Special groups Young people

Young people with opiate problems often have other emotional and/or behavioural problems, and frequently fall between the adult and child psychiatric services as well as the addiction services, compounding difficulties in the delivery of service. In addition to the absence of a dedicated service for young people with substance misuse problems, there is the added problem of engaging this group with services. There is a twofold need to break down the 'us and them' barrier at the patient-doctor and the child-adult level. Service delivery is further compounded by the need to address developmental issues, cognitive and emotional immaturity, education rather than employment problems, and the greater importance of the family and child protection issues. These issues are uncommon in the adult addiction service and this points to the need for the development of a new skill base. Such a service should be comprehensive, competent, child centred, and lawful. Separation of such a service from adult providers would also assist in preventing experienced drug users from influencing more naive users. Ultimately a tiered approach would appear appropriate, since it would allow maximum utility of current services and focused development of new services. Generic services in primary health care could provide accurate screening with initial referral to youth-oriented services within existing departments. Beyond this, referral to specialist and super-specialist regional services could be employed to provide secure environments with the option of residential rehabilitation and therapeutic communities. Full and accurate assessment will be the key issue, with the adage of history, examination, and special investigations being as valid here as elsewhere in medicine. It will only be through early identification and accurate assessment that this vulnerable group will be accessible to service providers. Once engaged they will be able to receive the full range of possible therapies from family work and cognitive-behavioural therapy to pharmacotherapy and self-help groups.

Pregnancy

Maternal opiate use abuse may harm both mother and fetus with damage mediated through the bio-psychosocial consequences of drug use. For the injecting drug user, continued exposure through risk behaviours to pools of infections combined with vertical transmission makes intervention in this group of paramount importance. Increased rates of stillbirth, premature birth, antenatal complications, low birth weight, and neonatal withdrawal are all associated with maternal opiate use, through the pharmacological and lifestyle consequences of drug use. In considering the management of the pregnant drug user, liaison between the primary health care team (especially if also the prescriber) and the drug and pregnancy services is paramount to promote both engagement and compliance with treatment.

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