nova scotia adolescent withdrawal management guidelines 2013€¦ · 6 adolescent withdrawal...

Nova Scotia Adolescent Withdrawal Management Guidelines

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

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

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.

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.

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

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.

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

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.

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

• 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.

• 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).

• 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.

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:

• 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;

• 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).

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.

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.

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.

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.

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)

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.

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.

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.

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.

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.

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.

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.

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.

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).

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

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.

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

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).

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.

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)

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.

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).

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.

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.

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

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

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

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

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.

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

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:

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

(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.

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

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).

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.

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.

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.

Hormones • Ensurethattransgenderyouthonhormonesareabletoaccesstheirmedicationwhenneeded.

• Considertheconsequencesofalcoholwithdrawalandtreatmentforthoseonhormones.

• Understandthetransitionprocessfortransgenderyouth,anddeterminewheretheymaybeinthatprocess.

Dress codes• Ensurethattransgenderyouthcandressandpresentthemselvesasthegendertheyidentify.

• Ensurethatstaffdresscodesallowtransgenderstafftodressastheyidentify.

• Pronounsandnames

• Respecttransgenderyouthbyusingthepronounandnamepreferencetheyidentify.

• Ensurethatthereisapolicyinplacetoaddressnamesandpronounswhennolegalchangehasbeenmade.

• Checkwithtransgenderyouthonwhentousetheirpreferrednameandpronounandwhennotto.

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.

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.

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.

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.

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

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.

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.

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

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).

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.

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.

ThefiftheffectiveinterventionstrategyforserviceprovidersinNovaScotiaisthatservicesshouldbenomoreintrusivethantheyneedtobe,meaningthatinterventioneffortsshouldinterferewithayouth’slifeaslittleaspossibleunlessitisrequired.Allowingyouthtoformandmaintainrelationshipsthatexistoutsideaninterventiondynamicprovidesthemwiththeopportunitytocreateand/ormaintainmeaningfulrelationshipswithotherpeoplewhowillactassocialsupportsoncetreatmenthasended.

Thefinalfactoristhatservicesconsideredeffectivebyprogramevaluatorsaretheservicesthattypicallyshowthehighestsuccessrates.Whilethismaysoundobvioustosome,itisincludedtoshowtheimportanceofserviceprovidersstayinguptodateonthemosteffectivetreatmentstrategies.Newtreatmentoptionswillalwaysbecreatedtoreplacecurrentones,andthesenewerstrategiesgiveserviceprovidersmoreeffectivetreatmentoptionstohelpfacilitateresilienceinyouth.

Takentogether,thesesixinterventionstrategieshavebeenshowntohelpAtlanticCanadianyouthwithcomplexneedstoavoidindividual,family,andcommunityriskfactorsthatjeopardizetheirwell-being.

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

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).

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).

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.

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.

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.

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.

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

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

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

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)

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.

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.

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.

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.

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

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

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

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.

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

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.

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.

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

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

• 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

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”

2.Concurrentuseofothersubstances,includingtheuseoftobaccoandcannabismix3.Previouswithdrawalattempts:

• withdrawalsymptomsexperienced

4.Medicalandpsychiatrichistory

Examination1.Evidenceofintoxication2.Evidenceofwithdrawalsymptoms—recordabaselineofwithdrawalsymptomsbyusingan

ObjectiveCannabisWithdrawalAssessmentScale3.Vitalsignsandweight

Pathology investigations1.Urinedrugscreen,ifconcernedaboutundisclosedsubstanceuse

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.

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.

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.

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”)

• anorexia

• diarrhea

• tremor

• muscletwitches

• muscleandjointaches

• abdominalcramps

• anxietyandrestlessness

• insomnia

• cravings

• lethargyandweakness

Onset of opioid withdrawal symptomsOpioidwithdrawalsymptomsmaybegin6–12hoursafterthelastdose,peakat48–72hours,andsubsideafter7–10days.Thetimingofonsetanddurationofwithdrawalisprotractediftheindividualisusinglongactingopioids,suchasmethadone.Theseverityofthewithdrawalfromopioidsisdeterminedbyanumberoffactorsincluding:• dosage

• frequency

• chronicityofuse

• 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.

Managing Opioid WithdrawalPurposeToprovidestaffwithanunderstandingofthetoxicitiesassociatedwithopioiduseaswellasthemedicationsusedfortheeffectivemanagementofopioidwithdrawalsymptoms.

PrincipleToensurethatstaffmanageopioidwithdrawalbyminimizingprogressionofwithdrawal,byaccurateassessmentofsubstancehistoryandrelevanthealthissues,andbyearlyrecognitionandtreatmentofwithdrawal.

Clinical ManagementAssessment1.Detailedhistoryofopioiduse:• typeofopioid

• quantityofopioid

• patternofuseandforhowlong—alwaysdocumentthetimeoflastuse

• routeofadministration(oral,nasal,oriducanallresultindependence)

2.Concurrentuseofothersubstances3.Previouswithdrawalattempts:• withdrawalsymptomsexperienced

• previousmedicalmanagementofopioidwithdrawal

• previoushistoryofOpioidSubstitutionTherapy(MethadoneorSuboxoneMaintenanceTreatment)

Examination1.Evidenceofintoxication2.Evidenceofwithdrawalsymptoms3.Vitalsignsandweight4.Injectionsites(ifinjectingdruguser)5.Physicalsignsofliverdisease,e.g.,jaundice

Pathology investigations1.CBC,electrolytes,glucose,creatinine,BUN2.Liverfunctiontests3.HepatitisBandCandHIVscreening(ifinjectingdruguser)4.Urinedrugscreen,ifconcernedaboutundisclosedsubstanceuse

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].

• 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].

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.

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).

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.

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).

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

• insomnia

• confusion

• aggression

• paranoia

• panic

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

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

Managing Stimulant WithdrawalPurposeToprovidestaffwithprotocolsforthemanagementofstimulantwithdrawal.

PrincipleTomanagestimulantwithdrawalbyminimizingprogressionofwithdrawalandbyaccurateassessmentofsubstancehistoryandrelevanthealthissues.

MedicationDiazepam(Valium)

Assessment1.Detailedhistoryofstimulantuse:

• typeofstimulantsused

• quantityofstimulantsused

• routeofadministration(cocaine—inhalingcrack,snortingpowder,injection)

• riskofcomplicationsfromacuteorchronictoxicity

2.Concurrentuseofothersubstances3.Previouswithdrawalattempts:

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.

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.

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

Stimulant-induced psychosis CasesofpsychosiswillbereferredouttotheEmergencyDepartment.

Itisadvisabletomonitoradolescentsforanysignsofdrug-inducedpsychoticphenomena,whichcanoccurinsusceptibleadolescentsfollowingstimulantuse.

Emergingpsychoticsymptomsshouldbemonitored,withareferraltotheappropriatementalhealthserviceforongoingassessment/treatment.

Volatile substancesVolatile substance intoxicationVolatilesubstancesincludearangeofproductstypicallyusedbyadolescentstoproducetheeffectsofintoxication.Theyactasadepressantonthecentralnervoussystem.

Types of volatile substances:• adhesives

• aerosols

• cleaningagents

• solventsandgases

• petrol

Signs of intoxication:• excitementandeuphoria

• disinhibition

• drowsiness

• halitosis—breathoftenhasacetone(nailvarnish)smell

• 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”

Features of volatile substance withdrawal:Theseareusuallymild,butcanbeseverewithprotractedandheavyuse.• anxiety

• depression

• anorexia

• irritability

• aggression

• dizziness

• tremors

• headaches

• tachycardia

• diaphoresis

Managing volatile substance withdrawalPurposeToprovidestaffwithprotocolsforthemanagementofinhalantwithdrawal.

PrincipleTomanageinhalantwithdrawalbyminimizingtheprogressionofwithdrawal,byaccurateassessmentofsubstancehistoryandrelevanthealthissues,andbyearlyrecognitionandtreatmentofwithdrawal.

MedicationDiazepam(Valium)Metoclopramide(Maxeran)—oralandintramuscularProchlorperazine(Stemetil)—oralandintramuscularAcetaminiphen

Assessment1.Detailedhistoryofinhalantuse

• typeofsubstance

2.Concurrentuseofothersubstances3.Previouswithdrawalattempts:

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

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

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

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

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.

• Advisenosmoking2hoursbeforebed.

• Createasleep-promotingenvironmentthatisdark,quiet,cool,andcomfortable.Theoptimumtemperatureforqualitysleepis19ºC.

• Encouragedrinkingchamomileteaorwarmmilkbeforegoingtobed,oriftheywakeduringthenight.Theuseofmagnesiumsupplementspriortobedcanassistwithrelaxation.

Ifmedicationsaregoingtobeused,goodchoicesare:Trazadone25–100mgQHS,Zopiclone2.5–7.5mgQHS,Quetiapine25–50mgQHS,Amitriptyline10–50mgQHS

Generallybenzodiaepinescanbeusedforsleepanddohelpintheshorttermafterstartingthem,butcarrysignificantriskofthedevelopmentoftoleranceanddependence.

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?

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.

Appendix II: Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A)Source:AddictionResearchFoundation

Nausea & vomiting: Ask“Doyoufeelsicktoyourstomach?Haveyouvomited?”Observation.

nonausea/vomiting 0

intermittentnauseawithdryheaves 4

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

moderate,withpatient’sarmsextendedv 4

severe,evenwitharmsnotextended 7

Auditory disturbances: Ask“Areyoumoreawareofsoundsaroundyou?Aretheyharsh?Dotheyfrightenyou?Areyouhearinganythingthatisdisturbingyou?Areyouhear-ingthingsyouknowarenotthere?”Observation.notpresent 0

verymildharshnessorabilitytofrighten 1

mildharshnessorabilitytofrighten 2

moderateharshnessorabilitytofrighten 3

Paroxysmal sweats: nosweatvisible 0

barelyperceptiblesweating,palmsmoist 1

beadsofsweatobviousonforehead 4

drenchingsweats 7

Visual disturbances: Ask“Doesthelightappeartobetoobright?Isitscolourdifferent?Doesithurtyoureyes?Areyouseeinganythingthatisdisturbingtoyou?Areyouseeingthingsyouknowarenotthere?”Observation.notpresent 0

verymildsensitivity 1

mildsensitivity 2

moderatesensitivity 3

Anxiety: Ask:“Doyoufeelnervous?”Observation.noanxiety,atease 0

mildlyanxious 1

moderatelyanxious,orguarded,soanxietyisinferred 4

equivalenttoacutepanicasseeninseveredeliriumoracuteschizophrenicreactions

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

moderatelyfidgetyandrestless 4

pacesbackandforthduringmostofinterview,orconstantlythrashesabout

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

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

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

Bone or Joint Aches (ifpatientwashavingpainpreviously,onlytheadditionalcomponentattributedtoopiateswithdrawalisscored)notpresent 0

milddiffusediscomfort 1

patientreportsseverediffuseachingofjoints/muscles 2

patientisrubbingjointsormusclesandisunabletositstillbecauseofdiscomfort

Gooseflesh skin skinissmooth 0

piloerectionofskincanbefeltorhairsstandinguponarms 3

prominentpiloerection 5

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

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 ______________________________

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?________________________________________________________________________________

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?

Spirits

Marijuana

Hash/WeedOil

MagicMushrooms

Mescaline

Valium

Ativan

Rivotril

Percocet

Ritalin

Dexedrine

Cocaine

Methamphetamine

Morphine

Demerol

Tylenol3

Oxycodone

Dilaudid

MDMA/Ecstasy

Solvents

Over-the-counter(e.g.Gravol,Nytol,coughsyrup)

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?________________________________________________________________________________

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?________________________________________________________________________________

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

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

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