Young People and Substance Misuse: Characteristics, Needs and Perception of Treatment Services of Drug Users Aged 18 to 25 in Liverpool.
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1 Young People and Substance Misuse: Characteristics, Needs and Perception of Treatment Services of Drug Users Aged 18 to 25 in Liverpool. June 2007 Dr. Michelle Wareing Senior Researcher Dr. Harry Sumnall Senior Research Fellow Jim McVeigh Reader in Epidemiology Centre for Public Health, Faculty of Health and Applied Social Sciences Liverpool John Moores University Castle House, North Street Liverpool L3 2AY 1
2 Executive Summary Introduction This study investigated the characteristics and needs of young substance misusers, aged between years, and their perceptions of treatment services in the Liverpool area. The research was developed following consultation with representatives of Liverpool D(A)AT, with the aim of identifying patterns of young people s drug and alcohol use and to provide essential information relating to the way young people access both specialist drug services and generic services. Methodology An individual survey/interview method approach was employed in order to examine the views and perceptions of Liverpool s year olds and to establish what their beliefs and behaviours were relating to substance misuse and to drug and treatment services. The interview/questionnaire also set out to establish if current treatment services was meeting the needs of Liverpool s young people and to highlight any barriers they felt were in place that were preventing them from attending services. In total, 26 young people were recruited from young people s services in the Liverpool area to take part in this study, 15 females and 11 males (mean age 23 years). Thirteen individuals were recruited from counselling services, 12 participants came from drug treatment services and one individual came from the Criminal Justice system. Findings An equal number of the young people interviewed lived in either local authority rented accommodation (n = 6) or in a hostel (n = 6), the remaining individuals lived in private accommodation, owned home, housing association 2
3 accommodation, a treatment centre and one young person said they had no fixed abode (NFA). Five young people reported they were registered as homeless and eight individuals reported they had slept rough in the past 12 months (see section 3.1). For most young people questioned, claiming benefits (n=22) was their main source of income, although five young people from the sample were in education and three young people in employment (section 3.1.2). The main sources of information about the use of drugs that was consulted by this young cohort were friends, followed by services and television but they rated services the most trustworthy source of information (section 3.4.1). Using standardised measures such as the Alcohol Use Disorders Identification Test (AUDIT) and the Severity of Dependence (SDS) scale, approximately one third of the participants questioned in this study were classified as dependent on alcohol and cannabis, with females attaining a higher score for dependency on cannabis than males (section 3.4.2). While this cohort were currently using a variety of substances, most commonly alcohol and cannabis, followed by cocaine and ecstasy, they were also apparently aware of the risks involved in using such substances and rated heroin, crack, solvents, ecstasy, alcohol and LSD as the most risky drugs in that order (section 3.4.5). Only a small number of participants were using heroin and crack cocaine and only two members from the current sample were injecting heroin users. With regards to treatment services, while just over half of the participants had positive previous experiences of services and explained that services had helped them with their drug/alcohol problems, the other half of respondents reported more negative experiences such as having to engage with problematic drug users and the perception that service staff were not always supportive of their needs. The main barriers to attending services cited by young people in the 3
4 Liverpool area again seem to stem from having to engage with problematic drug users and the stigma young people perceive that is attached to attending services. In general, this sample of young people perceived their drug use to be less frequent and problematic than that of heroin and/or crack users and felt that they needed their own type (or to be physically separated) of service where they would not have to mix with this particular type of drug users and were service staff would not judge them (section 3.5). 4
5 1. Introduction Young People and Substance Misuse Young People and Homelessness Young People and Crime Young People and Barriers to Accessing Service Summary and Aim of the Current Study Methodology Participants Materials Procedure Ethics Results Participants Education and Employment Current Service Criminal Convictions Drug and Alcohol use Sources of Information AUDIT Current Drug use, Age of First use and Frequency of use Summary Young People s Risk Perceptions of Various Drugs Injecting Drugs and Infections from Injecting Drugs Treatment Services Barriers to Treatment Services Encouraging Young People to Attend Services 'Other' Services Attended by Young People Type of Treatment Offered to Young People Changes in Drug and Alcohol use since treatment commenced Overall Perceptions of Attending Services Summary Database Information National Drug Treatment Monitoring System (NDTMS) Syringe Exchange Schemes in Liverpool 2005/ Pharmacy Syringe Exchange Agency Syringe Exchange Schemes in Liverpool Conclusions Current Drug Use Anabolic Steroid Use Sources of Information Current Treatment Services Limitations...68 References
6 Tables Graph Title Page No. Table 1 Young people who had used one 19 of the support organisations Table 2 Accommodation Type 28 Table 3 Attendance in Current Service 29 Table 4 Sources of Information 31 Table 5 AUDIT Score 32 Table 6 SDS Score 34 Table 7 Current Drug Use 37 Table 8 Perceptions of Risks Associated 39 with Illegal Various Drugs Figure1 Alcohol 40 Figure 2 Amphetamine 41 Figure 3 Cannabis 41 Figure 4 Cocaine 42 Figure 5 Crack 43 Figure 6 Ecstasy 44 Figure 7 Heroin 45 Figure 8 Steroid 46 Figure 9 Encourage to Attend Treatment 50 Services Table 9 Previous Type of Service 51 Attended Table 10 Referral into Other Service 51 6
7 Table 11 Sessions Offered to Young People Table 12 Table 13 Figure 10 Figure 11 Perceptions of Change since treatment Commenced NDTMS Main Drug of Use 57 NDTMS Main Drug of Use by Gender Agency Attendance by Young People Aged Years in Liverpool between the Years Table 14 Reason Young People were Discharged from Treatment in Liverpool Between Table 15 Table 16 Syringe Exchange (Agency) Main drug of Choice New Clients Entering into Agency Syringe Exchange 2005/
8 1. Introduction This study investigated the characteristics and needs of young substance misusers, aged between years, and their perceptions of treatment services in the Liverpool area. The research methodology was developed following consultation with Liverpool D(A)AT, with the aim of identifying patterns of young people s drug and alcohol use and to provide essential information relating to the way young people access both specialist drug services and generic services. Following on from the 10 year drug strategy, Tackling Drugs to Build a Better Britain (1998), the Updated Drugs Strategy (2002) increased focus upon young people s (aged under 25 years) substance use in England and Wales. Its broad aim is the prevention of problematic drug use through the development of a range of preventative services and initiatives. More recent policy continues to support these aims. For example, the youth green paper, Youth Matters (July, 2005), concerning youth services, is analogous to Every Child Matters in that all five outcomes set out in the former report are made applicable to older young people (being healthy, staying safe, making a positive contribution and economic well-being). There are a wide range of potential consequences of alcohol and drug misuse in young people, such as serious accidental injury, violence or even death. Less severe health problems may be caused by infections such as blood borne virus and problems with abscess and veins through drug injection. Comorbid mental health problems may also arise. Furthermore, young substance users may also experience, and be open to, family problems, peer pressure, homelessness, school exclusions, reduced employment opportunities and criminal behaviour. 8
9 1.1 Young People and Substance Misuse In the British Crime Survey (BCS), young people are defined as those aged between the years of 16 to 24 living in England and Wales 2. In 2005/2006 an estimated 45.1% of young people reported having used one or more illicit drugs in their lifetime, 25.2% had used one or illicit drug in the previous year and approximately 15.1% in the previous month (Roe & Man, 2006). The BCS estimated that last year prevalence of cannabis was the highest in this age group (21.4%) followed by cocaine (5.9%), and ecstasy (4.3%). With regards to the use of Class A drugs, approximately 16.9% of young people have ever used a Class A drug at least once in their lifetime, 8.4% had used a Class A drug in the past year and 4.0% in the past month representing current use. This is estimated to be equivalent to over one million young people reporting a lifetime use of Class A drugs, 525,000 in the last year and 250,000 in the previous month. The most commonly used Class A drugs in 2005/06 for the previous year were cocaine (370,000) and ecstasy (269,000), while the lowest estimates of Class A drugs reported were for opiates (excluding heroin and methadone) (11,000), heroin (10,000) and methadone (4,000). Class A drug use among young people has remained stable since 1998; however between 1998 and 2005/06 the use of cocaine powder by young people increased significantly. The 20 to 24 age group reported the highest levels of last year and last month use of cocaine powder in 2005/06. Establishing the prevalence of substance misuse in young people is difficult because many respondents are hesitant to reveal their use or involvement with illegal drugs (Ghodse 2004). However, young people in the UK regard some types of drug use as socially normal, particularly cannabis and psychostimulant use, although, the opposite is true for heroin, and in general, young people regard heroin use as high risk (Strang and McCambridge, 2005). 1 Although this is not always congruous with the upper age limit of young people s drug service provision, which tends to be 18 (Burrell et al., 2005) 9
10 This may lead to under and over estimates in drug prevalence. Ghodse (2004) suggests that young people often first engage in substance misuse because they want to experiment and are curious about drugs and therefore a lifetime use of drugs is not a good indicator of future problems. Participating in drug use as well as smoking cigarettes and drinking alcohol is seen as adult behaviours with some children feeling pressure to adapt to these particular practices. In general, it is believed that by the age of 16 years approximately half of the children in the UK will have at least tried an illegal drug. Strang & McCambridge (2005) investigated how non-heroin users found themselves in the presence of heroin users and injectors, with the aim of trying to establish if there were any major concerns regarding those that already use illegal drugs other than cannabis, as well as those living in socioeconomic deprivation. In total, 179 cannabis users (who had never used or injected heroin), aged between 16 and 20 years, were recruited from ten further education colleges across London. Results showed that 34.5% of the sample had been offered heroin and 36% had been in the presence of heroin users smoking the drug. With regards to injecting heroin, 12% of the sample had been present during injecting practices and cannabis users with friends involved in non-cannabis illicit drug use were significantly more likely to be present during injecting heroin practices. The authors claimed that the increased possibility of actually being present during heroin smoking as well as being involved with drug using friends were both associated with interactional risks. Young people face considerable personal changes as they make the transition into independent young adulthood through work/college, family and especially with regards to social networks. Those aged between years represent the largest age group in the social sector in the UK and approximately nine million young adults from this cohort go to pubs and clubs every week and are considered to be the principal weekly drinking group. The misuse of alcohol can cause both health and social problems and in recent years increases in consumption patterns, heavy drinking and alcohol related harm have become evident, especially in relation to women who consume 10
11 alcohol (Institute of Alcohol Studies) According to the Office of National Statistics (ONS, 2004), almost 30% of adults exceeded the dailyrecommended benchmark of alcohol on at least one day in the previous week (four units for men and three units for women). The proportion of people exceeding the recommended daily intake of alcohol was highest among young adults (45%) in the age group. Almost half of the young men, 49% and 42% of young women exceeded the recommended daily intake of alcohol. The rate of young women in the age group who exceed the recommended daily intake of alcohol more than doubled from 15% in 1988/89 to 33% 2002/03. In the North West of England, drinking patterns are similar to the country as a whole with the age cohort being the most likely to binge drink, although the number drinking more than double the recommended daily intake on at least one day varies across the region from 27% in Wirral to over 70% in St. Helens and Knowsley (Hughes et al, 2004). Drinking is seen as integral to a night out and young people tend to share this activity in a group setting. The term binge drinking is now often used in place of lager louts in media, government bodies and in discussions of alcohol related anti social behaviour (Wine Trade Action Group [WTAG], 2004). There is no universally agreed definition of binge drinking although the most commonly used explanation in the UK is men drinking at least eight units and women drinking at least six units of alcohol on at least one day in the previous week (i.e. twice the recommended daily unit intake) (Engineer et al, 2003). Binge drinking is most prevalent in the age group and is the most common form of risky alcohol consumption among young people (Murgraff et al, 1999; Hammersley & Ditton, 2005). The most frequently reported drinks associated with binging was lager, shots, pre-packaged spirits and vodka, especially when served with the stimulant drink Red Bull (WTAG, 2004). The type of alcohol preferred appeared to be influenced by gender with males preferring lager and shots and females having a preference for pre packed spirits and wine. In a recent study carried out by Hammersley and Ditton, (2005), young people aged between years interviewed on licensed premises reported that 11
12 males drank more than females but, after adjusting for body size and the recommended daily upper limits for both males and females, results showed that females drinking did not differ from males. This cohort described binge drinking as drinking excessively and fast and the majority of the sample planned to consume a quantity of alcohol that was putting their health at risk (mean units of alcohol was 14 for males and just under 10 units for females). The authors stated that most of the sample was moderately intoxicated and thus describing this as a binge may be unhelpful and suggest the term bout may be better. Parker and Williams (2003) followed a group of young people from 1991 to 2001 who where recruited from eight various secondary high and grammar schools in the North West of England. The going out sector (N=465) consisted of 22 year olds who had been tracked since the age of 13. Approximately 50% of the sample had completed higher education and the majority of respondents were employed (only 7% were unemployed). As this sample was predominately female and derived from a middle class background, this population of young people were not considered to be likely to engage in risk taking behaviours or to break the law. At age 17 years, Parker and Williams identified four key status pathway groups; current drug users (28%), opportunistic drug users (31.6%), ex-drug users (15.8%), and abstainers (24.5%). Cannabis was the main drug used by this sample, and stimulants such as ecstasy and cocaine were used to enhance nights out. Other Class A drugs such as heroin and crack tended to be avoided by this sample of young people. Interestingly, the current drug users earned the highest mean income and spent most of their disposable income in pubs, nightclubs, and being with friends. The majority of the this sample were classified as social drinkers, although current users and opportunistic drug users were classified as being the heaviest drinkers as well as the most frequent drinkers of alcohol. The authors also reported a gender difference with regards to alcohol consumption with females being defined as binge drinkers. The cohort was broken down 12
13 further into light drinkers (consume alcohol 2-3 times per week or once a week), moderate drinkers (consume alcohol 2-3 times per week to most days) and heavy drinkers (consume alcohol everyday to most days). Within this sample was a small sub-sample of working class males who reported petty delinquency. Those who were categorised as heavy drinkers also reported the highest criminal activity and in general, this involved offences such as drunk and disorderly, assaults and wounding and the possession of drugs. Furthermore, more females than males reported being convicted of assault and wounding. Parker and Williams (2003) concluded that because of the number of young people that engaged in this particular lifestyle, public health and public order policies needed to be in-line with the going out sector as the scale, characteristics and motives of this population of young adults is poorly understood. 1.2 Young People and Homelessness According to Fountain and Howes (2002) homelessness can place an individual in a vulnerable position for the development of problematic drug use. In their research they interviewed 389 homelessness people, one third were under the age of 25 years, and 21% of the sample was under the age of 21 years. Overall, 83% had used drugs (other than alcohol) in the previous month with two thirds of young people citied drugs or alcohol use as a reason for first becoming homelessness. Moreover, four out of five participants said that they had engaged in new drug use since becoming homelessness. More recently, Wincup and colleagues (2003) examined young people s use of drugs, alcohol and tobacco whilst they were homeless. In all, 160 people under the age of 25 years were interviewed, most of who were male with an average age of 20 years. Thirty four percent of the sample lived in hostels for young people, although, 9% of females and 20% of males were living on the streets. In general, the most frequent responses given for being homeless 13
14 were family conflict and experience of emotional, sexual or physical abuse within the family network. With regards to substance misuse, the majority of the sample used tobacco and smoked an average of 15 cigarettes per day; alcohol use was more varied with 9% claiming that they drank everyday and 18% reporting that they did not drink alcohol whatsoever and 14% could be defined as problem drinkers. The majority of the sample used illegal drugs (95%), with cannabis being the most common followed by amphetamines, ecstasy, LSD and cocaine. Twenty percent of the sample had ceased drug use as a result of becoming homeless. The use of heroin (43%) and crack (38%) was high among the sample; with just over half of the young people commencing heroin (55%) and crack (58%) when they became homeless. Problem drug use was defined as those using heroin, crack or cocaine on five or more days in the previous week and 17% of the sample was classified as problem drug users, these individuals were predominantly white, male and many had mental health problems. This sub-sample reported family conflict and running away as the reason for their homelessness and most wanted access to help and treatment. Barriers to accessing services and service provision were also highlighted by the young people. With regards to homelessness services, young people were in general appreciative and praised individual workers but felt that there was: General lack of awareness of what is available Dislike or fear of other service users Dirty and poorly equipped premises Exclusionary rules or restrictive admissions criteria Insufficient bed spaces Having to be drug or alcohol free prior to admission or on the premises Having to pay for food or drink, or affordable rents Having to leave the premises during the day 14
15 Feeling shame, embarrassment and stigma. (Wincup et al, 2003) While most young people were registered with a GP, accessing health services also presented barriers to young people, they were listed as: Stigmatisation by NHS Staff Shame and embarrassment at their appearance and situation Problems registering with a GP due to having no address Long waits for appointments and consultations. (Wincup et al, 2003) Drug services were mostly accessed by those injecting drugs and most had used a syringe exchange service in the previous month. Other drug users felt that barriers to access drug services were: Unsympathetic and poorly informed GPs and medical staff Long waiting lists for detoxification, community and residential services A desire to avoid other drug users Health concerns about methadone prescribing, in that they were swapping one addiction for another A preference to do things themselves and previous bad experiences of such services A dislike of the ethos of some services. (Wincup et al, 2003) The report highlighted a number of recommendations with regards to youth homelessness and substance misuse and stated that service provision needs to address substance use within the context of the multiple problems of young homeless people are experiencing. Moreover, and perhaps most importantly, prevention and harm reduction work with this cohort needs to overcome resistance from young people themselves. 15
16 1.3 Young People and Crime As discussed by Hunter and colleagues (2005) the reduction of drug related crime has been central to the aim of UK s drug strategy, resulting in many interventions being placed in the criminal justice system, arrest, courts and prisons. According to the 2003 Crime and Justice Survey (Hayward and Sharp, 2005) for those aged between years factors associated with anti social behaviour are also associated with offending behaviour, these included being drunk on a frequent basis, being male and aged between 17 and 19 years, having delinquent friends, being a victim of force or violence, using drugs in the last year and delinquent personality factors. Findings from the 2004 Offending Crime and Justice survey (Budd et al, 2005) found that just over half (52%) of those aged between years who had taken drugs in the previous year had also committed an offence in the last year compared to those (19%) young people who had not taken any drugs. Interestingly, 62% of those that had used drugs frequently had committed an offence in the previous year. With regards to gender and crime, selling drugs was the most common offence recorded for males aged years (45% of crimes committed). This was followed by property crime (31%) and violence (24%). With regards to females aged years the reverse was true, violence was the most commonly recorded offence (44%) followed by property crimes (31%) and selling drugs (26%). Locally, Citysafe Liverpool, a Safe City-Crime, Disorder, Antisocial Behaviour and Drug Misuse Strategy, reported that Merseyside police crime figures showed a 60% increase in arrests for supplying drugs (617 arrests in 20001/02 to 987 arrests in 2003/04). With regards to trigger offences (offences likely to be associated with substance misuse, e.g. theft, robbery, burglary, handling stolen goods, possession of a controlled drug etc.) in 2003/04, data showed that there were; 723 arrests, 90% of whom were males and 41% were under the age of 25 years. Fifty one per cent were arrested for possession of Class A drugs, 26% were arrested for heroin and 25% for cocaine. 16
17 1.4 Young People and Barriers to Accessing Service Researchers from the Centre for Public Health have previously estimated problematic drug use within Liverpool, and Sefton D(A)AT teams (Beynon et al., 2004). Using capture re-capture methods it was estimated that within Liverpool D(A)AT there was a total of 6,170 problematic drug users and the number of young drug users aged between years had increased from 1,344 in 1998 to 1,563 in 2001/2. However, while there was an increase in the number of drug users in this age category there was not a corresponding increase in the number contacting agencies for help and support. More recently, Hay et al (2006), also using multiplier methods (a different means of estimation), reported that there were 6,786 problematic drug users in Liverpool indicating a large increase from 2001/2 (Beynon et al 2004). Using data from four main sources (The National Drug Treatment Monitoring System-NDTMS, The National Offender Management Service Offender Assessment System-OASys, Police National Computer-PNC, Counselling, Assessment, Referral, Advice and Throughcare services data for drug users in prison-carat) Hay et al (2006) reported that 1,019 of those drug users were in the year age category and that 820 from this group were opiate users. There appears to be a general lack of consensus in defining what specifically constitutes a young person and this has implications for service provision. According to the National Treatment Agency (NTA) guidelines, a young person is someone aged between 10 and 25 years, whereas, drug service definitions of young people is a person under the age of 18 years, which is the definition used in the legal and criminal justice system. Differences in the definition of a young person can be a cause for concern not only for the young person in question but also for service providers, and difficulties arise as to which service they should attend i.e. young person or adult service, and how transition between the two types should be managed. Therefore, a need for clarification between the guidelines set out by national organisations and by service providers needs to be put in place. 17
18 In some of the most deprived areas of the UK, young people experience higher levels of unemployment, benefit dependency, ill heath and fear of crime, compared with young people in more affluent communities (Wood et al., 2006). Reaching the Hard to Reach (Princes Trust, 2004) investigated the lives and views of disadvantaged year olds in Scotland, England and Wales. One of the aims of this report was to identify gaps and trends in the provision of services for young people at a local level. In order to explore the aims and aspirations of disadvantaged young people and the obstacles that hold them back from achieving their aims, more than 900, year olds were consulted and divided into four groups; the first group consisted of young people that were unemployed, the second group was made of educational underachievers, the third was ex-offenders and serving prisoners and the last group was those leaving care aged A control group of young people was also included and consisted of year olds who did not come from any or one of the specified disadvantaged backgrounds. The report suggested that young people would rather use informal sources of advice such as family and friends, rather than seek help and advice from statutory or voluntary support services. Furthermore, 39% of disadvantaged young people turned to parents as their first source of advice, 29% of young people would not turn to specialist services and 15% said that they would not seek help from anyone. Interestingly, 92% of all year olds said that they believed there were gaps in service provision in their local areas, especially in relation to substance misuse, safe sex and pregnancy, money management and setting up home. Within this set of respondents, 44% of the disadvantaged young people were males aged between years who stated that there was a lack of substance misuse support in their area, and 41% of the ex-offenders and serving prisoner group also mentioned that there were also insufficient substance misuse services. Moreover, when results were broken down by location, young peoples perceptions of gaps in service provision was most evident in the North West of England, with 50% of young people claiming that drug, alcohol and substance misuse provision did not 18
19 meet their needs, this was followed by the Midlands and the East (40%) and Wales (38%). As this report highlighted, disadvantaged young people were generally reluctant to engage with specialist services, although, they do appear to have a high level of awareness of a number of organisations and the services they provide. However, as shown in table 1, more young people in the disadvantaged group had accessed one of the listed services in comparison to the control group. Table 1. Young people who had used one of the support organisations Control and Disadvantaged Organisation Control Disadvantaged Connexions/Career Service 15% 23% 28% 24% 3% Citizens Advice Bureaux 15% 14% 6% 18% 30% NACRO 2% 8% 9% 9% 4% The Princes Trust 4% 7% 2% 14% 7% Childline 3% 5% 5% 5% 3% Barnardo s 1% 4% 2% 7% 6% Samaritans 2% 4% 1% 8% 6% NSPCC 1% 2% 2% 4% 1% (Reaching the Hard to Reach, 2004) In addressing the gaps in service provision six main issues and recommendations were put forward. 1. Mapping provision in order to ensure the visibility of support networks and the services they provide. 2. One size does not fit all - services need more structured support and they need to work more on young people s situations rather than age. 3. Working together services need more partnership agreements in order to establish data sharing, smooth client transfers and effective aftercare provisions. 19
20 4. Signposting while perceived gaps in service provision were highlighted by young people this was mostly due to their lack of awareness of what specific services provide. Therefore, youth organisations need to signpost specific services to ensure they reach the disaffected youth. In general, young people want more information from a single source, but, organisations must accept that young people usually have a number of issues that need to be resolved and more must be done to identify their problems in order to ensure effective referrals to organisations that are better equipped to deal with young peoples specific needs. 5. No one to turn to the UK has among the highest rates of youth suicide, teenage pregnancy and drug and alcohol misuse. Of this sample one in five young people would not seek advice from anyone. The report recommends that this group should be top priority for services as they represent the most socially excluded margins of society. 6. Sources of advice disadvantaged young people often seek advice from family and friends who are not necessarily equipped to deal with such issues. While disadvantaged young people often lack self confidence and motivation, they are more likely to find the information they need from a service that insights a relationship were trust can be established. The Social Exclusion Unit s report Transitions: Young Adults with Complex Needs (2005) investigated the effectiveness of current services for young people with complex needs as they make the transition into becoming an adult. As highlighted by this report, young people aged can often experience various kinds of disadvantages ranging from homelessness, unemployment, lack of training and education, poor health (mental, physical and sexual health) as well as being at risk of engaging in anti-social behaviour and drug use. While many of these concerns are regularly associated with teenagers, often young adults in their early twenties experience the same difficulties as teenagers and this is when support is most needed. However, as policy tends to focus more on teenagers than young adults the Social 20
21 Exclusion Unit have introduced the phenomenon of the invisible early twenties and have highlighted the difficulties these young adults experience. Young adults report a number of barriers that prevent or obstruct them from accessing services. In a similar vein to the findings from the Reaching the Hard to Reach report (2004) young people in this study were more likely to seek advice from family and/or friends rather than from specialist support services. Young people raised a number of issues specifically around age restrictions or age cut-off s at services and stated that services needed to listen to them more instead of passing them on when they reached a certain age. They also raised concerns around the attitudes of service providers and the importance of having someone that they could rely on and trust. Young people felt that it was vital that services addressed a range of needs instead of just focusing in on one (e.g. drug use). They also mentioned that services should communicate more with each other and that while they were happy for individual services to pass on information about them that they should first ask their permission. Perhaps one of the most important issues raised by young people was for services to be more joined-up and in accordance with the Reaching the Hard to Reach report would prefer a single source organisation instead of having to move from one service to another. The report concluded with 27 recommendations and three main points of action which will form the basis for a second phase of the project, (1) age boundaries of policy provision, (2) the benefits of a holistic service and the role of the trusted adult, and (3) the thinking and behaviour of young adults. 1. Age boundaries of policy provision the blurring of age boundaries of services aimed at vulnerable young adults should be considered. Often the abrupt ending of services occurs when the young adult reaches a certain age and the transition into adult services can be difficult which in turn may have a detrimental effect. Therefore, good working relationships and an overlapping of services between youth organisations and adult services needs to be established. 21
22 2. The benefits of holistic services and the role of the trusted adult a holistic service approach such as a one-stop-shop would offer young people advice on a range of problems, as often it can be daunting for some young people to access to a range of services and to deal with many different workers. A holistic service means that the young person can address a number of problems and at the same time have a trusted adult (e.g. personal advisor, key worker, and mentor) to advise them. 3. The thinking and behaviour of young adults this point of action is based on the idea of how young people think and behave and the decisions they make which can have important ramifications and affect their future aims. Therefore, this should be an all-important factor with policy makers and in interventions and should directly address and take into account the thinking and attitudes of young people. 22
23 1.5 Summary and Aim of the Current Study In summary, within the Liverpool area an apparent decrease in problematic drug use has been estimated for young people aged between years since 2001/2 from 1,563 (Beynon et al, 2004) to 1,019 in 2004/5 (Hay et al, 2006). However, it is uncertain whether this has been accompanied by a decrease in non-problematic use. According to the BCS 2005/06, the most commonly used drugs by young people in the UK are cannabis, followed by Class A drugs such as cocaine and ecstasy (Roe & Man, 2006). Furthermore, young people in the age group are more likely than other groups to engage in binge drinking, to become involved in drug related antisocial behaviour and may become homeless as a result of their alcohol and drug use. Aim The aim of this study was to investigate substance misuse in young adults in the Liverpool area aged between years and to consider their perceptions of treatment services. This was achieved firstly through reviewing the current substance misuse literature relating to drug use in young people (aged years) (see section 1) and establishing how young people access drug and treatment services in the United Kingdom. Following this, a semi structured interview/questionnaire was employed in order to examine the views and perceptions of Liverpool s year olds and to establish what their beliefs and behaviours were relating to substance misuse and to drug and treatment services. The interview/questionnaire also set out to establish if current treatment services were meeting the needs of Liverpool s young people and to highlight any barriers they felt were in place that were preventing them from attending. Lastly, a discussion of results from Liverpool s young people in the context of the recommendations of national guidance such as Transitions and Reaching the Hard to Reach reports was completed. 23
24 2. Methodology An individual survey/interview method approach was employed in order to ascertain the types of substances misused by young adults (18-25 years) in Liverpool and the perceptions they had regarding treatment services. 2.1 Participants In total, 26 young people from various different young people s services in the Liverpool area participated in this study (15 females and 11 males, mean age 23 years, range years), 13 (50%) individuals were recruited from counselling services, 12 (49%) participants came from drug services and one (1%) individual came from the Criminal Justice System. Because of the sensitive nature of this research key workers identified prospective participants and asked if would they would be willing to take part in the study. The requirement for inclusion into this study was that subjects were aged between years and that they reported substance use. 2.2 Materials Participants were asked to respond to a number of questions relating to their type of accommodation, employment, education, criminality and lifestyle in a semi structured/interview questionnaire. Participants were asked a series of questions relating to their existing and previous drug and alcohol use. They were also asked where they obtained information about drugs and alcohol, their current drug and alcohol use, age of first using drugs and alcohol and the frequency of use. They were then asked to rate their perception of their personal level of risk, from a list of drugs provided, on a rating scale from one to six (where 1=very risky, 2 = risky, 3=little risky, 4=not very risky, 5=not risky, 6=don t know) and the type of risks they may be exposed to from taking particular drugs. 24
25 Participants were encouraged to discuss their views and perceptions of drug treatment services in the Liverpool area. The young people were asked about their previous experiences of treatment services, the type of service attended, length of time attending previous services, any perceived barriers that would prevent them from attending services and if they had altered their patterns of drug and alcohol use while or since attending services. It is perhaps noteworthy to mention that there is a difference between a drug service and a treatment service. A drug service provides information and advice regarding the use of illegal drugs as well as promoting drug prevention programs. Whereas, a drug treatment service can be operationally defined as using specific medical and/or psychosocial techniques with the goal of reducing or abstaining from illegal drug use thereby improving the general health of the client (UK Focal Point, 2007; The young people were also required to complete two standardised measures previously used within the scientific literature namely, the Alcohol Use Disorders Screening Test (AUDIT) and the SDS cannabis scale. AUDIT The Alcohol Use Disorders Identification Test (AUDIT) was used as a screening instrument for hazardous and harmful alcohol consumption, as it has been found to be valid and reliable in the general population (Babor et al., 2001). A score of below seven on the AUDIT is considered to be low risk of alcohol related harm or dependency, on the other hand, if an individual scores in the range of 8 15 on the AUDIT they are considered to be at moderate risk of alcohol related harm. Attaining a score of between shows that individuals are at a high risk and may be dependant on alcohol, whereas, scoring 20 or more on the AUDIT scale is believed to be indicative of dependence on alcohol. 25
26 SDS The Severity of Dependence Scale (SDS) is a short, unidimensional scale (with good validity and reliability) that assesses the degree of dependence on controlled drugs (Gossop et al, 1995). In this study it was only used to assess cannabis dependence (Swift et al., 1998). According to Gossop et al (1995), who devised the SDS scale, a score of three or more is indicative of dependence. Database Interrogation The National Drug Treatment Monitoring System (NDTMS) database, held at the CPH was interrogated to investigate the number and characteristics of Liverpool based young people who enter into any treatment services and also to determine the number and characteristics of young people whom successfully complete treatment programs. Both agency and pharmacy syringe exchange databases are held at the CPH. Therefore, data from the Inter Agency Drug Misuse Database (IAD) was interrogated to identify the characteristics of Liverpool based young people in contact with syringe exchange services (both pharmacy and agency based) and to establish the type of drugs young people were injecting (agency based only). Agency Syringe Exchange is a specialised service offering free injecting paraphernalia such as syringes, needles, acidifiers (i.e. citric acid) and other materials necessary for safe injecting of a range of substances to injecting drug users, including those using Anabolic Steroids. These services also typically offer harm reduction interventions such as safer injecting advice and Blood Borne Virus (BBV) testing and vaccination. Typically, the service user is expected to return the used needles and syringes to exchange for sterile equipment. Pharmacy Syringe Exchange is a more basic approach to syringe offering syringes and needles and occasionally some other paraphernalia. Typically these services offer less in the way of harm reduction interventions like BBV 26
27 testing but have the advantage of being more accessible than Agency based services simply by having longer opening hours (including weekends, holidays and late nights) and being more numerous, thereby providing greater geographical 2.3 Procedure In order to ensure consistency, accuracy and completeness, all interviews were undertaken by the same researcher. Interviews were conducted at various different services throughout Liverpool. All participants were informed regarding the purpose of the research and were advised of their right to withdraw from the study at any time. Confidentially was assured at all times. 2.4 Ethics Prior to the commencement of the study ethical approval was gained from NHS, Cheshire East Local Research Ethics Committee (LREC) and from Liverpool John Moores University research ethic committee. All young people that participated in this study were provided with a Participant Information Sheet (PIS) which included the title of the project, the purpose of the study, the type of questions that would be asked and approximately how long it would take to complete the questionnaire. Confidentially was assured at all time and participants were informed of their right to withdraw from the study at any time. 27
28 3. Results 3.1 Participants In total, 26 young people from various treatment services throughout Liverpool completed the semi-structured questionnaire, 11 (42.3%) were males and 15 were females (57.7%). The mean age of respondents was 23.4 (SD 3.22) years and the age range was 18 to 25 years. As shown in table 2, an equal number of clients either lived in local authority rented accommodation (n = 6, 23.1%) or hostels (n = 6, 23.1%), followed by four (15.4%) young people who were currently living in private rented accommodation and four (15.4%) individuals who were residing in treatment centres. Half of the respondents, 13 (50.0%), stated that they lived alone; nine (34.6%) young people said that they lived with family members and two (7.7%) individuals mentioned that they lived with a partner. Only one member of the sample said they lived with friends. In all, 19 (73.1%) young people said that they lived in stable accommodation. Five (19.0%) of the young people interviewed stated they were registered as homeless and one (4.0%) participant did not know if they had actually been included on the homeless register. While eight (32.0%) respondents had claimed to have slept rough in the previous 12 months, Table 2. Accommodation Type Accommodation Type N (%) Private (rented) 4 (15.4) Local Authority (rented) 6 (23.1) Housing Association Private (own home) Hostel NFA Treatment Centre 2 (7.7) 3 (11.5) 6 (23.1) 1 (3.8) 4 (15.4) Total 26 (100) 28
29 3.1.2 Education and Employment When questioned about their educational attainment, 20 (76.0%) respondents stated that they had achieved an educational qualification and six (24.0%) reported they had no qualifications. Five (20.0%) of the sample were currently engaged in education, three (12.0%) were attending college on a full-time basis and two (8.0%) individuals were undertaking part-time college courses. Most of the young people were claiming unemployment benefits (n = 22, 84.0%) and three of the young respondents were in employment, two worked part-time and one young person held a full-time position. 3.2 Current Service As shown in table 3, most individuals from the sample attended their current service twice weekly (n = 8, 28.0%) or daily (6, 24.0%), four (16.0%) participants attended on a weekly basis and four (16.0%) individuals were in residential care. From the sample as a whole, respondents had been attending their current service for an average of weeks (ranging from one week to 208 weeks). Table 3 Attendance in Current Service Attend N (%) Daily Residential Weekly Fortnightly Twice weekly Threes times weekly Four times weekly 6 (24.0) 4 (16.0) 4 (16.0) 1 (4.0) 8 (28.0) 1 (4.0) 1 (4.0) Not in Service 1 (4.0) 29
30 When young people were asked how they were referred into the current service, half (13, 50.0%) said they were self-referred and six (24.0%) participants were referred by Lighthouse projects. One (4.0%) individual each was referred in to their current service through a key worker, school, probation, hostel, Addaction or by the hospital and one individual was not in treatment. 3.3 Criminal Convictions Firstly, participants were asked if they had any criminal convictions that were not drug related, and secondly, if they had criminal convictions for drugs. Twenty one (84.0%) reported that they did not have previous convictions. Four (16.0%) young people (three of which were male and one of whom was female) stated that they had convictions that were not drug related The type of convictions that young people had been charged with were drunk and disorderly, criminal damage, driving whilst under the influence of alcohol, aggravated bodily harm (ABH), and shoplifting. The average age that young people committed these criminal offences was 19 years old (range 16 to 24 years). When respondents were questioned about drug related criminal convictions, again, only a small number of participants, (two, 8.0%), stated they had convictions for drugs. Both of the young people (males) stated that they had been charged with supplying Class A drugs. In order to explore this area further the two young people were also asked if they had spoken to someone about their drug use when they were arrested, both young people said that they had spoken to an arrest referral worker while in custody and that they had been advised to seek treatment for their drug use. 30
31 3.4 Drug and Alcohol use Sources of Information Displayed in table 4, are a list of possible sources were young people obtained information about drugs. Interviewees were asked to select as many sources of information as appropriate from the list that they used to find out information about drugs and to rate how trustworthy they thought each source was. Table 4. Sources of Information Drugs Information News TV Magazines Internet Friends Dealer Services Education Doctor Police Official sources Other Drug Users Other Parents Other Library Number using N (%) 11 (42.3) 14 (53.8) 8 (30.8) 8 (30.8) 19 (73.1) 5 (19.2) 14 (53.8) 5 (19.2) 9 (34.6) 5 (19.2) 7 (26.9) 1 (3.8) 1 (3.8) 1 (3.8) As with most research in this area (e.g. Murphy et al., 2006), the most frequent source of information consulted by young people was friends, with 19 (73.1%) young people from the current sample stating that they had spoken to their friends when they needed to find out information about drugs. However, when asked to rate how trustworthy they believed friends were as a source of information about drugs, only seven (36.8%) participants thought they were 31
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