Time to reconsider the best practice models of substance use care for young people
Datos Bibliográficos
The NSW Government announced on 21 September 2022 a half-a-billion dollar investment to deliver targeted health and justice reforms in response to the Special Commission of Inquiry into the Drug Ice. A total of $358 million over 4 years will be directed towards health-related programs including evidence-based treatment, support and early intervention services for priority populations notably young people, Aboriginal people, pregnant women and people with co-occurring mental illness. Many young people try drugs but for some, drug taking becomes problematic and they need help to get their lives back on track. Between one-fifth and one-quarter of young people in New South Wales (NSW) engage in a risky level of substance use [1]. Young people are especially vulnerable to serious developmental issues, physical harm, psychological issues and social problems due to substance use [2, 3]. Early treatment can reduce use in the long term and improve employment, housing and health outcomes [4, 5], however the window of opportunity to prevent the transition from episodic substance use to a substance use disorder is narrow. Of the individuals who develop a substance use disorder, half will do so within the first two to 4 years of first use [6]. Despite such urgency of early identification and treatment effective interventions for young people using drugs and alcohol are neither well understood nor widely implemented. In this commentary, we argue for a reconsideration of how best to provide alcohol and other drug (AOD) care to young people and put forward several strategies to enhance the benefits young people can gain from engagement with services. Almost 40% of all people receiving drug and alcohol treatment in Australia are aged less than 30 years [7]. Despite this, numerous barriers exist for young people in accessing services. Young people are reluctant to engage in health and treatment services [8, 9]. Limited health literacy, lack of knowledge of services, difficulties navigating the health system, geographic isolation, poverty, social exclusion, language barriers and concerns about confidentiality are significant barriers for young people seeking treatment [10-12]. Health services have generally moved to youth-centred service models to improve engagement with young people [1]. Valuable principles for service provision have been documented in the NSW framework such as harm minimisation, human rights, respect, safety and non-discrimination [1]. However, implementing youth-friendly healthcare into adult-orientated health spaces remains a challenge. Hospital-based services are consistently found to be less effective in engaging young people [13] and less able to respond effectively to young people with multiple disadvantages compared to community-based interventions [14, 15]. Do to the limited number of youth-specific AOD services in Australia [16], young people often end up in adult services, placing them at considerable risk by exposing them to more risky drug use behaviours, more experienced adult users, different drugs and adult networks of users and suppliers [17, 18]. Adult services predominantly take a biomedical approach seeing substance use disorders as a chronic relapsing illness [19]. Young people use drugs differently and have different treatment goals compared to adults [18, 20-22]. Young people often have mild to moderate drug use and do not wish to completely cease using drugs [22]. Many seek instead to reduce their use, or learn about drug use to make more informed choices [23]. A health system adopting a biomedical approach to substance use may be at odds with the meaning young people themselves ascribe to their drug use [24]. There have been substantial investments in youth AOD services in Australia. Such services are delivered through specialist health services that include youth-specific residential withdrawal and rehabilitation centres, outreach and support services, and assisted accommodation [25]. A majority of these offer residential rehabilitation models of care, which are generally not suitable for mild use. A related barrier is the insistence of some treatment services that consumers attend withdrawal management services before admission to treatment, which is often unnecessary for youth presentations. An alternative approach, such as a period of ‘time out’ in a youth residential setting, where young people would be among peers in a drug free environment, could be better placed to care for young people. Many young people with substance use issues come into contact with community-based youth services, offering psycho-social models of support that emphasise youth-centredness, nonjudgmental environments, safety and support and forming therapeutic relationships with young people [26]. These capacity-building approaches are effective components of a more comprehensive approach to treatment [27] and may begin to address some of the underlying reasons for substance use among young people [28]. However, many youth services do not have the capacity to employ appropriately trained allied health professionals with substance use skills. Youth specialist organisations such as Headspace, established in recognition of the low rate of service access for young people, generally lack substance use expertise and few, if any, substance use services operate within a similar framework. Additionally, young people with severe substance use are excluded from Headspace services. Little research exists on how youth AOD service providers understand young people's substance use and how they work within the boundaries and resourcing structure of the clinical environment. Additionally, descriptions and evaluations of effective, holistic and youth-friendly models of care and which service elements are the most impactful, are few in the research literature [29]. We have identified several strategies potentially able to increase young people's service seeking, service uptake and satisfaction. These strategies are based on findings from three different studies. A study drawing on semi-structured interviews with nine health and community staff about their experiences providing healthcare to young people involved with AOD services [30]. A study examination disadvantaged young people's experiences in different types of youth services. This study involved three purposefully sampled, qualitative case studies of young people and youth workers across three different types of youth services. This included semi-structured interviews with 12 program workers and managers and group-based workshops with 16 young people aged between 16 and 19 [31]. Lastly, a study investigating a peer-led youth program supporting socioeconomically disadvantaged young people. This study was a qualitative field study drawing on ethnographic methods and participant observation data from weekend workshops and semi-structured interviews with 15 workers and 23 young people aged between 16 and 25 years [26, 32]. Data from all studies were subjected to thematic analysis. Methods and results have been reported elsewhere [26, 31-33]. The approaches outlined below may assist services as they develop their response to the special commission and also have broad applicability, beyond the NSW health system. Young people benefit from a treatment system able to account for the unique conditions of their lives. Trauma, poverty and entrenched disadvantage are not prerequisites for substance use but are strong risk factors [34]. Young people who experience disadvantage are both over-represented and underserviced in the Australian system [15, 35]. Responses to substance use must therefore comprehensively engage with the drivers of disadvantage and incorporate holistic approaches such as wraparound supports for intersecting needs. Broader strategies to reducing poverty, increasing retention in education and training, reducing un- and underemployment, provision of affordable and secure housing, increasing access to suitable primary health care and early childhood services, support for navigating the justice systems and promoting positive community connections and opportunities for meaningful and active participation may prevent or reduce morbidity and mortality and the need for youth AOD treatment. To facilitate accessibility, engagement and to fill gaps in local service provision, drug and alcohol services should be placed where young people naturally congregate and feel safe. The use of flexible delivery methods such as outreach, drop-in, out-of-hours services, and digital and culturally-based interventions has been identified as effective ways of engaging young people in health services [27, 36]. This includes a ‘multiple access point’ approach facilitated through partnerships with local services such as arts, sports and gaming venues [36]. Services that facilitate peer connections [31] and are low-threshold, strengths-based, person-centred and youth-led are especially well placed to engage young people [28]. Youth-friendly services should encompass holistic, person-centred services actively working alongside young people, and their identified support systems, on their journey to independence. This may include case management, youth-friendly spaces, privacy, targeted communication on issues related to youth, therapeutic group work, life skills, youth participation and engagement on issues that directly affect them. Services also need to consider the specific needs of First Nations young people and those from culturally and linguistically diverse communities, and/or the LGBTI+ community [27]. Many young people come into contact with hospital-based adult services such as emergency departments and AOD services. Although this places young people at considerable risk, attending adult services may be unavoidable in more remote or regional areas. Investment to build capacity to address access to and appropriateness of adult-focused services should be prioritised including service- and systems-level investment to deliver better and integrated services and appropriate referral pathways. Hospital-based services would benefit from greater engagement with young people when designing and running services including the use of peer workers from marginalised communities and client advocates [37]. Increasing hospital resources to provide food, decorations and electronic devices could foster a youth-friendly environment. Additionally, services need to be prepared to manage family involvement and intergenerational differences between young people and parents in a sensitive and supportive manner [38]. Improving the transition between paediatric and adult care is an ongoing issue as well as improving inclusion criteria for services. Young people with mild but still problematic substance use often do not meet the substance dependence criterion qualifying them for service admission, treatment and Medicare rebate. Additionally, when young people present with co-occurring mental health and substance use disorders, they may be excluded from specialist services. As an example of innovative service models Orygen in Victoria runs relationally-informed integrated service hubs for young people with mental health issues. Orygen offers a range of services and treatment options to young people across the spectrum of severity of mental health issues and develops resources for clinicians working with young people who have co-occurring mental health and drug problems [39]. Such a model may have relevance for services caring for young people with substance use issues. Substance use issues require a mix of responses tailored to individual needs [40]. This is best delivered through multi-agency and multidisciplinary service programs [41]. Solo-focused interventions or single-professional group styles of practice develop high-level skills in their discipline but may be unable to work across siloes thus failing to address the complexity of young people's needs. An appropriate response requires comprehensive assessments, integrated care and active collaborative care models. How well services will be able to achieve this is yet to be seen, but such de-siloing of healthcare will be critical for success [42]. Principles of integrated care in the case of young people involve making services available locally, within a reasonable distance from the family home and embedding substance use treatment services into other youth health and social services. Service linkages between health services including mental health and social sectors such as education, social services, community youth services, accommodation agencies, Juvenile Justice and legal services assist especially marginalised young people in navigating the complex health systems and improve engagement [15]. Treatment by referrals to services not in the local community fails these principles. To assist young people in navigating available services, person-centred case or peer workers focusing on service navigation, information and referral are recommended, especially in regional and remote areas. A focus on prevention may be especially relevant for young people, allowing services to identify problematic patterns of substance use that are amenable for early intervention [43]. This involves broadening the range of treatment options to include offerings more aligned with how young people themselves understand their substance use and treatment needs. Access to traditional harm reduction services such as needle and syringe programs and opioid agonist therapy should be ensured, consistent with the Australian National Drug Strategy [44]. Capacity building may be required for current and future staff in youth AOD services relating to harm reduction principles, especially for staff and peers who may view abstinence as the only acceptable outcome for young people who use substances. Addressing the challenges of young people with substance use issues requires a highly skilled and dedicated team of community and health professionals able to work across disciplines and in close partnership. This approach has capacity to minimise substance-related health, social and economic harms for young people, their families and communities. Additionally, services need to consider the broader social determinants that contribute to substance use. Despite the clear articulation of these principles almost a decade ago [1], there remains a shortfall of services available that reflect these principles. The new injection of funding to address substance use, in NSW at least, provides an important opportunity to address this shortfall and, quality evaluation of such services provide broader benefit for other jurisdictions to learn and refine their own service models. Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australian University Librarians. The authors have no conflicts of interest
Psychiatry · Substance use · Adolescent and Pediatric Healthcare · Child and Adolescent Health · Medicine · Psychology · Substance Abuse Treatment and Outcomes
‘ Sasadecc ’—A Unique Model of Collaborative Care Between Government and Non‐Government Health Services for Adolescents With Complex Substance Use Issues
A scoping review of key domains for youth outcome measurement in alcohol and other drug treatment
The stakes of stimulant use, psychosis, and antipsychotic treatment among youth who use drugs
Prevention, early intervention, harm reduction, and treatment of substance use in young people
Primary healthcare in the time of Covid-19
Improving the effectiveness and inclusiveness of alcohol and other drug outreach models for young people
Youth Practitioners’ Perspectives on Building Agency and Supporting Transitions with and for Young People Experiencing Disadvantage
Does Childhood Adversity Lead to Drug Addiction in Adulthood? A Study of Serial Mediators Based on Resilience and Depression
How drug policy should (not) be
Building inclusion, maintaining marginality
Collectively learning to talk about personal concerns in a peer‐led youth program
Addressing alcohol and other drug use among young people from migrant and ethnic minority backgrounds
Improving access to drug and alcohol treatment in NSW Australia
Getting Better”
Addiction, agency, and the politics of self-control
Alcohol and the Constitution of Friendship for Young Adults
| Obras citantes distintas | 3 |
|---|---|
| Citas por año | 3 |
| Intervalo de citas | 2025 - 2026 (2) |
| Velocidad de citación | current |
| Altamente citado | No |
| Tipos de cita | Neutras: 3 |