththeopportunitytoestablishnewrelationshipswithadultsandpeers,thepotentialtocreateapowerfulidentity,andasenseofcohesionandbelongingthatmaybeabsentintheirlives.
Itshouldalsobenotedthatauniversalapproachtofacilitatingresilienceinyouthdoesnotexist.AsBottrell(2007,2009)hasshownfromherresearchwithat-riskandhigh-riskyouth,thereneedstobeaflexibleapproachtointerventionservices.Thereisnouniformwayinwhichyoucanintervenewitheveryyouthexperiencingadversity;rather,interventionsmustbetailoredtomeetthespecificneedsofeachyouth.Youthcomefromdiversebackgrounds(forexample,somemayhavesupportivefamilymembers,othersmaynot),soservicesneedtomeetthesecontextualdifferences.Inaddition,youthalsopossesstheirownnormsandvalues,ideasofsuccess,andculturalbeliefs.AsUngaretal.(2008)haveshown,serviceinterventionsthatcomplementratherthanconflictwiththesebeliefsachieveahigherdegreeofsuccessthanserviceinterventionsthatdonot.
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Engaging youth to foster resilienceResearchonresilienceisprovidinginsightintothecomplexinteractionsbetweenindividualsandthenestedsystemsthatshapepositivedevelopmentincontextswherechildrenfaceabove-averagelevelsofadversity.Asyet,therehavebeenlimitedstudiesdedicatedtofindingouthowtoengageyouthfromNovaScotiainaninterventionsettingwiththepurposesoffacilitatingresilientactionsandbehaviours.ResearchconductedbyUngar,Liebenberg,andIkeda(2012)withyouthaccessingmultipleservices(addictions,mentalhealth,justice,education,socialwelfare)inAtlanticCanadaidentifiessixfactorsthatareconducivetofacilitatingchangeinyouthwithcomplexneedswholiveinchallengingsituations:
• servicesaremulti-level;
• servicesarecoordinated;
• servicesarecontinuousovertime;
• servicesarenegotiatedwithclients;
• servicesprovidedareonlyasintrusiveastheyneedtobe;and
• servicesusedhavebeenpreviouslyshowntobeeffective.
Thefirstfactor,multi-levelservices,meansbringingtogetherprofessionalsfromdifferentareasofexpertise(addictions,mentalhealth,justice,education,socialwelfare)toplan,implement,andadministeraninterventionstrategythataddressesthecomplexneedsofclientsaccessingmultipleservices.However,formingarelationshipbetweenmultipleserviceprovidersaloneisnotenough;serviceproviderswhoareincludedinthisrelationshipmustalsocoordinatewithoneanothertoensurethatyouthcangettotheirappointments,andthatclientsarenotreceivingconflictingmessagesandinformationonhowtonavigatetheirwaythroughadversity.Theremustbefidelitybetweenserviceproviderstoensurethateachmemberisawareoftheneedsoftheyouthandtheproperwayfortheyouthtomeetthoseneeds.
ThesecondfactoristhattreatmentinterventionsaremoreeffectiveforAtlanticCanadianyouthifthoseinterventionsarecarriedoutoveralongperiodoftime.Providingcontinuedservicestoyouthnotonlyallowsthemtoaccesshelpoveralongperiodoftimebutitalsohelpstobuildmeaningfulrelationshipswithserviceproviders.
Forthethirdfactor,research(Ungaretal.,2008;Ungar,Liebenberg,&Ikeda,2012)hasshownthatAtlanticCanadianyouthrespondbettertointerventionsiftheyareabletohelpdecidehowserviceswillbedeliveredtothem.
FindingsfromUngar,Liebenberg,andIkeda’sresearch(2012)alsoshowthatinterventionstrategiesthatprovideaspaceforyouthtoinfluencetheirowninterventionstrategyhaveproventohavegreatersuccessthanonesthatdonot.
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ThefiftheffectiveinterventionstrategyforserviceprovidersinNovaScotiaisthatservicesshouldbenomoreintrusivethantheyneedtobe,meaningthatinterventioneffortsshouldinterferewithayouth’slifeaslittleaspossibleunlessitisrequired.Allowingyouthtoformandmaintainrelationshipsthatexistoutsideaninterventiondynamicprovidesthemwiththeopportunitytocreateand/ormaintainmeaningfulrelationshipswithotherpeoplewhowillactassocialsupportsoncetreatmenthasended.
Thefinalfactoristhatservicesconsideredeffectivebyprogramevaluatorsaretheservicesthattypicallyshowthehighestsuccessrates.Whilethismaysoundobvioustosome,itisincludedtoshowtheimportanceofserviceprovidersstayinguptodateonthemosteffectivetreatmentstrategies.Newtreatmentoptionswillalwaysbecreatedtoreplacecurrentones,andthesenewerstrategiesgiveserviceprovidersmoreeffectivetreatmentoptionstohelpfacilitateresilienceinyouth.
Takentogether,thesesixinterventionstrategieshavebeenshowntohelpAtlanticCanadianyouthwithcomplexneedstoavoidindividual,family,andcommunityriskfactorsthatjeopardizetheirwell-being.
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Substance WithdrawalTheseguidelinesandthemedicalprotocolsforwithdrawalmanagementthatfollowrecognizetheuseoftheDiagnosticandStatisticalManualofMentalDisorders(DSM)indefining“substancewithdrawal.”.TheDSM-Vdefinessubstancewithdrawalas
…thedevelopmentofasubstance-specificmaladaptivebehaviouralchange,withphysiologicalandcognitiveconcomitants,thatisduetothecessationof,orreductionin,heavyandprolongedsubstanceuse.Thesubstance-specificsyndromecausesclinicallysignificantdistressorimpairmentinsocial,occupational,orotherimportantareasoffunctioning.Thesymptomsarenotduetoageneralmedicalcondition,andarenotbetteraccountedforbyanothermentaldisorder.
TheDSM-Vsuggeststhatthereisnoevidenceofaphysiologicalwithdrawalfromsubstancessuchashallucinogens,orvolatilesubstances,andthatwithdrawalisusually,butnotalways,associatedwithsubstancedependence.TheinclusionofcannabiswithdrawalisnewtotheDSMV.
Mostindividualsinwithdrawalhaveacravingtoreusethesubstancetoreducetheirsymptoms,andthismaybethecasewithmanyyoungpeoplewhoengageinaperiodofabstinencefromtheirsubstanceofchoice.Someyoungpeopleexperiencearangeofphysicalandemotionalsymptomsuponcessationofthesesubstances.Forthepurposeoftheseguidelines,referencestowithdrawalfromthesesubstancesismadetocapturesymptomsthatmayrequiretreatmentratherthantosuggesttheactualpresenceofaphysiologicalwithdrawal.
Youngpeoplemayalsopresentforwithdrawalepisodesfromsubstancesthatarenotcoveredintheseguidelines,e.g.,GHB(Gamma-hydroxybutyrate),SpecialK(ketamine),magicmushrooms(psilocybin),LSD,andbathsalts.
Forthepurposeoftheseguidelines,polysubstanceuseisdefinedastheuseoftwoormoredrugsonasingleoccasionorwithinadefinedperiodtoachieveaparticulareffect.Thismakeswithdrawalsyndromesdifficulttoassess.Adolescentsaremorelikelytobepolysubstanceusers.
Nicotine Smokingistheleadingcauseofpreventabledeath,andtobaccoistheonlyconsumerproductthatkillsonehalfofitsuserswhenusedasdirected(WHO,2003).Thevastmajorityofadultsmokersstartedwhentheywereyouth(Batra,Patkar,Weibel,&Leone,2002).RecentsurveydataindicatethatalmostfivemillionCanadiansaged15+smoke,andthatthevastmajorityofthemsmokeonadailybasis(HealthCanada,2006).AccordingtotheU.S.DepartmentofHealthandHumanServices(2008),amongadultswhohaveeversmokeddaily,90%triedtheirfirstcigarettebeforeage21.Mostwhodonotquitduringhighschoolwillcontinuetosmokefor16–20moreyears(Pierce&Gilpin,1996).Adolescentsareveryinterestedinquitting:82%ofsmokersaged11–19arethinkingofquitting(U.S.DepartmentofHealthandHumanServices[USDHHS],2008)and64%havealreadymadea
Withdrawal Protocols
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quitattempt(HealthCanada,2002).Youngpeoplevastlyunderestimatetheaddictivepotentialofnicotine,andbothoccasionalanddailysmokersarelikelytothinkthattheycanquitatanytime(Fiore,Jaen,&Baker,2008).However,therateoffailedadolescentquitattemptsexceedsthatofadultsmokers;only4%ofsmokersaged12–19successfullyquitsmokingeachyear(USDHHS,2008).Weknowthatindividualscanbecomedependentoncigarettesaftersmokingasfewas100cigarettes(Heyman,2002),andthatthehealthbenefitsofquittingsmokingaresignificant;quittingbeforetheageof30restoreslifeexpectancytothatofapersonwhoneversmoked(Doll,Peto,Boreham,&Sutherland,2004).
Inadditiontotheknownhealthrisksinherentinsmoking,thereisevidencethatnicotine,themainaddictivecomponentoftobacco,increasestheuseofotherdrugs.Onelaboratorystudyshowedthatparticipantswhosmokedregularcigarettesworkedhardertoobtainalcoholcomparedtothosewhosmokeddenicotinizedcigarettes(Barrett,Tichauer,Leyton,&Pihl,2006).Furthermore,astudyofsubstanceabusersreportedthattobaccousewasassociatedwithincreasedcravingforcocaine(Epstein,Marrone,Heishman,Schmittner,&Preston,2010).Therefore,availabilityofsmokingcessationforyouthhasmuchbroaderhealthimplications.
AccordingtoHealthCanada(2010),12.2%ofCanadianyouthaged15–19continuetoreportbeingacurrentsmoker;inNovaScotiathatnumberisevenhigher,withaprevalencerateof15.8%.HigheryetistheprevalenceforourNovaScotiahigh-riskadolescentpopulation.Atoneresidentialfacilityforat-riskyouthintheMetroHalifaxarea,aninformalsurveyof29residentswasadministeredbystaff.Theresultsshowedthat90%hadtriedtobacco,and55%oftheseat-riskyouthweresmokingonaregularbasis.Additionally,aHealthCanada–fundedstop-smokingresearchandtreatmentprojectforyouthinruralnorthernNovaScotia,whichtargetedsixhighschoolsandcollecteddatafrom161students,foundthattheaveragelengthoftimethattheyouthhadsmokedbeforecomingtotheprogramwas3.6yearsandtheysmoked,onaverage,morethan11cigarettesdaily.
Nicotine Treatment in Addiction Treatment Settings:Althoughtherehasbeensomereluctancetotreattobaccodependenceinaddiction-treatmentsettings,recentstudiessuggesttreatmentiseffective,doesnotjeopardizerecovery,andmayevenimprovesobrietyfromdrugsandalcohol(Hughes,1996;Hughes,Novy,Hatsukami,Jensen,&Callas,2003;Hurt,Eberman,Slade,&Karan,1993).Ingeneral,quittingsmokingdoesnotappeartonegativelyaffectabstinencefromothersubstances(Burling,Burling,&Latini,2001;Rustin,1998)andcanevenenhancerecovery(Bobo,Walker,Lando,&McIlvain,1995;Pletcher,1993).Evidencealsosuggeststhatsubstanceuserscansuccessfullyquitsmokingalongwith,orshortlyafter,quittingothersubstances(Hurt,Eberman,Croghan,Offord,Davis,Morse,etal.,1994;Martinetal.,1997).Furthermore,concurrenttreatmentofnicotineandotherdependenciescancontributetofewerrelapseswithalcoholanddrugs(Boboatal.,1995;Bobo,McIlvain,Lando,Walker,&Leed-Kelly,1998;Currie,Nesbitt,Wood,&Lawson,2003;Martinetal.,1997;Patten&Martin,1996;Patten,Martin,Myers,Calfas,&Williams,1998;Pattenetal.,1999).
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Pharmacology of Nicotine Nicotinedependenceisaprogressive,chronic,relapsingdisorder(Henningfield,Schuh,&Jarvik,1995).Unlikeotherdrugdependencies,however,tobaccodependenceisstillnormalizedinsocietyandtheharmfulnessisoftenminimized.Addictiontonicotineisacomplexbraindiseasewithsignificantbehaviouralcharacteristics(AmericanSocietyofAddictionMedicine[ASAM],2011),anditaffectsthepleasureandrewardcircuitryofthebrain(Erickson,2007).Addictioninvolvingnicotinetypicallyoriginateswithuseinadolescencewhenthebrainisstilldevelopingandismorevulnerabletotheeffectsofnicotine(NationalCenteronAddictionandSubstanceAbuseatColumbiaUniversity[CASA],2012).Itisnotnicotineitselfbutthethousandsoftoxinspresentintobaccoanditscombustionproductsthatareresponsibleforthevastmajorityoftobacco-causeddisease(OntarioMedicalAssociation,2008).Nicotinecanbeahighlyaddictivedrug—asaddictiveasheroinorcocaine(USDHHS,1988).Itspotentialforaddictiondiffersprimarilybytherateandrouteofnicotinedosing;themostaddictivemethodofnicotinedeliveryisinhalationofnicotinethroughcigarettes(Benowitz,1998).Becausenicotinefromcigarettesisabsorbedthroughthelungs,nicotinelevelsinthebloodreachapeakwithinsecondsthendeclinerapidly,andthispatternisrepeatedandreinforcedwitheveryinhalation;thequickdeliveryofnicotinetothebrainresultsinafasterandmoreintenseresponse,whichleadstoaddiction(Benowitz,1996).
Theareasofthebrainaffectedbynicotineaddictionareamongthosethatareresponsibleforsurvival,includingareasassociatedwithmotivation,decisionmaking,riskandrewardassessment,pleasureseeking,impulsecontrol/inhibition,emotion,learning,memory.andstresscontrol(Dackis&O’Brien,2005).Virtuallyalladdictivesubstancesaffectthepleasureandrewardcircuitrydeepinthebrain,whichisactivatedbytheneurotransmitterdopamine(Erickson,2007).Withrepeateduseofnicotine,thebrainbeginstoexpectthisstimulation(releaseofdopamine)andanaddictedindividualmayexperienceintensedesireorcravingswhenevernicotineisnotreadilyavailable,especiallywhentheindividualisexposedtocuesassociatedtotheirnicotineuse(ASAM,2011;Hyman,2007).Nicotinedependenceisestablishedrapidly,evenamongadolescents(USDHHS,2008).Ithasbeenestimatedthatasfewas100cigarettescanformdependency(Heyman,2002).Alargeandgrowingbodyofscientificresearchhasdemonstratedclearlythataddictioninvolvingnicotineisacomplexbraindisease(CASA,2012).
Thediagnosisofaddictionisbasedonitssymptoms,includingcompulsiveuseofaddictivesubstances(e.g.nicotine),significantlyimpairedfunction,andpersistentusedespitenegativeconsequences(ASAM,2011).
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TheDiagnosticandStatisticalManualofMentalDisorders(DSM-V,2013)liststhediagnosticcriteriaforNicotineWithdrawal:
• Nicotinehasbeenuseddailyforatleastseveralweeks.
• Therehasbeenanabruptcessationofnicotineuse,orreductionintheamountofnicotineused,followedwithin24hoursbyfour(ormore)ofthefollowingsigns:
• dysphoricordepressedmood;
• insomnia;
• irritability,frustration,oranger;
• anxiety;
• difficultyconcentrating;
• restlessness;
• decreasedheartrate;and
• increasedappetiteorweightgain.
• ThesymptomsinCriterion(b)causeclinicallysignificantdistressorimpairmentinsocial,occupational,orotherimportantareasoffunctioning.
• Thesymptomsarenotduetoageneralmedicalconditionandarenotbetteraccountedforbyanothermentaldisorder.
NicotineisaCentralNervousSystem(CNS)stimulant.Ithasahalf-lifeofabout30–120minutes.Thepharmacologicaleffectsofnicotinearebroadanddiverse.Inanon-tolerantindividual,200–300mcgofnicotinecanproduce:
• dizziness;
• headache;
• sweating;
• nausea;
• abdominalcramps;and
• possiblevomitingandweakness.
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However,insmokers,thesesymptomsabateastolerancedevelops.Inregularsmokers,nicotinemayproducethefollowingeffects:
• mildeuphoria;
• increasedarousal;
• enhancedabilitytoconcentrate;
• feelingofrelaxation;and
• temporaryreliefofwithdrawal.
Nicotine Replacement Therapy (NRT) AnypersonwithdrawingfromnicotineandexhibitinganyoftheabovesymptomscanbeconsideredforwithdrawalusingtheNRTmedicationsoutlinedintheprotocol.ThedecisiontousethisprotocolistheresponsibilityoftheStaffNurseandisbasedonnursingassessmentoftheclient.TheNRTslistedbelowcanbeusedincombinationtomanagenicotinewithdrawalsymptoms,baseduponnursingassessment.
Nicotinereplacementtherapy,whenusedasdirected,provideslowerdosesofnicotineataslowerratethansmokingandservestoeasenicotinewithdrawalsymptoms(Stead,Perera,Bullen,Mant,&Lancaster,2008).Formanysmokers,NRTworksbestasanaidtomanagingnicotine-relatedcravingswhenusedinconjunctionwithpsychosocialtherapies.Inmostcasesofacutecaretreatment,atherapeuticlevelofnicotineisreachedandthenuseisreducedinordertoeliminatethemedicationentirelyorreachamaintenancelevel(Fiore,Jaen,Baker,Bailey,Benowitz,etal.,2008).NRTisconsideredacornerstoneinclinicalguidelinesforsmokingcessationintheU.S.(Fioreetal.,2008).TheOntarioMedicalAssociation(OMA)releasedasetofrecommendationsaroundnicotinecessationaidsandrecommendsthatNRTshouldbemadeavailabletoyoungpeopleundertheageof18whowanttostopsmoking.ItisalsorecommendedthatpeoplewhosmokeshouldbeencouragedtoindividualizetheirNRTdosagetomeettheirnicotineneeds.Lastly,itisrecommendedthatpeoplewhosmokeshouldbeencouragedtouseNRTforaslongasneededtoprolongtobaccoabstinence,withperiodicassessmentstoevaluatethecontinueduseofnicotinebeingofferedtothepatient/client(OMA,2008).
UseofNRThasbeenshowntobesafeinadolescents;however,itshouldbenotedthatresearchwithyouthandnicotinetreatmentisinitsinfancy,andasaresultthereislittleresearchprovingthatthesemedicationsareadequateinpromotinglong-termsmokingabstinenceinadolescents(Fioreetal.,2008).Additionalresearchisongoinginthisarea.
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ThefollowingisalistofNRTproductsthatcanbeutilizedbasedonnursingassessment:• nicotinetransdermalpatch
• nicotineinhaler
• nicotinegum
• Nicorette®(2mgofnicotine)
• NicorettePlus®(4mgofnicotine)—ifdeemednecessary,anorderwillneedtobewritten(ClinicalPracticeguidelinesdosing—TreatingTobaccoUseandDependence2008)
NRT DosingFagerström 1–6 points (seeAppendixI)Mayprescribe14-mgpatchorinhalerfor6weeksThen7-mgpatchfor4weeksDuringthistimeclientcantake2-mggumeveryhourprn(max20pieces/day)Fagerström7–10pointsMayprescribe21-mgpatchfor6weeksThen14-mgpatchfor2weeksThen7-mgpatchfor2weeks
Duringthistimetheclientmayusethenicotineinhalerfor10minatatimetoamaxof6timesperdayor2-mggumeveryhourprntoamaxof20piecesperday.
Ensurethatthenicotineinhalerandcartridgearetakenfromtheclientaftereachuse.Also,whenapplyinganicotinepatchensurethatthepreviouspatchispassedback;donotassumetheclienthasthrownitinthegarbage.Itisimportanttonotethatnonicotineproductsshouldbeusedafter2000hduetotheirstimulantaffect.Thisisimportanttopreventnightmares.Neverapplyapatchafter1800h,andensurethatallpatchesareremovedby2000h.
Mechanismsshouldbeinplacetoreview,measure,andrevisethisprotocolasnecessary.
Althoughthereisscantliteratureonpharmacotherapyforsmokingcessationinadolescents,somestudieshaveshownpositiveoutcomesfortheuseofbuproprion(Muratmotoetal,2007).Thisstudyconcludedthat“sustained-releasebupropionhydrochloride,300mg/d,plusbriefcounselingdemonstratedshort-termefficacyforadolescentsmokingcessation.Abstinencerateswerelowerthanthosereportedforadults,withrapidrelapseaftermedicationdiscontinuation”.Arecentstudycomparingverenaiclinetobuproprionforthetreatmentofsmokingcessationinolderadolescentsshowed“noseriousadverseevents’(Grayetal,2012),orsideeffectsfromtheuseoftheseagentsinadolescentsaged15-20years.
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Alcohol
Alcohol intoxicationAlcoholisacentralnervoussystemdepressant,whichcausesdepressionofrespiration,coughingreflex,gagreflex,andcardiovascularfunction,andmaythereforeinducevariouscardiacarrhythmias.
Signs of intoxication:• smellofalcohol
• ataxiaandslurredspeech
• lossofinhibition
• depression
• alteredbehaviourandcognition
• alteredmood/emotions
• inappropriatebehaviour/emotionalresponses
• relaxation,euphoria,confusion,disorientation
• analgesicandanaestheticeffects
• alteredconsciousness
• positivebreath/bloodalcoholreading
Signs of alcohol overdose:• strongsmellofalcohol
• stupororcoma
• coldandclammyskin
• hypothermia
• hypotension
• labouredandnoisyrespiration
• tachycardia(heartrate>100)orbradycardia(heartrate<60)
• positivebloodalcoholreading
Thepatternofalcoholuseinadolescentsisgenerallyofabingeingnatureandnotthemorecommonchronic,regular,ifnotdailyusethatpresentsinadultalcoholusedisorders.Withlessregularuse,theindividualisveryunlikelytodevelopneuroadaptationleadingtoanyobviousphysicalwithdrawalsymptoms.Despitetheveryuncommonpresentationofsignificantalcoholwithdrawalintheadolescentpopulation,itishelpfultonotethattheonsetofalcoholwithdrawalsyndromeusuallybegins6to24hoursafterthelastalcoholicdrink.Inyoungpeoplewhohaveatolerancetoalcohol,thewithdrawalsyndromemaybeginwhilethereisstillasignificantbloodalcoholreading.
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Theseverityofalcoholwithdrawalrangesfrommild(simple)tosevere(complex).Severealcoholwithdrawalispotentiallylife-threatening.Earlyrecognitionandcorrectmanagementoftheinitial,milderstagesofwithdrawaliscrucialinpreventionofitsprogressionintothesevere,life-threateningstages.Alcohol-relatedseizurescanoccuratanytimeduringwithdrawalandpeakwithin24-48hours.Someadolescentsmayexperiencevisual,tactile,orauditoryhallucinationsduringseverewithdrawal.
Features of alcohol withdrawalMild withdrawalSignsandsymptomsmayoccur6–24hoursafterstoppingorsubstantiallyreducingalcoholintake.Simplewithdrawalsymptomsusuallypeakwithin48hoursandrapidlysubsideoverthefollowing1–2days.
Symptomsinclude:• mildanxiety
• headaches
• insomnia/sleepdisturbance/vividdreams
Signsinclude:• achycardia
• mildsweating/perspiration
• slighttremor(6-8Hz,bestbroughtoutbyextensionofhandsortongue)
• hyperactivereflexes
• hyperthermia
• milddehydration
• mildhypertension
Moderate withdrawalSignsandsymptomsoccurwithin24hoursandsubside72hoursafterstoppingorsubstantiallyreducingalcoholintake.
Symptomsincludetheaboveplus:• moderateanxiety(willrespondtoreassurance)
• anorexia
• nauseaandvomiting
• abdominalcramping
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Signsincludetheaboveplus:• dehydration
• moderatesweating,particularlyfacial
• facialflushing
• diarrhea
• mildtremor
Severe withdrawalSignsandsymptomsmayoccurin24–48hoursormaybedelayeduntilmorethan48hoursafterstoppingorsubstantiallyreducingalcoholintake.Delaysinonsetcanbecausedbyadministrationofothercentralnervoussystemdepressants,e.g.,opioidanalgesiaoranaesthetics.Theusualcourseofwithdrawalis3–5days,butcanbeupto14days.
Symptomsincludetheaboveplus:• acuteanxiety(mayormaynotrespondtoreassurance)
• hyperventilationandpanic
• agitation
• disorientation
• fever
• confusion&delirium
• hallucinations—tactile,visual,orauditory
• hypersensitivitytostimulation(noiseandlightespecially)
Signsincludetheaboveplus:• excessiveperspiration
• moderatetoseverehypertension(dangersignisadiastolicpressuregreaterthan120mmHg)
• orhypotension
• markedtremor
• fever
• withdrawalseizures
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Alcohol Withdrawal Seizures Grandmalseizuresareonemanifestationofalcoholwithdrawal.Withdrawalseizuresusuallybegin8–24hoursafterthelastdrinkandmayoccurbeforethebloodlevelhasreachedzero.Mostaregeneralizedmajormotorseizuresoccurringsinglyorinshortburstsofseveralseizuresoccurringoveraperiodof1–6hours.Thepeakincidenceofwithdrawalseizuresiswithin24hoursafterthelastdrink,correspondingtoabnormalitiesinEEGreadings.Lessthan3%evolveintostatusepilepticus.
Thereisanincreasedriskofseizureactivityinpatientswithahistoryofpriorwithdrawalseizures.Theriskmayalsoincreaseifanindividualisundergoingconcurrentwithdrawalfrombenzodiazepinesorothersedative-hypnotics,andthereisevidencetosuggestthatgeneticsmayalsoplayafactor.
Clientswhohaveahistoryofseizuresduringdrugwithdrawalandarereceivingaprescriptionofphenytoinwillremainonthismedicationduringtreatment.
Alcohol Withdrawal Delirium and Delirium Tremens (the DTs)Progressiontoseverealcoholwithdrawalsymptoms,includingdeleriumtremens,isaveryuncommonpresentationinadolescents.Youngadults,whomayhavehadmoreopportunitytodevelopachronicaregularpatternofuseofalcohol,maypresentinprogressedalcoholwithdrawal.
Milderalcoholwithdrawaldeliriumoccursmoreoften;atthesevereendofthespectrumitprogressesintodeliriumtremens(theDTs).TheDTsisthemostsevereformofalcoholwithdrawalsyndrome,andisamedicalemergency.TheDTsusuallydevelop2–5days(mostoften3–4days)aftercessationorsignificantreductionofalcoholconsumption,butmaytake7daystoappear.Theusualcourseis2–3days,butcanbeupto14days.AnecdotallyitisunusualforadolescentstosufferfromtheDTs;however,iftheyoungpersonhasbeenabusingalcoholforasignificantlengthoftime,he/shemayexperiencetheDTsinwithdrawalifhe/sheisnotmedicated.Dehydration,infection,cardiacarrhythmias,hypotension,kidneydisease,andpneumoniamaybeprecipitatingfactors.
Deliriumtremensmanifestsas:• acuteconfusionaccompaniedby
profounddisorientationtoplaceandtime
• dehydration
• delirium
• elevatedbodytemperature
• sweating
• extremefear
• hypertension
• tachycardia
• tremor
• hallucinations—tactile,visual,orauditory
• severeagitation
• severesleep-wakecycledisruption
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Alcoholichallucinosisanddeliriumtremenscanoccuriftheyoungpersonhasahistoryofheavyalcoholconsumption,isundergoingseverewithdrawal,and/orisnotbeingadequatelymedicatedforalcoholwithdrawal.
Managing Alcohol WithdrawalPurposeToprovidestaffwithprotocols/guidelinesforthemanagementofalcoholwithdrawal.
PrincipleTomanagealcoholwithdrawalbyminimizingprogressionofwithdrawal,byaccurateassessmentofsubstancehistoryandrelevanthealthissues,andbyearlyrecognitionandtreatmentofwithdrawal.
Associated documentationNursingAssessmentandAdmissionformasperdistrictpoliciesCIWA-A(SeeAppendixII)
EquipmentAlcometer
Assessment Seepreviousdocumentationre:assessment
Pathology investigations1.Urinedrugscreen,ifconcernedaboutundisclosedsubstanceuse2.bHCG(pregnancytestpriortoadministeringanymedication)
Other tests to consider(theseinvestigationsshouldbeincludedastheclinicalpresentationapplies.Adolescentsandyoungadultsareveryunlikelytohavemedicalcomplicationsofchronicalcoholuse,includingendorgandamage.ThereforetheroutineuseofCXRsandECGsisnotapplicableinthispopulation)1.TBtest2.CXR3.ECG4.HepatitisAandBimmunity,HepatitisC5.STIs(includingRPR,HIV)
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Assessment of withdrawal symptoms using the CIWA-APrimary Goal:Toassureclinicalstability.
TheClinicalInstituteWithdrawalAssessmenttool(CIWA-A;seeAppendixII)haswell-documentedreliability,reproducibility,andvalidity.Ittakes2–5minutestocomplete,allowsrapiddocumentationofthepatient’ssignsandsymptoms,andprovidesasimplesummaryscorethatfacilitatesaccurateandobjectivecommunicationbetweenstaff.Ascorebelow10indicatesmildwithdrawal,10–18moderatewithdrawal,andover18severewithdrawal.Patientswithlowscoresinthefirst24hourshavelittletonoriskforseverewithdrawal.Highscoresearlyinthecoursearepredictiveofthedevelopmentofseizuresanddelirium,butothermedicalconditionsthatcanresultinelevatedscoresneedtoberuledout.
Riskfactorsforseverewithdrawalinclude:• historyofpriorDTsorwithdrawalseizures
• tachycardiaonadmission
• bloodalcohollevelof>100mg/dLonadmission
• serumelectrolyteabnormalities
• medicalcomorbidity(especiallyinfection)
CharacteristicsNOTusefulinpredictingseverewithdrawalinclude:• amountofdailyintake
• durationofheavydrinking
• age
• gender
TheCIWA-A-Arshouldbeusedforyoungpeopleexperiencingmild,moderate,orseverealcoholwithdrawal.Itmeasurestheimpactofpharmacotherapy,andtheinformationitprovidesaboutthecourseofwithdrawalisusedtocommunicatetheexperienceofwithdrawalandthefrequencyandseverityofsymptoms.Evenforyoungpeoplewhoappearasymptomatic,theCIWA-Awillconfirmtheabsenceofawithdrawalsyndrome.
TheCIWA-Amaygive“falsepositive”highscoresiftheyoungpersonhasahighanxietystateduetofear,unfamiliarsurroundings,orothercauses.ScoreshighonAnxiety,Agitation,andevenTremormayleadtoatotalscoreofover10withoutnecessarilybeingduetoalcoholwithdrawal.Thiscanleadtoover-prescribingofdiazepam.
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Toavoidthistheobjectivesigns,suchasbloodpressure,pulserate,andsweating,shouldbeconsidered,aswellaswhetheranxietysymptomscorrelatewiththetimeintervalsincethelastdrinkandthelikelyonsetofwithdrawalsymptoms.Ifsymptomsarerelievedbydiscussionandexplanation,theyaremorelikelytobeduetogeneralanxietythanaphysiologicalwithdrawalstate.Ifayoungpersonwhoisnotaregularheavydrinkerhashadarecentheavybingeofalcoholandisexperiencingnausea,thesymptomsmaybeduetoahangoverratherthanalcoholwithdrawal.Thetreatmentofahangoverreliesmoreonrehydrationandmildanalgesicsthanondiazepam.
TheCIWA-Awasdevelopedforalcoholwithdrawalonly,notforpolydruguseorforanyothersubstancewithdrawals.Iftheyoungpersonhasahistoryofrecentbenzodiazepinedependence/abuseaswellasalcoholdependence/abuse,thensomeofthewithdrawalsymptomsmaybeduetobenzodiazepinewithdrawal.ThismayrendertheCIWA-Alessusefulinmonitoringprogressthanin“pure”alcoholwithdrawal.Insomeinstancesthiscombinedalcohol/benzodiazepinewithdrawalmayrequireadiazepamtapering-doseregime,ratherthanrelyingontheCIWA-Atoassessdiazepamtreatment.
FREQUENCY OF CIWA-AACIWA-Ascoreiscompletedonadmissionandinitiatedwhenthealcometerreadingisbelow0.150.CIWA-Ascoresarethentakenapproximatelyevery2–3hoursuntilthewithdrawalsymptomssubside.However,apatientwhoissleepingshouldnotbeawakenedjustforthepurposeofscoring.
Pharmacological Management of Alcohol WithdrawalWhenmedicatingadolescentsinwithdrawal,bodyweightandstaturemustalwaysbeconsidered,asadultdosesmayresultinover-medicatingofsmall-statureadolescents.Therecommendeddosagesintheseguidelinesmayneedtobereduced.
DiazepamOraldiazepamisusedtotreatalcoholwithdrawalsymptoms.Diazepamisprescribedinareducing-doseregime,butmayneedtobetitratedoverthefirst24–48hourstostabilizetheyoungperson.Othersymptomaticmedicationmaybeindicated.Medicationisindicatedforadolescentswithmoderatetoseverealcoholwithdrawal.Adolescentswithmildalcoholwithdrawalshouldnotrequirepharmacologicalsupport.
1.Givediazepam5–20mg,q1hwhenCIWA-Ais>8–10(symptom-triggeredtherapy),toamaximumof50mgwithin24hours.
2.Diazepammaybeprescribedas5–10mgq6h(fixed-dosetherapy),withafurtherprnordertoatotalof50mgdailyforthefirst1–3daysiftheyoungpersonisshowingsignsofseverewithdrawal(assessedwithCIWA-A),hasahistoryofwithdrawalseizures,orneedstoavoidallwithdrawalformedicalreasons.Ifthedoseexceeds40mgdailyforthefirst1–3days,thereducing-doseregimeshouldbeassessedeachday.Theyoungpersonwillgenerallyonlyrequiremedicationoverthefirst4–5daysofwithdrawal.
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3.Iftheyoungpersonhashadapreviousadmissiontotheresidentialwithdrawalunit,itisvaluabletoreviewthemanagementofhisorherlastwithdrawal.Thepreviouslevelsofdiazepamcanbeusedasaguidelineforthemanagementofhisorhercurrentwithdrawalsyndrome.
4.Inthefollowingcircumstances,theyoungpersonwillrequireamedicallysupervisedsettingforwithdrawal:•ifinitiallythereisabloodalcoholreadingandtheyoungpersonisshowingclinicalsignsofwithdrawal;•ifthereisahistoryofcomplicatedwithdrawal(seizure,delirium);and/or•ifwithdrawalissevereandnotabletobemanagedonamaximumof50mgofdiazepamdaily.Itisimportanttoensurethatfemaleclientsarenotpregnant,ascarbamazepineisteratogenic.Italsointeractswithothermedicationsthatundergohepaticmetabolism,soitmustbeusedcautiouslyinthoseindividualswithconcurrentmedicalillness.
Thiamine• Thiamine100mgpodailyfor3days,plusacomprehensivemultivitamindaily
Alcoholconsumptioncancausenutritionaldeficiencies,especiallyofB-groupvitamins.Iftheyoungpersonhashadinadequatenutritionoversomeweeksandisdrinkingheavily,heorshemaybecomeVitaminB1(thiamine)–deficient,whichcancauseneurologicaldamage.ThiaminedeficiencyisamajorcauseofWernicke’sencephalopathy/Wernicke-Korsakoffsyndrome.Thisisanacuteconditionassociatedwithhigh-risklevelsofalcoholuse,oranyconditionthathascausedpoornutritionalstatusanditssequelae(e.g.,malnutrition,anorexia,orboweldisease).Iftheconditionisnottreatedeffectivelyandearly,itcanleadtopermanentbraindamageandmemoryloss.Itcanoccurinheavydrinkers(80mgBACdailyforadultmalesand60mgBACdailyforadultfemales),whetheryoungorolder.
Thebodycanonlyabsorbasmallamountoforalthiamineperday,anditcanonlybestoredbythebodyforafewdays.
Agitation and deliriumAtivan1–2mgpogivenonceforsevereagitation
Nausea and vomitingDiphenhydramine25–100mgq6–8hprn
DiarrheaLoperamideHydrochloride2mg4mginitially,then2mgaftereachloosebowelaction,toamaximumof16mg/day
HeadachesAcetaminophen325–650mgq4hprnIbuprofen200–400mgq4hprn,nottoexceed1200mg/dayTheamountofacetaminophenadministeredtoadolescentswhoareHepatitisC–positivemustbemonitored,asitmayadverselyaffectliverfunction.
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BenzodiazepinesBenzodiazepine intoxicationBenzodiazepineshaveageneralcentralnervoussystemdepressanteffect,whichisdose-dependent.Asthedoseincreases,thereisprogressionfromsedationthroughhypnosistostupor.Theycauserespiratorydepression,butthiseffectisminimalunlessothercentralnervoussystemdepressantsaretaken(e.g.alcoholandopioids).Whenalcoholoropioidsareusedinconjunctionwithbenzodi-azepines,thedepressanteffectsofeachofthesubstancesmaybepotentiated.Thiscouldresultinrespiratorydepressionthatmaybelife-threatening.Sometimesbenzodiazepinesproduceapara-doxicalreactionofdisinhibitedbehaviourandviolence.
Signs of intoxication:• ataxiaandslurredspeech
• poormotorco-ordination
• dizziness
• blurredvisionandnystagmus
• eyesappear“glassy”
• drooling
• poormemoryrecall
• confusion
• drowsiness
• stupor
• disinhibitionandemotionalinstability
Signs of benzodiazepine overdose:• slurredspeech
• stupororcoma
Benzodiazepine WithdrawalThepatternofbenzodiazepineuseinadolescentsisgenerallyofabingeingnatureandmaynotproduceanyobviousphysicalwithdrawalsymptoms.Adolescentswhousebenzodiazepinesonaregularbasismaydeveloptolerancetothesedativeeffectandcanshowsymptomsofwithdrawal.Benzodiazepineuseshouldnotceaseabruptly,thereforeadose-reductionregimeisrecommended.
Thebenzodiazepinewithdrawalsyndromevariesbetweenindividualsandaccordingtodurationandconsistencyofuse,amountused,andtype(short-,medium-orlong-acting)ofbenzodiazepineused.
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Table3
Benzodiazepine(brand name)
Equivalence to Diazepam 5mg
Onset of Action Time to Peak Concentration
Duration (t1/2)
Long-ActingChlordiazepoxide(Librium)
10mg 1–3h 0.5–4h 100
Chlorazepate 7.5mg <1h 0.5–2h 100Diazepam(Valium)
5mg <1h 0.5–2h 100
Flurazepam(Somnol)
15mg <1h 0.5–1h 100
Intermediate-ActingAlprazolam 0.5mg 1–3h 1–2h 12–15Bromazepam(Lectopam)
3mg 1–3h 1–4h 8–30
Clobazam 10mg 1–3h 1–4h 10–46Clonazepam(Rivotril)
0.25mg 1–3h 1–2h 20–80
Lorazepam(Ativan)
1mg 1–3h 2–4h 10–20
Nitrazepam(Mogadon)
5mg 1–3h 2–3h 16–55
Oxazepam(Serax) 15mg >3h 2–4h 5–15Temazepam(Restoril)
15mg 1–3h 2–3h 10–20
Short-ActingTriazolam(Halcion)
0.25mg <1h 1–2h 1.5–5
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Aclinicallysignificantwithdrawalsyndromeismostapttooccurafterdiscontinuationofdailytherapeuticdose(lowdose)useofbenzodiazepineforatleast4–6monthsor,atdosesthatexceedtwotothreetimestheupperlimitofrecommendedtherapeuticuse(highdose),formorethan2–3months.Theseverityofwithdrawalisinfluencedby:1)dose2)durationofuse
Thelatencytoonsetofwithdrawalisrelatedtoeliminationhalf-life.
Elimination half-life Onset/Latency Peak of withdrawal Duration from start of withdrawal symptoms
Short-Acting within24hours 1–14days(usuallyearlier)
7–21days
Long-Acting 2–7days(usuallywithin5days)
1–20days(usuallylater)
10–28days
Features of Benzodiazepine WithdrawalVital Signs• tachycardia
• hypertension
• fever
Central Nervous System• anxiety
• sleepdisturbances
• depression
• irritabilityandaggression
• aches,painsandnumbness
• headachesanddizziness
• sweating
• hypersensitivitytonoise,lightandtouch
• impairedconcentrationandmemory
• nightmares
• agoraphobia
• feelingsofunreality
• depersonalisation
• panicattacks
• increasedmuscletensionandtwitching
• delusions
• paranoia
• hallucinations
• tremors
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Gastrointestinal • anorexia
• diarrhea
• nausea
High-Dose (severe) Withdrawal• seizures/convulsions
• delirium
• death
Host factors negatively affecting withdrawal severity1.psychiatriccomorbidity2.concurrentuseofothersubstances3.familyhistoryofalcoholdependence4.concurrentmedicalconditions5.femalegender
Managing Benzodiazepine WithdrawalPurposeToprovideprotocolsforthemanagementofbenzodiazepinewithdrawal.
PrincipleToensurethatbenzodiazepinewithdrawalismanagedbyminimizingprogressionofwithdrawal,byaccurateassessmentofsubstancehistoryandrelevanthealthissues,alongwithearlyrecognitionandtreatmentofwithdrawal.
MedicationDiazepam(Valium)Metoclopramide(Maxeran)Prochlorperazine(Stemetil)Paracetamol
Adolescent Withdrawal Management Guidelines 201386
Assessment1.Detailedhistoryofbenzodiazepineuse:
• typeofbenzodiazepine
• quantityofbenzodiazepine
• routeofadministration
• patternofuseandforhowlong—alwaysdocumentthetimeoflastuse
• symptomsofdependence
2.Concurrentuseofothersubstances(especiallyalcohol,butalsoincludingallotherprescribedornon-prescribedlicitorillicitdrugs)
3.Previouswithdrawalattempts:• withdrawalsymptomsexperienced
• symptomaticmedicationused
• anycomplications
4.Medicalandpsychiatrichistory5.Familyhistoryofsubstanceuseandpsychiatricormedical(especiallyseizure)disorders6.Psychosocialhistory,includingcurrentsocialstatusandsocialsupport
Examination1.Evidenceofintoxication2.Evidenceofwithdrawalsymptoms—recordabaselineofwithdrawalsymptomsbyusingan
objectivebenzodiazepinewithdrawalscale3.Vitalsignsandweight
Pathology investigations1.Fullbloodexamination2.Urinedrugscreenifconcernedaboutundisclosedsubstanceuse(note:theUDSmaynotpickup
somebenzos,e.g.clonazepam)3.HepatitisBandC,HIV,andBBVscreeningifinjectingdrug-user4.BreathalyzerNote:Pre-andpost-testcounsellingmustalwaysbegivenpriortoandfollowingblood-bornevirusscreening.
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Management of WithdrawalTheabove-describedsymptomsofwithdrawalreferonlytobenzodiazepinedependency,whichusuallytakes2–4weeksofdailybenzodiazepineusetodevelop.
Thediagnosisofbenzodiazepinedependenceshouldbemade,basedonhistory,aspartoftheinitialassessmentprocess.
Thelistofsymptomsmaynotberelevanttobenzodiazepinebingeusers,andthisgroupgenerallydoesnotrequireaslowtaperingbenzodiazepineregimen.Theymayrequiremanagementofanxiety,wherelowdosesofbenzodiazepinesforafewdaysmaybesufficienttomanagesymptoms.
Supportive Care1.Informationaboutwhattoexpect2.Supportivecounsellingfromthenurseandotheralliedhealthworkers3.Educationaboutdrinkingfluidsandmaintainingnutritionthroughoutthewithdrawalperiod
Pharmacological Management of Benzodiazepine WithdrawalWhenmedicatingadolescentsinwithdrawal,theirbodyweightandstaturemustalwaysbeconsidered,asadultdosesmayresultinover-medicatingofsmall-statureadolescents.Therecommendeddosagesintheseguidelinesmayneedtobereduced.1.Assessbenzodiazepineuseasaccuratelyaspossible2.Converttoalong-actingbenzodiazepine(diazepam)3.Ascertainthattheyoungpersonisexhibitingclinicalsignsofbenzodiazepine
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Pharmacokinetic Properties of BenzodiazepinesTable4
Generic Name Trade Name Onset of Action1
Daily DosageRange (mgs)
ApproximateEquivalentDose (mg)2
ActiveMetabolites
Short-ActingMidazolam Versed® YesTriazolam Halcion®,
GenericsFast 0.25–0.5 0.25 No
Intermediate-actingAlprazolam Xanax®,
GenericsIntermediate 0.75–4.0 0.5 Yes
Bromazepam Lectopam® Intermediate 6–60 6 YesClobazam Frisium®,
GenericsIntermediate 10 Yes
Clonazepam Rivotril®,Generics
Intermediate 1.5–20 1 No
Lorazepam Ativan®,Generics
Intermediate 1–10 1 No
Nitrazepam Mogadon®,Generics
Intermediate 5–10 5 No
Oxazepam Serax®,Generics Slow 30–120 15 NoTemazepam Restoril®,
GenericsIntermediate 15–30 15 No
Long-actingChlordiazepoxide Librium®,
GenericsIntermediate 5–100 10 Yes
Clorazepate Tranxene®,Generics
Fast 15–60 7.5 Yes
Diazepam Valium®,Generics
Fast 4–40 5 Yes
Flurazepam Dalmane®,Generics
Fast 15–30 15 Yes
Source:AdaptedfromtheCompendiumofPharmaceuticalsandSpecialties,2000.Notes:1.Fast<1hour Intermediate1–3hoursSlow>3hours2.Approximateequivalentdosages:
Thereisnoagreed-uponequivalencytableforthebenzodiazepines.Theaboveequivalenciesmayvaryslightlyforeachindividual.
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ProcedureMedicationDiazepam(otheroptionsareclonazepamandchlordiazepoxide)1.Someadolescentsmayrequiretheirshort-actingbenzodiazepinetobeconvertedtoalong-acting
benzodiazepineandstabilizedonadosepriortocommencingonareductionregime(especiallyiftherehasbeenlong-termuse).
2.Generallyitisrecommendedthatashort-actingbenzodiazepinebesubstitutedforalong-actingbenzodiazepinebeforeareductioniscommenced.Aslong-actingbenzodiazepinesremaininthebloodstreamlonger,thiscanfacilitateamoretolerablereduction.
3.Diazepamisusedforpharmacologicalmanagementofbenzodiazepinewithdrawal.4.Theyoungpersonmayrequireamedicallysupervisedwithdrawalif:
• thereisahistoryofhigh/prolongedusage
• thereisahistoryofseizuresassociatedwithbenzodiazepinewithdrawal
• withdrawalissevereandnotabletobemanagedonthemaximumdoseof50mgofdiazepamdaily
Generally,afixed-dosescheduleshouldbeused,withprnforbreakthroughinthefirstweektoestablishthedose;afterthat,prnbenzodiazepineshouldnotbeused.
5.Asageneralrule,patientstoleratemoredosereductionandwithshorterintervalsearlyinthetaperingprocess,andthenrequiredecreaseddosereductionoverlongerintervalsasthetaperprogresses.
6.Generally,reductionswouldbe10%oftheaveragedailyuse.IntheResidentialWithdrawalUnits,however,thereductionmaybeachievedatafasterrateundermedicalsupervision.
7.Thefinal25–35%ofthetapershouldbesloweddowntohalfthepreviousdosereductionperweek,andtheintervalfordosereductionsdoubled.
8.Itmaybenecessarytohaltreductionsandplateauthedoseifsymptomsaresevereoriftheyoungpersonisexperiencingseverepsychosocialstressors.
9.Onceareductionhascommenced,thereductionsshouldbemademoreslowlyratherthanincreasingthedoseagain.
AnexcellentresourceforBenzodiazepinetaperingisbenzo.org.uk/manual.Thiswebsitehastablesforconversionofmanydifferentehaviorginestodiazepamandalsoschedulesforweaningdownthediazepam.
Nausea & vomiting • Diphenhydramine25–100mgq6–8hprn
Headaches • Acetaminophen325–650mgq4hprn
• Ibuprofen200–400mgq4hprn,nottoexceed1200mg/day
TheamountofacetaminophenadministeredtoadolescentswhoareHepatitisC–positivemustbemonitored,asitmayadverselyaffectliverfunction.
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CannabisCannabis IntoxicationCannabisinsmalldosesisacentralnervoussystemstimulantanddepressant,andinhighdosesismainlyadepressant.ThemainactiveconstituentisDelta9-tetra-hydrocannabinol(THC),whichcausesthepsychoactiveeffectsofcannabis.THCisstoredinthefatcellsofthebodyandproducesanaccumulativeeffectovertime.Toleranceanddependencecanoccurwithprolongedregularuse,whichmayleadtosymptomsfollowingcessation.
Cannabismainlyaffectsthecentralnervousandcardiovascularsystems.
Thereisgrowingevidenceandmedicalliteraturethatindicatesanassociationbetweenregularcannabisuseandthedevelopmentofpsychosis.Mostindividualswhopresentwithcannabisinducedpsychosishaveahistoryofriskforpsychosis(afamilyhistoryofpsychoticillnessesorapre-morbidhistoryofmentalhealthchangesthat,inretrospect,areoftenidentifiedaspre-psychoticsymptoms.Apresentationofcannabisinducedpsychosisismorecommonthanapresentationofsignificantwithdrawalsymptomsassociatedwiththecessationofcannabisuse.Afirstepisode,orearlypresentation,ofpsychosisinanadolescentoryoungadultmaybeanindicationforreferraltoamentalhealthprofessional.,insomecases,referraltoanacutecaresetting(hospitalEmergencyDepartment)formedicalandpsychiatricassessmentmayberequired.Riskassessmentisstronglyadvisedtodeterminetheappropriatesettingformedicalcareofayoungpersonwithnewpsychosis.
Symptoms of intoxication:• relaxation
• euphoria
• disinhibition
• sleepiness
• hunger
• feelingofwellbeing
• perceptualdistortions
• impairedmemory
• depersonalization
Signs of intoxication:• conjunctivalinjection
• tachycardia(sometimeswithpalpitations)
• orthostatichypotension(sometimesresultinginsyncope)
• drymouth
• impairedcoordination
Peripheral effects of cannabis• tachycardia(heartrate>100)
• vasodilation
• bronchodilation
• musclerelaxant
• orthostatichypotension
• reducedintra-ocularpressure
• anti-emetic
• analgesia
• anticonvulsanteffects
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Acute toxicity:• anxiety
• confusion
• panicattacks
• delusionsofpersecution
• visualhallucinations
• short-termmemoryandattentionimpairment
• impairmentofmotorskills
Cannabis CessationSymptoms of cannabis cessation:• anxiety,restlessnessandirritability
• insomnia
• lethargy
• cravings
• increasedbodytemperature
• tremors
• milddepressivefeatures
• panicattacks
• nightmares
• anorexia
• nauseaandvomiting
• sweating(especiallynightsweats)
• headaches
• moodswings
Muchlesscommonarephysicalsymptomssuchasgastrointestinaldistress,diaphoresis,chills,nausea,shakiness,andmuscletwitches.
TheDSMVhasnowrecognizedandhasincludedmarijuanawithdrawal,thecriteriaareasfollows:
1.Hadrecentlystoppedusingmarijuanaafterhavinguseditheavilyforalongtime.
2.Experiencesatleast3ofthefollowingwithdrawalsymptomswithinseveraldaysofstoppingmarijuanause:
• Anger,irritabilityorfeelingsofaggression
• Depressedmood
• Feelingsofrestlessness
• Alossofappetite(orweightloss)
• Insomniaorothersleepingproblems
• Feelingsofanxietyornervousness
• Physicalsymptomsofwithdrawal,suchasheadache,stomachpains,increasedsweating,fever,chillsorshakiness.Tocountasasymptomsofwithdrawalatleastoneoftheabovelistedphysicalsymptomsmustbepresentandtheseverityofthesymptom(s)mustbegreatenoughtocausesubstantialdiscomfort
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3.Thesymptomsofwithdrawalaresevereenoughtocausethepersonsubstantialproblemswithfunctioningatworkorinsocialsituations–orsignificantimpairmentinfunctioninginotherimportantareas.
4.Thesymptomsofwithdrawalcannotbebetterexplainedbyanotherphysicalormentalhealthcondition.
Managing Cannabis WithdrawalPurposeToprovidestaffwithprotocolsforthemanagementofsymptomscausedbythecessationofcannabis.
PrincipleTomanagecannabiscessationbyminimizingprogressionofsymptoms,byaccurateassessmentofsubstancehistoryandrelevanthealthissues,andbyearlyrecognitionandtreatmentofsymptoms.
MedicationBenzodiazepinesarenotindicatedforcannabiswithdrawalexceptinexceptionalcases(i.e.extremeanxiety,psychosis,and/oraggression)andthenonlyonanextremelylimited,prnbasis.
Assessment1.Detailedhistoryofcannabisuse
• patternofuseandforhowlong
• methodofadministration,e.g.,ingested,“joint,”or“bong”
• symptomsofdependence
2.Concurrentuseofothersubstances,includingtheuseoftobaccoandcannabismix3.Previouswithdrawalattempts:
• withdrawalsymptomsexperienced
• symptomaticmedicationused
• anycomplications
4.Medicalandpsychiatrichistory
Examination1.Evidenceofintoxication2.Evidenceofwithdrawalsymptoms—recordabaselineofwithdrawalsymptomsbyusingan
ObjectiveCannabisWithdrawalAssessmentScale3.Vitalsignsandweight
Pathology investigations1.Urinedrugscreen,ifconcernedaboutundisclosedsubstanceuse
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Management of WithdrawalSomeadolescentswillreportexperiencingsomeminorphysicalsymptomsinthefirstfewdaysfollowingcessationofmarijuanause.
1.Oftenadolescentsmayrespondbettertoaperiodofreductionandcontrolleduseofcannabisbeforetheydecideonanepisodeofabstinence.
2.Symptomsofcessationcanalsobeminimizediftheyoungpersonhasbeenreducinghisorhercannabisuseovertime.
3.Whentheyoungpersonisreferredforwithdrawalinaresidentialwithdrawalsetting,itisadvisableforhimorhertobemanagedbyreducingthecannabiswhilewaitingtobeadmitted.
Supportive Care1.Informationaboutwhattoexpect2.Supportivecounselling3.Educationaboutdrinkingfluidsandmaintainingnutritionthroughoutthewithdrawalperiod
Pharmacological Management of Cannabis WithdrawalMostadolescentsdonotrequiremedicationforthecessationofcannabis.Oftencannabisismixedwithtobacco(e.g.“joints”)andtheremaybesymptomsofnicotinewithdrawalwhentheamountoftobaccoisreducedthroughthecessationofcannabis.
Astherearerisksinvolvedinintroducingadolescentstobenzodiazepines,extremecautionmustbeusedinprescribingthem,evenforashorttime.Theprosandconsmustbeconsideredbeforemedicatingyoungpeoplewithbenzodiazepines.Forthepurposeofcannabiswithdrawal,benzodiazepinesareusuallyusedasalastresort.
ProcedureMonitorthewithdrawalepisodeandnotehowtheyoungpersoniscoping
MedicationWhenmedicatingadolescentsinwithdrawal,theirbodyweightandstaturemustalwaysbeconsidered,asadultdosesmayresultinover-medicatingofsmall-statureadolescents.Therecommendeddosagesintheseguidelinesmayneedtobereduced.
Headaches • Acetaminophen325–650mgq4hprn
• Ibuprofen200–400mgq4hprn,nottoexceed1200mg/day
TheamountofacetaminophenadministeredtoadolescentswhoareHepatitisC–positivemustbemonitored,asitmayadverselyaffectliverfunction.
Generallyyoushouldnotexceed4000mgofacetaminophenina24-hourperiod.
Adolescent Withdrawal Management Guidelines 201394
Agitation or aggression• Low-dosesecond-generationantipsychotic(e.g.olanzapine5mg,quetiapine25–50mg)
Ifdiazepamisindicated:• Diazepamupto20mgdailyindivideddosesinitially,reducingdosesover3–5days(maximumof5
daysmedication)
Nausea and vomiting • Diphenhydramine25–100mgq6–8hprn
OpioidsOpioidsareaclassofdrugsthatincludeopium,morphine,andcodeineproduceddirectlyfromthepoppyplantandheroin,whichisfurthersynthesizedandthenavarietyofothersemi-syntheticandfullsyntheticformulations.Theyareprescribedasanalgesicsforbothcancerrelatedandnon-cancerpain.Theuseofopioidsforillicitpurposeshasalongstandinghistorythathasmostrecentlybeenhighlightedbythemassiveupswinginuseofprescriptionopioidsforrecreationaluse,inparticularbyyoungpeople.NovaScotia,aswellasotherjurisdictionsinCanada,haswitnessedashockingimpactofprescriptionopioiduse,abuseanddependence.TheneedfortreatmentofOpioidUseDisordersandopioidwithdrawalhasdramaticallyincreased.
Types of opioidsTable1showsthegenericnames,tradenames,andapproximateequivalentdoseofopioidsavailableinCanada,brokendownbyagonists,agonists–antagonists,andantagonists.
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Prescription Opioids Available in CanadaTable5
Generic Name Trade Name Route of Administration
Approximate Equivalent Doses
AgonistsAlfentanil Alfenta Intravenous 0.4–0.8mgCodeine Various Oral 200mgFentanyl Duragesic Transdermal NAHydrocodone Tussionex OralHydromorphone Dilaudid Oral 4–6mgMethadone OralMorphine MOS,MSContin Oral 30mgOxycodone Percodan Oral 30mgPethidine Demerol Oral 300mgSufentanil Sufenta Intravenous 75mgTramadol Tramacet Oral 0.01–0.04mg
Agonists–AntagonistsBuprenorphine-naloxone
Suboxone Sublingual NA
Butorphanol Apo-Butorphanol Intranasal 2mgNalbuphine Nubain Subcutaneous 10mgPentazocine Talwin Oral 180mg
AntagonistsNaloxone Targin Intravenous NANaltrexone Revia Oral NA
Notes:Thedoses(milligrams)areapproximatelyequivalentto10milligramsofmorphineintramuscular.NA=non-applicable
Withtheexceptionofmethadoneandbuprenorphine,theopioidagonistsandagonists–antag-onistsareconsideredshort-acting,withtheiranalgesiceffectlastingapproximately4–6hours.
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Signs and symptomsSigns and symptoms of opioid intoxication• euphoria
• sedation
• analgesia
• constipation
• itchingandscratching
• miosis(constricted,“pinpoint”pupils)
• bradycardia(heartrate<60)
• hypotension
• respiratorydepression
• recentuseofinjectionsites(ifintravenoususer)
Signs of opioid overdose• respiratorydepression(<12breaths/min)****mostimportantsign****
• labouredandnoisybreathing
• hypothermia
• bradycardiawithweakpulse
• miosis(constricted,“pinpoint”pupils)
• cyanosis
• decreasedlevelofconsciousness
Signs and symptoms of opioid withdrawal• hotandcoldflushes
• sweating
• yawning
• lacrimation
• rhinorrhea
• mydriasis(dilatedpupils)
• piloerection(erectionofthehairfollicles—“goosebumps”)
• nauseaandvomiting
• anorexia
• diarrhea
• tremor
• muscletwitches
• muscleandjointaches
• abdominalcramps
• anxietyandrestlessness
• insomnia
• cravings
• lethargyandweakness
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Onset of opioid withdrawal symptomsOpioidwithdrawalsymptomsmaybegin6–12hoursafterthelastdose,peakat48–72hours,andsubsideafter7–10days.Thetimingofonsetanddurationofwithdrawalisprotractediftheindividualisusinglongactingopioids,suchasmethadone.Theseverityofthewithdrawalfromopioidsisdeterminedbyanumberoffactorsincluding:• dosage
• frequency
• chronicityofuse
• routeofadministration
• extentofotherdrugandalcoholabuse
• theextentofdrug-relatedmedicalandpsychiatriccomplications
Signs of toxicity or overdoseNursingstaffshouldassesstheyoungpersonforsignsoftoxicityoroverdose.Iftheyoungpersonisdrowsy,donotadministeranymedication(particularlyopioidsorbenzodiazepines)thatislikelytomakehim/hermoresedated.Stage1• slurredspeech
• unsteadygaitandpoorbalance
• drowsiness
• slowedmovement,sloweating
• stupor(confusion)
• noddingoffforprolongedperiods
Stage2:Coma—SeriousEmergency• unrousable,unresponsive,unabletobe
awakened
• snoring,gurgling,orsplutteringwhenbreathing
• sloworshallowbreathing,orapnea
• floppylimbsandneck
• bluelipsandfingers
• pale,clammyskin
• eyesrollingback
TheyoungpersonMUSTbereviewedbythepharmacotherapyprescriberassoonastoxicityorover-medicationissuspected.However,iftheyoungpersonisinStage2(coma),callanambulanceimmediatelyandadministerNarcanandrespiratorysupport.Allwithdrawalunitsshouldhavepulseoximetersaspartofvitalsignchecks.Inanemergency,administeroxygen(ifavailable)andcommenceCPR.Allwithdrawalunitsshouldhavenarcanonsite.
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Managing Opioid WithdrawalPurposeToprovidestaffwithanunderstandingofthetoxicitiesassociatedwithopioiduseaswellasthemedicationsusedfortheeffectivemanagementofopioidwithdrawalsymptoms.
PrincipleToensurethatstaffmanageopioidwithdrawalbyminimizingprogressionofwithdrawal,byaccurateassessmentofsubstancehistoryandrelevanthealthissues,andbyearlyrecognitionandtreatmentofwithdrawal.
Clinical ManagementAssessment1.Detailedhistoryofopioiduse:• typeofopioid
• quantityofopioid
• routeofadministration
• patternofuseandforhowlong—alwaysdocumentthetimeoflastuse
• routeofadministration(oral,nasal,oriducanallresultindependence)
2.Concurrentuseofothersubstances3.Previouswithdrawalattempts:• withdrawalsymptomsexperienced
• symptomaticmedicationused
• anycomplications
• previousmedicalmanagementofopioidwithdrawal
• previoushistoryofOpioidSubstitutionTherapy(MethadoneorSuboxoneMaintenanceTreatment)
4.Medicalandpsychiatrichistory
Examination1.Evidenceofintoxication2.Evidenceofwithdrawalsymptoms3.Vitalsignsandweight4.Injectionsites(ifinjectingdruguser)5.Physicalsignsofliverdisease,e.g.,jaundice
Pathology investigations1.CBC,electrolytes,glucose,creatinine,BUN2.Liverfunctiontests3.HepatitisBandCandHIVscreening(ifinjectingdruguser)4.Urinedrugscreen,ifconcernedaboutundisclosedsubstanceuse
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Pre-andpost-testcounselingmustalwaysbegivenpriortoandfollowingblood-bornevirusscreening.
Supportive care1.Informationaboutwhattoexpect2.Supportivecounselling3.PsychologicalsupportfromcarersinHome-BasedWithdrawal4.Educationaboutdrinkingfluidsandmaintainingnutritionthroughwithdrawalperiod
Assessing the severity of opioid withdrawal symptomsTheClinicalOpiateWithdrawalScale
Clinical considerationsWhenmedicatingadolescentsinwithdrawal,theirbodyweightandstaturemustalwaysbeconsidered,asadultdosesmayresultinover-medicatingofsmall-statureadolescents.Therecommendeddosagesintheseguidelinesmayneedtobereduced.ItisimportantthatyoungpeoplebeingstartedonMethadoneorSuboxoneareeducatedaboutthepossiblerisksoftoxicityandoverdose.Theriskofoverdoseishighestinthefirst14daysoftreatment,duetoeitheradosethatistoohighorlowtolerancetothemedication.Theuseofotherdepressantmedicationalsoaddstotherisk.
Pharmacological management of opioid withdrawalThereissubstantialevidenceforthreedifferentPharmacotherapiesforthepharmacologicalmanagementofopioidwithdrawal:• Suboxone(buprenorphine/naloxone)
• Methadone
• AbstinenceBasedtreatments:includingsymptomatictreatmentwithClonidine(Capapres)
ThefollowingisincludedintheCentreforAddictionandMentalHealth(CAMH)BurpenorhineClinicalGuidelinesfrom2011(2012updatedversion)):
• Whilescientificdataontheuseofmethadoneandbuprenorphineinadultswithopioiddependenceisplentiful,thereisverylittleliteratureaboutsubstitutiontherapyinadolescents(13-18years)andlessso,inyouthandyoungadults(18-25years).Afewstudiesfromthe1970saddresstheuseofmethadonefordetoxificationandsubstitutiontherapyinadolescents.RecentliteraturefromAustraliaandtheUnitedStateshasexaminedtheuseofbuprenorphineforreplacementtherapyandformedicationassistedwithdrawalmanagement.[6,7,8,9,10,11,12,13,14,15].Dataonshort-termdetoxificationwithbuprenorphineshowsevidenceofdecreaseduseofopioidsandenhancedengagementintreatmentfollowinga3daydetoxschedule.[11].Longerwithdrawalschedulesaremorelikelytoincreaseratesofabstinenceandsustainedengagementinrecovery.Pendingresearchresultscomparing1-2weekand3monthdetoxificationschedules,bothincombinationwithpsychosocialtherapy,areeagerlyanticipated.[10].
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• Withrespecttoagefortreatmentinitiation,therecentstudiesincludeparticipantsbetweentheagesof13-18years,withnoburdenofcomplicationsorpooroutcomesinyoungerversusolderadolescents.Atpresent,buprenorphine/naltrexoneproductsarelicensedforuseintheU.S.forpersonsage16yearsandolder.JurisdictionsinEurope,arelicensedtotreatadolescents14yearsandup.InCanada,atpresent,Suboxoneislicensedonlyforpatients18yearsorolder.UseinyoungerindividualswouldbeanofflabeluseofSuboxoneandtheadolescentshouldbeadvisedofthis.
• Recentstudiesclearlyrevealthatbuprenorphinewithbehavioralinterventionsissignificantlymoreefficaciousinthetreatmentofopioid-dependentadolescentsrelativetocombiningclonidineandbehavioralinterventions.[9].
• Concernoverinducingtolerancebyadministratingmethadoneisonereasonwhytheavailabilityofthepartialagonistbuprenorphinehasbeenseenasausefulalternativeforyoungopioidusers.Youngerpatientswhopresentfortreatmentofopioiddependenceoftenhaveashorterhistoryofdrugusethantreatment–seekingadults.ReflectionsfromAustralianexperienceinclude:“Intreatingyoungpeoplewithrelativelybriefhistoriesofheroinuse,andoftenwithsignificantpolydruguse,itissometimeseasiertorecognizequiteseveredrugrelatedproblemsthantobeconfidentthatthepersonisusingopioidsregularlyenoughtoproduceneuroadaptation.”[7]
• Buprenorphinewithitshigheraffinityfortheopioidreceptorthanfullagonists,providesablockthatmaydiminishpatients’abilitytobecomeintoxicatedwithotheragonistswhilereceptorsaresaturated.Buprenorphinetherefore,hasseveraladvantagesovermethadone,includinglowerabusepotentialandastrongersafetyprofile.Additionally,withbuprenorphine’sslowdissociationfromthemureceptor,discontinuationofbuprenorphinetreatmentresultsinreducedwithdrawalsymptomsrelativetodiscontinuationoffullagonists.Thisrepresentsanadvantageovermethadoneinapopulationwheredetoxificationorstabilizationandexpeditedwithdrawalschedulesaredesirable.
• Foradolescentandyouthwhoarediagnosedasopioiddependent,treatmentoptionsshouldbeofferedincludingmedicallysupportedwithdrawalmanagement,opioidassistedwithdrawalmanagement,andsubstitutiontherapy.Buprenorphineoffersdistinctadvantagesovermethadoneforsubstitutiontherapyinadolescentsandyoungadults.Atpresent,buprenorphineisnotliscencedinCanadaformedicationassisteddetoxification.Buprenorphineforopioidwithdrawalmanagementwouldbeanofflabeluse,atpresent.
• TheuseofbuprenorphinetotreatopioidusedisordersinadolescentsandyouthiswellestablishedinEuropeandAustralia.RecentliteraturefromtheUnitedStatesshowsthatcombiningbuprenorphinewithbehavioralinterventionsissignificantlymoreefficaciousinthetreatmentofopioiddependentadolescentsrelativetocombiningclonidineandbehavioraltherapy(8).Thepharmacologicadvantagesofapartialagonistoverafullagonistrenderbuprenorphinefavourableinmedicationassistedwithdrawaltreatmentforopioiddependenceinyoungpersons.[7].Optimaldurationofdetoxificationpharmacotherapyisthetopicofongoingresearch.USresearchsuggeststhatthatlongerduration(12weeksversus14days)ofbuprenorphinetreatmentsignificantlyimprovesoutcomes(10).Australiandatareviewingtreatmentretentioninadolescentpatients(age14-17years)treatedwithmethadoneorbuprenorphineforopioiddependencesuggeststhatbuprenorphinebethefirstlinepharmacotherapyforsubstitutiontreatment.[7].
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Theprescribingofmethadoneandsuboxoneshouldbedoneinconsultationwithaphysicianwhohasanexemeptiontoprescribelongactingopioidsinthetreatmentofopioiddependence.Theprotocolsforprescribingshouldbeincompliancewiththenovascotiaguidelinesforprescribingmethadone.Anoutlineofsomesuggestedprotocolsforprescribingsuboxoneormethadoneareasfollows:
Suboxone (buprenorphine/naloxone) for chemical withdrawalProcedureThegoalistohavewithdrawalsymptomsrelievedfor24hoursandtotheninitiateataperingregimeoffthestabilizationdose.
TodetermineastabilizationdoseofSuboxone(buprenorphine/naloxone):Day 11.Patientswhoareexperiencingobjectivesignsofopioidwithdrawal(COWSequaltoorgreater
than13)andwhoselastuseofashort-actingopioid(seeTable1)wasmorethan12to24hourspriortotheinitiationofinductioncanreceiveafirstdoseof4/1mgofSuboxone.
2.Givethefirstsublingualtablet(supervised)onlywhenthepatientisinwithdrawal.Ifthepatientisnotinwithdrawal,Suboxonemayprecipitatewithdrawalbecauseitdisplacesotheropioidsfromtheopioidreceptors.
3.IftheinitialdoseofSuboxoneis4/1mgandopioidwithdrawalsymptomssubsidebutthenreturn(orarestillpresent)after2hours,aseconddoseof4/1mgcanbeadministered.
4.ThetotalamountofSuboxoneadministeredinthefirst24hoursshouldnotexceed8/2mg.
Day 21.PatientswhodonotexperienceanydifficultieswiththefirstdayofSuboxonedosingandwho
arenotexperiencingwithdrawalsymptomsonDay2areconsideredstabilizedfromtheiropioidwithdrawalsymptoms.
2.ThedailystabilizationdoseofSuboxoneisequivalenttothetotalamountofSuboxonethatwasadministeredonDay1.OnDay3,thetaperingregimemaybegin(seeTaperingRegimebelow).
3.Dosesmaybesubsequentlyincreasedin2/0.5to4/1mgincrementseachday,ifneededforsymptomaticrelief,withatargetdoseof12/3to16/4mgperdaytobeachievedwithinthenext2days.Onceastabilizationdoseisachieved,thetaperingregime(seebelow)maybeinstituted.
Tapering RegimeDecreasethestabilizationdoseby2/0.5mgincrementsevery1–2daysbasedonsymptomrelief.RefertoTable2foranexampleoftheestablishmentofastabilizationdoseandtaperingregimeforSuboxone.
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Suboxone (Buprenorphine/Naloxone)* Stabilization and Tapering Reduction RegimeTable6
Day Suboxone buprenorphine/naloxone ) Total daily doseEstablishingthestabilizationdoseDay1 •ForCOWS≥13,giveaninitialdoseof4/1mg**
•Observein2hours•Ifstillexperiencingopioidwithdrawalsymptoms(COWS≥13),administeranother4/1mgdose
4/1–8/2mg
Days2–3 AssesswithdrawalsymptomsusingCOWSForCOWS≤13,givethetotalDay1doseforDays2and3andtheninitiatetaperonDay4
4/1–8/2mg
ForCOWS≥13,givethetotalamountofSuboxoneonDay1andincreasedoseevery2hourstoadosagerangeof12/3–16/4mg
12/3–16/4mg
TaperingSchedule(examplebasedonastabilizationdoseof12/3and2/0.5mgdecreasesevery2days)Day4 10/2.5mgDay5 10/2.5mgDay6 8/2mgDay7 8/2mgDay8 6/1.5mgDay9 6/1.5mgDay10 4/1mgDay11 4/1mgDay12 2/0.5mgDay13 2/0.5mgDay14 0mg
Notes*Suboxone(buprenorphine/naloxone)isavailableintwodifferentsublingualdosagestrengths:
• 2mgbuprenorphine/0.5mgnaloxone
• 8mgbuprenorphine/2mgnaloxone
Thepurposeofthenaloxonecomponentistodeterintravenousadministrationofthesublingualtablet.**Toachievealoadingdoseof4/1mg(i.e.4mgofbuprenorphine/1mgnaloxone),two(2)ofthe2mgSuboxonesublingualtabletsshouldbedosedsimultaneously.Dissolutiontakesabout2to10minutes.Adaptedfrom:Kahan,M.,Srivastava,A.,Ordean,A.&Cirone,S.(2011).
103Adolescent Withdrawal Management Guidelines 2013
Someindividualswilleitherrequestorrequirelongertreatmentthan2weeks.OpioidSubstitutionTherapy(OST)foradolescentswithOpioidUseDisordersisappropriateforthoseindividualswhohavebeenassessedbyaphysicianwhoiseducatedintheuseofSuboxoneforthetreatmentofOpioidDependenceandwhoaredeemedclinicallysuitableforSuboxoneOST.
Methadone for chemical withdrawal supportProcedureMonitorvitalsignspriortotheadministrationofeachmedicationdose.
Day 1Todeterminemethadonestabilizationdose:• AdministerMethadone20mgpox1loading
doseforClinicalOpiateWithdrawalScale(COWS)scoresequaltoorgreaterthan13.
• Threehourspostloadingdose,administerMethadone5mgpoq3hprnwhileCOWSscoreremainsequaltoorgreaterthan13,toamaximumtotaldoseof40mgin24hours.
Forindividualsstabilizedonlessthanmetha-done40mg,contactphysicianforspecificmethadonetaperingschedule.Donotproceedwithordersbelow.
Day 2 Methadone20mgpobidFirstdosetobeadministeredaminimumof6hoursafterlastdoseonDay1.
Day 3 BeginMethadoneTaperingSchedule(SeeTaperAlgorithmbelow)thisregimeisNOTwhatwouldbeprescribedinthecommunity,butaslongasthereis24hourmedicalsupport,thismaybefeasible.Inthecommunity,amaximumstartingdoseofonly30mgispermittedduetosafetyissuesandriskofoverdoseanddeath.
Methadone Withdrawal Taper AlgorithmTable 7
Taper Day Morning Dose (mg)1 352 353 304 305 256 257 208 209 1510 1511 1012 1013 514 515 0
Foradolescentsandyouthwhomayrequestorrequirelongertreatmentwithopioidsubstitu-tion,methadonemaintenancetreatmentisanoption.Inthiscase,theindividualshouldbeseenandassessedbyaphysicianwitheduca-tioninthetreatmentofOpioidDependencewithOpioidSubstitutionTherapyandanex-emptiontoprescribemethadone,ifmethadonemaintenanceisthetreatmentofchoice.
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ClonidineClonidineisseldomusedasanopioidwithdrawalmedication.Historicallyitisnotwelltoleratedbyadolescents.However,manyyouthmaynotbeinterestedintreatmentwithanopioidsubstituteandmayrequestabstinencebasedtreatment.Inthiscase,symptomatic/supportivemedicalmanage-mentofwithdrawalispossiblewiththeuseofclonidineandothermedicationstotreatwithdrawalsymptoms.Also,foryouthwhoareinterestedinSuboxoneassistedwithdrawalmamagement,iftheyarenotyetinwithdrawalwithaCOESscale>13,theymaybewellsupportedwithmedicaiotnsforsymptomaticreliefofwithdrawalsymptoms.InanticipationofadministeringSuboxone,whichhasasedativeeffect,usuallyothersedativemedicationswouldbeavoided.
ProcedureMonitortheyoungperson’sbloodpressurepriortoadministeringclonidinetoensurethatthepos-sibleresultanthypotensionwillnotadverselyaffecttherecipient.Giveaninitialtestdoseofclonidinetodeterminetheeffectsonbloodpressure.Monitorbloodpressureeverythirtyminutesfortwohoursfollowingtheadministrationofthetestdose.Iftherearenoadversereactionstothetestdose,commenceareducingregimeofclonidine.Iftheyoungperson’ssystolicreadingisover80mmHgandpulseisover60b.p.m.forbothreadings,andtheyoungpersonisnotcomplainingoforshowingsignsofdizziness,theclonidinedosemaybegiven.
Precaution: Useclonidinewithcautioninpatientswithpre-existingheartdiseaseorthosewhoareonantihypertensives.Cautionpatientsabouttheriskofdizziness/syncope,andadvisethemtoavoiddrivingorusingthebathtubuntiltheyknowhowtheywilltoleratethedose.
Table4illustratestheClonidineprotocoltomanageopioidwithdrawalsymptoms.
Clonidine ProtocolTable8
Protocol for clonidine dosing IfBP>90/60: Give0.1mgt.i.d.–q.i.d.prnfor5–7days
Warnaboutposturalsymptoms,drowsiness,driving;noprolongedhotshowersorbaths(venousdilatationcancausehypotension)
If0.1mgineffective:
Increaseto0.2mgt.i.d.–q.i.d.prnMonitorforhypotension
Continue Canbeusedfor5–7daysasanoutpatient
Source:Kahan,M.&Wilson,L.(2002).
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Symptomatic Medication RegimeAches and painsIbuprofen(Advil/Motrin)200–400mgq4hprn,nottoexceed1200mgin24hours
Nausea & vomitingDiphenhydramine25–100mgq6–8hprn
DiarrheaLoperamideHydrochloride2mg4mginitially,then2mgaftereachloosebowelaction,tomaximumof16mg/dayorLoperamideHydrochloride(Imodium)2mgt.i.d.
Precaution: Topreventanypossibledruginteractions,donotuseanymedicationcontainingatropine(e.g.,Lomotil)iftheyoungpersonisbeingadministeredclonidine.
StimulantsSome common stimulants:• amphetamine(speed)
• methamphetamine(crystal,meth,ice,speed)
• cocaine(coke)
• methylphenidate(Ritalin)
• khat(plant-derivedCNSstimulant)
Stimulant EffectsStimulantsarecentralnervoussystemstimulantsthathaveaperipheralsympathomimeticaction.
Signs of intoxication:• talkative
• vagueconcerns
• fidgety
• scratching
• twitching/shaking
• tremor
• ambivalent
• nervoustension
• rocking
• sniffing
• stereotypicalmotorbehaviour
• repetitiveness/pressureofspeech
• euphoriaandexhilaration
• enhancedself-confidence
• disinhibition
• tangentialthinking
• decreasedappetite
• tachycardia
• hypertension
• tachypnea(rapid,shallowbreathing)
• hyperthermia
• mydriasis(dilatedpupils)
• drymouth
• nauseaandvomiting
• insomnia
• confusion
• aggression
• paranoia
• panic
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Stimulant ToxicityTable9
Organ System Medical EffectsHead,eyes,ENT Pupildilation,headache,bruxismPulmonary(especiallyifdrugissmoked)
Hyperventilation,dyspnea,cough,chestpain,wheezing,hemoptysis,acuteasthmaexacerbation,barotrauma(pneumothorax/mediastinum),pulmonaryedema
Cardiovascular Tachycardia,palpitations,increasedBP,arrhythmia,chestpain,myocardialisch-emia/infarct,rupturedaneurysm,cardiogenicshock
Neurologic Headache,agitation,psychosis(especiallytactilehallucinations),tremor,hy-perreflexia,smallmuscletwitching,tics,stereotypedmovements,myoclonusseizures,cerebralhemorrhage/infarct(stroke),cerebraledema
Gastrointestinal Nausea,vomiting,mesentericischemia,bowelinfarctorperforationRenal Diuresis,myoglobinuria,acuterenalfailureduetorhabdomyolysisMildfever Mildfever,malignanthyperthermia
Signs of acute toxicity: • paranoia,hyperarousal,andbizarre,violent,anderraticbehaviours
• severeheadache(onsetimmediatelyafterusingamphetaminesshouldalerttothepossibilityofintracranialhemorrhage)
• cerebrovascularaccident(cocaine/otherstimulantuseshouldbeconsideredinanyyoungpersonpresentingwithacerebrovascularaccident)
Ifthereareanytroublingsignsorsymptomsofacutestimulantintoxication,patientsshouldbeassessedinanEmergencyDepartmentearlybecausetherearesomecomplicationswithhighmorbidityandpossiblemortality.
Signs of chronic use:• weightloss
• memoryimpairment
• poorconcentrationandattention
• sleepdisturbances
• hallucinationsandflashbacks
• depression
• panicattacks
• acutepsychoticepisodesresemblingparanoidschizophrenia
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Methylene dioxy-methamphetamine (MDMA, Ecstasy)MDMAissimilarinstructureandaffecttoamphetamines,butactsasahallucinogenaswell.MDMAstimulatesthecentralnervoussystemandalsoaffectsperception.
Signs of MDMA intoxication:• tachycardia
• hypertension
• hyperthermia
• increasedconfidence
• jaw-clenching,bruxism
• feelingsofwell-being
• nausea
• feelingsofclosenesstoothers
• anxiety
• anorexia
• sweating
MDMA taken in greater quantities may produce:• vomiting
• floatingsensations
• irrationalorbizarrebehaviour
• hallucinations
• convulsions
Signs of acute MDMA toxicity:• hyperpyrexia/hyperthermia
• extremehypertension
• dehydration
• tachycardia
• cardiacarrhythmia
• hallucinations
• seizures
Features of stimulant withdrawal In first 2–3 days (“crash”):• exhaustion
• increasedsleep
• depression,anxiety
Following days or weeks:• irritabilityandanxiety
• cravings
• moodswings
• poorconcentration
• hypersomnolence/sleepdisturbances(increaseddreamingduetoincreasedREMsleep)
• increasedappetite
• depression
• paranoiddelusionsandpsychoticphenomena
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Managing Stimulant WithdrawalPurposeToprovidestaffwithprotocolsforthemanagementofstimulantwithdrawal.
PrincipleTomanagestimulantwithdrawalbyminimizingprogressionofwithdrawalandbyaccurateassessmentofsubstancehistoryandrelevanthealthissues.
MedicationDiazepam(Valium)
Assessment1.Detailedhistoryofstimulantuse:
• typeofstimulantsused
• quantityofstimulantsused
• patternofuseandforhowlong
• routeofadministration(cocaine—inhalingcrack,snortingpowder,injection)
• riskofcomplicationsfromacuteorchronictoxicity
2.Concurrentuseofothersubstances3.Previouswithdrawalattempts:
• withdrawalsymptomsexperienced
• symptomaticmedicationused
• anycomplications
4.Medicalandpsychiatrichistory
Examination1.Evidenceofintoxication2.Evidenceofwithdrawalsymptoms3.Vitalsignsandweight4.Injectionsites(ifinjectingdruguser)5.Physicalsignsofliverdisease,e.g.,jaundice
Pathology Investigations1.Fullbloodexamination2.HepatitisBandCandHIVscreening(ifinjectingdruguser)3.Liverfunctiontests4.Urinedrugscreen,ifconcernedaboutundisclosedsubstanceuse5.bHCGiffemale
Pre-andpost-testcounsellingmustalwaysbegivenpriortoandfollowingblood-bornevirusscreening.
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Supportive Care1.Informationaboutwhattoexpect2.Supportivecounsellingfromthenurseandotheralliedhealthworkers3.PsychologicalsupportfromcarersinHome-BasedWithdrawal4.Educationaboutdrinkingfluidsandmaintainingnutritionthroughoutwithdrawalperiod5.Emphasisonrest,exercise,andhealthydiet
Pharmacological Management of Stimulant WithdrawalAlthoughamphetamineuseisincreasing,mostusersarenotdependent.
Whileamphetaminewithdrawalisawell-describedclinicalentity,thereislittleevidence-basedinformationonmedicationthatwillamelioratewithdrawaldiscomfortintheshortorlongterm,orfacilitatelong-termabstinence.
Mostadolescentsdonotrequiremedicationforstimulantwithdrawal.However,someadolescentsmayrequireashortcourseofdiazepamifthereissevereagitationoraggression.Astherearerisksinvolvedinintroducingadolescentstobenzodiazepines,cautionmustbeusedinprescribingthem,evenforashorttime.Theprosandconsmustbeconsideredbeforemedicatingyoungpeoplewithbenzodiazepines.
Risks of benzodiazepine use are:• potentialforabuse
• delayedreturnofnormalsleeppatterns
• developmentofdependenceonbenzodiazepines
• interactionwithothermedications/substances
IftheyoungpersonisusingEcstasy,itisveryimportantthatthemedicalpractitionerisawareofthis,asprescribingMono-AmineOxidaseInhibitors(MAOIs)mayleadtoahypertensivecrisisintheyoungperson.
MedicationWhenmedicatingadolescentsinwithdrawal,theirbodyweightandstaturemustalwaysbeconsidered,asadultdosesmayresultinover-medicatingofsmall-statureadolescents.Therecommendeddosagesintheseguidelinesmayneedtobereduced.
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Agitation or aggression• de-escalatingtechniques
Ifdiazepamisindicated:• diazepam5–10mginitially
• repeatafter30–60minutesifnecessary
• maximumof20mgdailyfor2days,reducingthedoseovernext3–5days
Serotonin toxicity (“serotonin syndrome”)Stimulantshavethepotentialtocauseserotonintoxicity,particularlyiftakenincombinationwithantidepressantsorantipsychotics.
Serotonintoxicitymaybeamild,self-limitingconditionorbepotentiallyfatal,andpresentationcanbeveryvariable,butneuromuscularsignsareusuallyprominent.
Thetriadofchangesincludes:1.mentalstatuschanges(anxiety,confusion,agitation,lethargy,delirium,coma)2.autonomichyperactivity(low-gradefever,tachycardia,diaphoresis,nausea,vomiting,diarrhea,
dilatedpupils,abdominalpain,hypertension,tachypnea)3.neuromuscularabnormalities(myoclonus,nystagmus,hyperreflexia,rigidity,trismus,tremor)
Other features of serotonin toxicity:• diarrhea
• lightheadednessordizziness
• bladderorboweldysfunction
• headache
• blurredvision
• nasalcongestion
• convulsions
• coma
Management of serotonin toxicityMildcases:• providesupportivecare
• seekmedicaladvice
• givediazepam,upto20mgdailyindivideddoses
• maintainobservationuntilsymptomsresolve
Severecases:• callambulanceandtransporttohospital
formedicalintervention
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Stimulant-induced psychosis CasesofpsychosiswillbereferredouttotheEmergencyDepartment.
Itisadvisabletomonitoradolescentsforanysignsofdrug-inducedpsychoticphenomena,whichcanoccurinsusceptibleadolescentsfollowingstimulantuse.
Emergingpsychoticsymptomsshouldbemonitored,withareferraltotheappropriatementalhealthserviceforongoingassessment/treatment.
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Volatile substancesVolatile substance intoxicationVolatilesubstancesincludearangeofproductstypicallyusedbyadolescentstoproducetheeffectsofintoxication.Theyactasadepressantonthecentralnervoussystem.
Types of volatile substances:• adhesives
• aerosols
• cleaningagents
• solventsandgases
• petrol
Signs of intoxication:• excitementandeuphoria
• disinhibition
• drowsiness
• halitosis—breathoftenhasacetone(nailvarnish)smell
• nauseaandvomiting
• flu-likesymptoms
• epistaxis(nosebleeds)
• disorientation
• lackofcoordination
• dizziness
• slurredspeech
Effectswillvaryaccordingtothesubstanceused.
Long-term effects:• tremors
• weightloss
• lethargy
• increasedthirst
• anemia
• gastritisandcolitis
• rupturedbloodvesselsineyescausingrednessandeventuallyleadingtoblindness
• damagetothenervoussystem,liver,andkidneys
• cognitiveimpairment
• aggression
• depression
• paranoia
Signs of acute toxicity:• laryngealspasm
• stupor
• coma
• cardiacarrhythmias
• convulsions
• “suddensniffingdeath”
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Features of volatile substance withdrawal:Theseareusuallymild,butcanbeseverewithprotractedandheavyuse.• anxiety
• depression
• anorexia
• nauseaandvomiting
• irritability
• aggression
• dizziness
• tremors
• headaches
• tachycardia
• diaphoresis
Managing volatile substance withdrawalPurposeToprovidestaffwithprotocolsforthemanagementofinhalantwithdrawal.
PrincipleTomanageinhalantwithdrawalbyminimizingtheprogressionofwithdrawal,byaccurateassessmentofsubstancehistoryandrelevanthealthissues,andbyearlyrecognitionandtreatmentofwithdrawal.
MedicationDiazepam(Valium)Metoclopramide(Maxeran)—oralandintramuscularProchlorperazine(Stemetil)—oralandintramuscularAcetaminiphen
Assessment1.Detailedhistoryofinhalantuse
• typeofsubstance
• patternofuseandforhowlong
• symptomsofdependence
2.Concurrentuseofothersubstances3.Previouswithdrawalattempts:
• withdrawalsymptomsexperienced
• symptomaticmedicationused
• anycomplications
4.Medicalandpsychiatrichistory
Adolescent Withdrawal Management Guidelines 2013114
Examination1.Evidenceofintoxication2.Evidenceofwithdrawalsymptoms3.Vitalsignsandweight
Pathology investigations1.Fullbloodexamination2.Urinedrugscreen,ifconcernedaboutundisclosedsubstanceuse3.STIscreenv4.Hepatitisscreen5.bHCG
Management of WithdrawalSupportive Care1.Informationaboutwhattoexpect2.Supportivecounselling3.Educationaboutdrinkingfluidsandmaintainingnutritionthroughwithdrawalperiod
Pharmacological Management of Inhalant Withdrawal Whilethereisnoevidenceofaphysicalwithdrawalsyndromeassociatedwiththecessationofinhalantuse,anecdotallywefindthatsomeadolescentswillexperiencesomeminorphysicalsymptomsinthefirstfewdaysfollowingcessationofuse.
Mostadolescentsdonotrequiremedicationforinhalantwithdrawal.Staffmayimplementcopingstrategiesthataddresstheanxietyandsleepdisturbance.However,someadolescentsmayrequireashortcourseofdiazepamifthereissevereagitationoraggression.
Astherearerisksinvolvedinintroducingadolescentstobenzodiazepines,cautionmustbeusedinprescribingthemforevenashorttime.Theprosandconsmustbeconsideredbeforemedicatingyoungpeoplewithbenzodiazepines.
Risks of benzodiazepine use:• potentialforabuse++++++
• delayedreturnofnormalsleeppatterns
• developmentofdependenceonbenzodiazepines
• interactionwithothermedications/substances
ProcedureMonitorthewithdrawalepisodeandassesshowtheyoungpersoniscoping
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MedicationWhenmedicatingadolescentsinwithdrawal,theirbodyweightandstaturemustalwaysbeconsidered,asadultdosesmayresultinover-medicationofsmaller-statureadolescents.Therecommendeddosagesintheseguidelinesmayneedtobereduced.
Anxiety and aggressionIfdiazepamisindicated:• diazepamupto20mgdailyindivideddosesinitially,reducingdosesover3–5days
• maximumof5daysmedication
Nausea and vomitingMetoclopramide10mgt.i.d.oralasrequiredORProchlorperazine12.5mgt.i.d.oralasrequiredIntramuscularinjectionmayberequiredifthereisseverevomiting.
Dystonicreactionscanbeasideeffectofmetoclopramideandprochlorperazine,andadolescentsmustbecloselymonitoredfortheonsetofthis.Benztropinemesylate(Cogentin)2mgbyintramuscularinjectionwillresolvethesymptoms.
Reviewbyamedicalpractitionerfollowingtheonsetofdystonicreactionsisessential.
Headaches Acetaminophen1000mgq6Hprnandibuprofen600mgQ8Hprn
TheamountofacetaminophenadministeredtoadolescentswhoareHepatitisC–positivemustbemonitored,asitmayadverselyaffectliverfunction.Generally,paracetamolshouldnotexceed4gina
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Thefollowinginformationistakenfrom:BestPractices—EarlyIntervention,OutreachandCommunityLinkagesforYouthwithSubstanceUseProblems(HealthCanada,2008)
Injectiondrugusers,sex-tradeworkersandhomelessyouthareyoungercohortsatriskfortransmissionofblood-bornepathogenssuchasHIVandhepatitisBandC(Boivin,Roy,Haley,&GalbaudduFort,2005;HealthCanada,2001).Researchhassuggestedthatoneinfourindividualsinjectingdrugsmaybeundertheageof20(HealthCanada,2001).Youthwhosharedruguseparaphernalia,suchassyringes,rinsewater,intranasalstrawsandpipes,areatriskofinfection.…
Youthwhousecocainemaybeatgreaterriskofcontractingblood-bornepathogensbecauseofthehighnumberofdrugadministrationsperday.Demandsondruguseparaphernalia(injectionorinhalation)increasethetendencytosharesuppliesamongusers(HealthCanada,2001).
AstudybyMillsetal.(2004)examiningthepatternsofheroinusereportedthatyouth(aged18to24)onaveragefirstinitiatedheroinuseatage16andsubsequentlyinjectedatage17.Ofthiscohort,41%hadoverdosedintheirlifetime,with24%overdosingwithinthepast12months.Approximatelyoneinfivehadborrowedusedneedles,whileanotherthirdindicatedtheyhadgivenneedlestoothers.Femalesweretwiceaslikelyasmalestohaveborrowedusedneedles(Millsetal.,2004).AspartofanenhancedsurveillanceofCanadianstreetyouth,nearly30%ofyouthwhoinjecteddrugsreportedthattheyhadnotalwaysusedcleaninjectionequipment.Approximately31%reportedtheyhadborrowedusedequipmentfromsomeoneelseatleastonce(PublicHealthAgencyofCanada,2006).…
Interventionapproachesforyouthwhoinjectdrugsshouldincludeflexiblepoliciesandlow-thresholdprogramsdesignedtoengageandretainyouthinneededsupportandtreatmentoptions(HealthCanada,2002a;PublicHealthAgencyofCanada,2006).Effortsshouldalsoincludeadditionalservicesthataddressspecificbasicneed,healthandsupportservices.Outreachisoftenacriticalcomponentininitiatingearlyinterventionapproaches(HealthCanada,2002a).
ThefollowinginformationistakenfromtheCanadianAIDSTreatmentInformationExchange(CATIE)
Tattoos, Piercings, and Needle Sharing—Hepatitis C
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Tattooingandbody-piercingpracticesthatdonotadheretorecommendedguidelinesalsoposehealthrisks(HealthCanada,2008).
ManyCanadiannetworksfollowaharm-reductionapproachtodruguse,HIV,andHepatitisC.Harm-reductionactivitiesaremostlybasedonavoidinghavingoneperson’sbloodcomingintocontactwithanotherperson’sblood.TheCanadianAIDSTreatmentInformationExchange(CATIE)providesanabundanceofbestpracticeguidelinesandinformation.ThefollowingthreediagramsfromCATIEembodyaharm-reductionapproach: Dangerous!
Never inject here!
Better NOT to inject here,but safer than red. Inject withcaution slowly
These are the safest and best veins to use (rember to rotatesites!).
Never Injecting
Using Sterile
Unused Equipment Every Time
Cleaning Your Own
Equipment Every TIme
Sharing, Lending, Selling or
Borrowing Equipment
HarmfulInjection PracticesSafest
If you can’t go to a needle exchange, try finding the equipment at a pharmacy. If you’re in prison, cleaning your own equipment with bleach can stop some skin infection, but reusing equipment that someone else
has already used means you can get Hep C, even if you clean it. Using sterile unused equipment every time you inject in a safer option
Not UsedSwallowed or Inserted
Snorted or Smoked Injected
HarmfulCocain: How is it taken?Safest
The way you take drugs changed how risky they can be. Basically, eating them is safer than injecting,
while not using at all is the safest
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Sleep Disturbance in WithdrawalSleepdisturbanceiscommonamongsubstanceusers.Ongoingsubstanceuseisalsoacontributingfactortosleepdisturbances.
Itisextremelycommonforyoungpeopletoexperiencedifficultysleepingduringwithdrawal.Assleepdisturbanceisoneofthemainprimaryhealthissuesforadolescentsubstanceusers,itisimportanttogiveyoungpeopleanopportunitytodevelopeffectivesleepingstrategies.Theuseofmedicationtoinducesleepshouldbeconsideredastheexception,asmostmedicationwilloftendelaythereturnofnormalsleeppatternsandhasthepotentialforabuse.
Duringassessmentitisimportanttoexploresleepdisturbancewiththeyoungperson.
Sleepdisturbanceusuallyinvolvestheinitiation,maintenance,orqualityofsleep;itmaybehelpfultoaskthefollowing:1.Doyouhaveproblemsgoingtosleep?—initiatingsleep2.Doyouhaveproblemsstayingasleep?—maintainingsleep3.Doyoufeelrefreshedwhenyouwakeup?—qualityofsleep
DuringaHome-BasedWithdrawaloradmissiontoaResidentialUnit,thefollowingstrategiescanbeusedtopromotehealthiersleeppatterns.
Strategies to help improve sleep during withdrawal• Encouragetheyoungpersontoacceptthatdifficultysleepingispartofwithdrawalandwillpass.
Whenheorshegetsannoyedaboutnotsleeping,thiscausesanxiety,whichresultsinmoresleeplessness.
• Encouragearegularbedtimeroutineandregularsleep/wakeschedule.Gettheyoungpeopleupatthesametimeeachmorningeveniftheyarestilltired.Thisoftenresultsinthembecomingsleepieratnight.
• Encouragewindingdownbeforegoingtobed,byreading,listeningtorelaxingmusic,havingawarmbath(canusesomecalmingessentialoils),orusingrelaxationtechniques.
• Encourageeatingonlylightmealsatnight—theirbodiesneedtouseenergytorejuvenatethemselves,ratherthanspendthenightdigestingthefoodtheyhaveeaten.Especiallylimitstarchyfoodsafter5p.m.ifpossible.
• Encouragetheavoidanceofingestingcaffeine(e.g.,drinkingcoffee)after2p.m.
• Encouragetheavoidanceofdrinkingcarbonateddrinks.
• Encouragesomekindofphysicalactivityduringthedaytopromotetirednessatnight;however,avoidexercisingtoolateatnight.
• EncouragetheavoidanceofTVandstimulatingvideo/computergamesbeforebed.
• Encouragetheavoidanceofnapslateintheafternoon.
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• Advisenosmoking2hoursbeforebed.
• Createasleep-promotingenvironmentthatisdark,quiet,cool,andcomfortable.Theoptimumtemperatureforqualitysleepis19ºC.
• Encouragedrinkingchamomileteaorwarmmilkbeforegoingtobed,oriftheywakeduringthenight.Theuseofmagnesiumsupplementspriortobedcanassistwithrelaxation.
Ifmedicationsaregoingtobeused,goodchoicesare:Trazadone25–100mgQHS,Zopiclone2.5–7.5mgQHS,Quetiapine25–50mgQHS,Amitriptyline10–50mgQHS
Generallybenzodiaepinescanbeusedforsleepanddohelpintheshorttermafterstartingthem,butcarrysignificantriskofthedevelopmentoftoleranceanddependence.
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Appendix I: Modified Fagerström Tolerance Questionnaire
1. How many cigarettes a day do you smoke?
over26cigarettesaday 2
about16–25cigarettesaday 1
about1–15cigarettesaday 0
lessthan1aday 0
2. Do you inhale?
always 2
quiteoften 1
seldom 1
never 0
3. How soon after you wake up do you smoke your first cigarette?
withinthefirst30minutes 1
morethan30minutesafterwakingbutbeforenoon 0
intheafternoon 0
intheevening 0
4. Which cigarette would you hate to give up?
firstcigaretteinthemorning 1
anyothercigarettebeforenoon 0
anyothercigaretteintheafternoon 0
anyothercigaretteintheevening 0
5. Do you find it difficult to refrain from smoking in places where it is forbidden (e.g. church, library, movies)?
yes,verydifficult 1
yes,somewhatdifficult 1
no,notusuallydifficult 0
no,notatalldifficult 0
6. Do you smoke even if you are so ill that you are in bed most of the day?
yes,always 1
yes,quiteoften 1
no,notusually 0
no,never 0
7. Do you smoke more during the first 2 hours than during the rest of the day?
yes 1
no 0
Total score:
Appendices
Level of dependence on nicotine:
Score Level0–2 nodependence3–5 moderate
dependence6–9 substantial
dependence
Source:“TheFagerströmTestforNicotineDependence:arevisionoftheFagerströmToleranceQuestionnaire.”Heathertonetal.,1991.
Prokhorov,A.V.,Pallonen,U.E.,Fava,J.L.,Ding,L.,&Niaura,R.(1996).Measuringnicotinedependenceamonghigh-riskadolescentsmokers.AddictBehav,21(1),117–127.doi:10.1016/0306-4603(96)00048-2
Prokhorov,A.V.,Koehly,L.M.,Pallonen,U.E.,&Hudmon,K.S.(1998).AdolescentnicotinedependencemeasuringbythemodifiedFagerströmquestionnaireattwotimepoints.JChildAdolescSubstAbuse,7(4),35–47.
ProtocolhasbeendevelopedbymodifyingtheAddictionService’sNicotineWithdrawalProtocoltomeettheneedsoftheadolescentpopulation.
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Appendix II: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A)Source:AddictionResearchFoundation
Nausea & vomiting: Ask“Doyoufeelsicktoyourstomach?Haveyouvomited?”Observation.
nonausea/vomiting 0
1
2
3
intermittentnauseawithdryheaves 4
5
6
constantnausea,frequentdryheaves,andvomiting 7
Tactile disturbances: Ask“Haveyouanyitching,pins-and-needlessensations,burning,ornumbness?Doyoufeelbugscrawlingonorunderyourskin?”Observation.
none 0
verymilditching,pins-and-needles,burning,ornumbness 1
milditching,pins-and-needles,burning,ornumbness 2
moderatepins-and-needles,burning,ornumbness 3
moderatelyseverehallucinations 4
severehallucinations 5
extremelyseverehallucinations 6
continuoushallucinations 7
Tremor: Observation(armsextendedandfingersspreadapart).
notremor 0
notvisible,butcanbefeltfingertiptofingertip 1
2
3
moderate,withpatient’sarmsextendedv 4
5
6
severe,evenwitharmsnotextended 7
Adolescent Withdrawal Management Guidelines 2013122
Auditory disturbances: Ask“Areyoumoreawareofsoundsaroundyou?Aretheyharsh?Dotheyfrightenyou?Areyouhearinganythingthatisdisturbingyou?Areyouhear-ingthingsyouknowarenotthere?”Observation.notpresent 0
verymildharshnessorabilitytofrighten 1
mildharshnessorabilitytofrighten 2
moderateharshnessorabilitytofrighten 3
moderatelyseverehallucinations 4
severehallucinations 5
extremelyseverehallucinations 6
continuoushallucinations 7
Paroxysmal sweats: nosweatvisible 0
barelyperceptiblesweating,palmsmoist 1
2
3
beadsofsweatobviousonforehead 4
5
6
drenchingsweats 7
Visual disturbances: Ask“Doesthelightappeartobetoobright?Isitscolourdifferent?Doesithurtyoureyes?Areyouseeinganythingthatisdisturbingtoyou?Areyouseeingthingsyouknowarenotthere?”Observation.notpresent 0
verymildsensitivity 1
mildsensitivity 2
moderatesensitivity 3
moderatelyseverehallucinations 4
severehallucinations 5
extremelyseverehallucinations 6
continuoushallucinations 7
123Adolescent Withdrawal Management Guidelines 2013
Anxiety: Ask:“Doyoufeelnervous?”Observation.noanxiety,atease 0
mildlyanxious 1
2
3
moderatelyanxious,orguarded,soanxietyisinferred 4
5
6
equivalenttoacutepanicasseeninseveredeliriumoracuteschizophrenicreactions
7
Headache, fullness in head: Ask“Doesyourheadfeeldifferent?Doesitfeellikethereisabandaroundyourhead?”Donotratefordizzinessorlightheadedness.Otherwise,rateseverity.notpresent 0
verymild 1
mild 2
moderate 3
moderatelysevere 4
severe 5
verysevere 6
extremelysevere 7
Agitation: Observation.normalactivity 0
somewhatmorethannormalactivit 1
2
3
moderatelyfidgetyandrestless 4
5
6
pacesbackandforthduringmostofinterview,orconstantlythrashesabout
7
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Score
Time: Total Score (max 67):
(Temp) : B/P: Apex rate: Reaps: Initials:
Orientation and Clouding of Sensorium: Ask:“Whatdayisthis?Whereareyou?WhoamI?”orientedandcandoserialadditions 0
cannotdoserialadditionsorisuncertainaboutdate 1
disorientedfordatebynomorethan2calendardays 2
disorientedfordatebymorethan2calendardays 3
disorientedforplaceand/orperson 4
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Appendix III: Clinical Opiate Withdrawal ScaleForeachitem,circlethenumberthatbestdescribesthepatient'ssignsorsymptoms.Rateonjusttheapparentrelationshiptoopiatewithdrawal.Forexample,ifheartrateisincreasedbecausethepatientwasjoggingjustpriortoassessment,theincreaseinpulseratewouldnotaddtothescore.
Patient'sName
ClientNumber
DateandTime
Addiction Services SharedServiceoftheCapeBretonDistrictHealthAuthorityandtheGuysborough/AntigonishStraitHealthAuthority
Resting Pulse Rate:beats/minute(measuredafterpatientissittingorlyingforoneminute)pulserate80orbelow 0
pulserate81–100 1
pulserate101–120 2
pulserategreaterthan120 4
GI Upset: (overlast1/2hour)stomachcramps 1
nauseaorloosestool 2
vomitingordiarrhea 3
multipleepisodesofdiarrheaorvomiting 5
Sweating: (overlast1/2hour,notaccountedforbyroomtemperatureorpatientactivity)noreportofchillsorflushing 0
subjectivereportofchillsorflushing 1
flushedorobservablemoistnessonfacebeadsofsweatonbroworface 2
sweatstreamingoffface 4
Tremor:(observationofoutstretchedhands)notremor 0
tremorcanbefelt,butnotobserved 1
slighttremorobservable 2
grosstremorormuscletwitching 4
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Restlessness: (observationduringassessment)abletositstill 0
reportsdifficultysittingstill,butisabletodoso 1
frequentshiftingorextraneousmovementsoflegs/arms 3
unabletositstillformorethanafewseconds 5
Yawning (observationduringassessment)noyawning 0
yawningonceortwiceduringassessment 1
yawningthreeormoretimesduringassessment 2
yawningseveraltimes/minute 4
Pupil sizepupilspinnedornormalsizeforroomlight 0
pupilspossiblylargerthannormalforroomlight 1
pupilsmoderatelydilated 2
pupilssodilatedthatonlytherimoftheirisisvisible 5
Anxiety or Irritability none 0
patientreportsincreasingirritabilityoranxiousness 1
patientobviouslyirritableoranxious 2
patientsoirritableoranxiousthatparticipationintheassessmentisdifficult
4
Bone or Joint Aches (ifpatientwashavingpainpreviously,onlytheadditionalcomponentattributedtoopiateswithdrawalisscored)notpresent 0
milddiffusediscomfort 1
patientreportsseverediffuseachingofjoints/muscles 2
patientisrubbingjointsormusclesandisunabletositstillbecauseofdiscomfort
4
Gooseflesh skin skinissmooth 0
piloerectionofskincanbefeltorhairsstandinguponarms 3
prominentpiloerection 5
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Runny nose or tearing (notaccountedforbycoldsymptomsorallergies)notpresent 0
nasalstuffinessorunusuallymoisteyes 1
noserunningortearing 2
noseconstantlyrunningortearsstreamingdowncheeks 4
Total Score
Initialsofpersoncompletingassessment_______
Score: Level: 5–12 mild13–14 moderate25–36 moderatelyseveremorethan36 severewithdrawal
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Appendix IV: Adolescent Bio-Psycho-Social-Spiritual Assessment Form
Adolescent information:ProvincialAssistance#______________________________________________________________Name(Last)________________(First)_______________ (Middle)__________________________HealthCard____________________________________ ExpiryDate _______________________Address_________________________________________________________________________City/Town_____________________________________ PostalCode_______________________Phone____________________DateofBirth(MM/DD/YYYY) ______________________________Age______________________Gender _____________Mother’sname_________________________________Homephone __________________________________ Workphone_______________________Cellphone_________________Father’sname__________________________________Homephone___________________________________ Workphone_______________________Cellphone ________________Language(s)spokenathome ________________________________________________________Step-parents(ifapplicable)__________________________________________________________Whoistheyoungpersoncurrentlyresidingwith?________________________________________ Indicate any private health insurance coverage: Planname_____________________________________ Group#___________________________Contract#_____________________________________
Listanyothersupportsavailabletotheyoungperson(e.g.,teacher,minister,coach,BigBrother/Sister,outreachworker,orfamily):________________________________________________________________________________ Other agency involvementIndicateotherpractitioners/agenciescurrentlyinvolved(e.g.,MentalHealth,Psychologists,Psychiatrists,ChildWelfareName_________________________________________ Position__________________________Agency _______________________________________ Phone___________________________Address_______________________________________ Fax______________________________Name_________________________________________ Position __________________________Agency _______________________________________ Phone ___________________________Address_______________________________________ Fax ______________________________
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Describethehistoryofinvolvementyou’vehadwiththisclient(firstcontact,family,work,individual/groupcounselling).________________________________________________________________________________HasthisclienthadapreviousreferralorinvolvementwiththeCHOICESProgramorotherAddictionsServices?________________________________________________________________________________
FamilyBrieflydescribefamily/livingsituations—indicatebiologicalfamily/blendedfamily,etc.________________________________________________________________________________Whatisthequalityoftherelationshipsinthisclient’sfamily?________________________________________________________________________________Hastheclienteverlivedawayfromhome?Ifyes,pleaseelaborate.________________________________________________________________________________Whatisthefamily’smeansoffinancialsupport?________________________________________________________________________________Hastheclienthadanypregnanciesordoeshe/shehaveanychildren?________________________________________________________________________________Ifso,whohascustodyofthechild(ren)?________________________________________________ Drug use/ historyPleasedescribethepatternofsubstanceuse(includingabuse)intheclient’sfamily:________________________________________________________________________________ Nicotine/tobaccoDoestheclientusenicotine/tobacco?YesNoIfyes,howlonghashe/shebeenusingandhowoftenperday?________________________________________________________________________________
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Drugs used by client
Age of first use
Age of regular use
Date of last use
Frequency of use
Average quantity used
Method of use
Do you have a problem with this drug?
Wine
Beer
Spirits
Other
Hash
Marijuana
Hash/WeedOil
Other
LSD
MagicMushrooms
Mescaline
Other
Valium
Ativan
Rivotril
Percocet
Other
Ritalin
Dexedrine
Cocaine
Methamphetamine
Morphine
Demerol
Tylenol3
Oxycodone
Dilaudid
Other
MDMA/Ecstasy
PCP
Solvents
Over-the-counter(e.g.Gravol,Nytol,coughsyrup)
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Doesthisclientfeelthathe/shehasaproblemwithalcohol?YesNoDoesthisclientfeelthathe/shehasaproblemwithotherdrugs?YesNoHowhastheclient’sdrug/alcoholuseimpactedthefollowingareasofhis/herlife?________________________________________________________________________________ Family relationshipsPhysicalhealth____________________________________________________________________Emotional/mentalhealth____________________________________________________________Schooland/oremployment _________________________________________________________Recreationinterests/involvement_____________________________________________________Legalinvolvement ________________________________________________________________Peerrelationships _________________________________________________________________Gambling behaviorHasthisclientdemonstratedanyhigh-riskgamblingbehavior(includingbettingonsportsgamesorpool,buyinglotterytickets,wageringtheirpossessions,playinginternetgames,orinternetgambling)?________________________________________________________________________________EducationWhendidclientlastattendschool?(Date)Nameoflastschoolattended________________________________________________________Contactperson___________________________________________________________________Locationofschool(community)______________________________________________________Lastgradeattended__________________Wasthisgradecompleted?________________________Doesclientplantoreturntoschoolafterleavingthisprogram?_____________________________If client is planning to return to school…Whatschoolwillhe/shebereturningto?_______________________________________________Whatgradewillhe/shebereturningto?________________________________________________Istheclientregisteredattheschooloftheirchoice?______________________________________Istheclientcurrentlyinvolvedinanyextracurricularsportsoractivities?________________________________________________________________________________
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Legal historyHastheclienthadpastlegalcharges?Ifso,pleaseprovidedetails,includingdatesandanyperiodsofincarceration.________________________________________________________________________________Listanypendingcourtdatesoroutstandingcharges.
________________________________________________________________________________DoestheclienthaveaProbationOfficerorRestorativeJusticeWorker?YesNoName _________________________________ Title ____________________________________Phone_________________________________ Fax_____________________________________Doestheclienthavealawyer?YesNoName _________________________________ Phone __________________________________*Pleaseattachanylegalconditions/courtordersassociatedwiththisclient.
Health and well-beingDoesthisclienthaveanyphysicallimitations,medicalproblems,orallergies?________________________________________________________________________________Isthisclientcurrentlytakinganyprescribedmedications?Ifso,pleaselistthemedication,dose,howlongtheclienthasbeentakingit,andwhoprescribedit.________________________________________________________________________________Whoistheclient’sfamilyphysician?Fullname ______________________________ Phone__________________________________Address_________________________________________________________________________Hastheclienteverbeenreferredtoorseenbyamentalhealthworker,psychiatrist,orpsychologist?Ifyes,providedetailsincludingreasonforreferral,dates,name,andphonenumberoftheprofessionalinvolved.________________________________________________________________________________Arethereothermentalhealthissuesaffectingthisclient(e.g.,ADDorADHD,depression,anxiety,etc.)?Ifso,providedetails.________________________________________________________________________________Aretherementalhealthissuesaffectingtheclient’simmediateorextendedfamily?Ifyes,pleaseexplain.________________________________________________________________________________Isthereahistoryofabuse,eitherasavictimoraperpetrator?Pleaseprovidedetails.________________________________________________________________________________Ifyes,hasitbeenreportedandtowhom?Hastherebeenanycounselingforsame?________________________________________________________________________________
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Doesthisclienthavedifficultymanaginganger?Ifso,providedetails,includinganyhistoryofaggression,interventions,etc.________________________________________________________________________________Isthereanyhistoryofsuicidalideationorattempts?Ifso,includedetails(dates,methodandplan,andcircumstancesleadingtoideationsorattempts).________________________________________________________________________________Isthereanyhistoryofself-harmideationorbehaviors?Ifso,includedetails(dates,method,andcircumstances).________________________________________________________________________________Howdoesthisclientdefinehis/hersexualorientation?________________________________________________________________________________PeersPleasedescribethepatternofsubstanceuse/criminalactivityamongtheclient’speergroup.________________________________________________________________________________SpiritualityExplainanyspiritualorreligiouspracticesthattheclienthasparticipatedin,orcontinuestoparticipatein. ________________________________________________________________________________Interests & hobbiesPleasedescribe.________________________________________________________________________________
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WewouldliketoacknowledgethemanypeopleandorganizationswhocontributedtothedevelopmentoftheNovaScotiaAdolescentWithdrawalManagementGuidelines2013:
Acknowledgements
Project Leaders Wanda McDonald,Manager,AddictionServicesDepartmentofHealthandWellnessYvonne daSilva,Knowledge Exchange Facilitator,SouthShoreHealth,AnnapolisValleyHealth,andSouthWestHealth
Nova Scotia Adolescent Withdrawal Management Working GroupMaureen Brennan,Manager,IWKCHOICESProgram
Kaylin Comeau,Community Outreach Worker—Adolescent,PictouCountyHealthAuthority
Kevin Fraser,Manager,AddictionServices,AnnapolisValleyHealth
Dana Pulsifer,Manager,Child&Youth,MentalHealth&AddictionsPrograms,AnnapolisValleyHealth
Myrtle Young,Nurse Manager,WithdrawalManagementUnit,GuysboroughAntigonishStraitHealthAuthority
Consultations/Reviewers Shaun Black,Manager,Pharmacological,Research&QualityServices,AddictionPreventionandTreatmentServices,CapitalHealth
Dr. P. R. Butt,MD,CCFP,FCFP,Associate Professor,Dept.ofFamilyMedicine,UniversityofSaskatchewan
Dr. James Collins,Physician Consultant,WithdrawalManagementUnit,GuysboroughAntigonishStraitHealthAuthority
Sharon Davis - Murdoch,Special Advisor on Diversity and Social Inclusion,DepartmentofHealthandWellness
Dr. Selene Etches,Psychiatrist,IWKHealthCentre
Dr. Zachary Fraser,AddictionPreventionandTreatmentServices,CapitalHealth
Wenche Gausdal,Manager,ImmigrantSettlement&IntegrationServices
Jane Gavin-Hebert,Student,MSWprogram,DalhousieUniversity
Dr. Ramm Hering,North End Community Clinic Direction180OpioidReplacementTreatment
Dr. David March,MDCCSAM,Associate Dean,CommunityEngagement,SeniorAssociateDean,EastCampus,NorthernOntarioSchoolofMedicine
David Maxwell,First Nations Community Outreach Worker,IWKCHOICESProgram
Daneila Meier,AddictionServices,DepartmentofHealth&Wellness
Brian Parris,Clinical Therapist,IWKCHOICESProgram
Dawn Peters,Community Outreach Worker,PictouCountyHealthAuthority
Patrick Russell,Research Associate,ResilienceResearchCentre,DalhouseUniversity
Tiroyamodimo (Tyro) Setlhong, Diversity & Inclusion Coordinator—Primary Health,IWKHealthCentre
Leighann Wichman,Executive Director,YouthProject,Halifax
Dr. Sharon Cirone,Addiction Consultant,ChildandAdolescentMentalHealthteam,St.Joseph’sHealthCentre,GPpsychotherapyandaddictionsmedicine
Adolescent Withdrawal Management Guidelines 2013150
ThisdocumenthasbeenadaptedfromYSASClinicalPracticeGuidelines:ManagementofAlcoholandOtherDrugWithdrawal,apublicationoftheYouthSubstanceAbuseService(YSAS)PtyLtd,Fitzroy,Victoria,Australia.WegratefullyacknowledgethepermissionofYSAStousetheabove-namedpublicationinfullandadaptittoourNovaScotiacontext.WethanktheDepartmentofHealth,Melbourne,Australia,forassistanceinobtainingthispermissionandforprovidingadditionalhelpfulinformation.Inparticular,wewouldliketoextendveryspecialthankstoAndrewBruun,Director—Services,YSAS,andJimSotiropoulos,Manager,OfficeoftheExecutiveDirector,MentalHealth—DrugsandRegions,DepartmentofHealth,fortheirinvaluablesupportandwillingnesstosharetheirworkwithourteam.WhileseveralnewsectionswereaddedandmodificationsweremadeforthepurposeofadaptingtheoriginaldocumentforusehereinNovaScotia,itistheYSASdocumentthatprovideduswiththebasisuponwhichtodeveloptheseProvincialguidelines.
ProductionofthisdocumenthasbeenmadepossiblethroughafinancialcontributionfromHealthCanada.TheviewsexpressedhereindonotnecessarilyrepresenttheviewsofHealthCanada.
Special Acknowledgement
Nova Scotia Adolescent Withdrawal Management GuidelinesPublished by: NovaScotiaDepartmentofHealthandWellnessnovascotia.ca/dhw/addictions
Furthercopiesofthispublicationmaybeorderedthroughthecontactdetailsabove.ThiseditionpublishedNovember2013