Heroin use as self-medication

HEROIN USE AS A FORM OF SELF-MEDICATION

Peter Norden, AO
Heroin and other illicit drugs are becoming the drug of choice of many young people in Australia who are experiencing mental health problems. These drugs are used as a form of self-medication to alleviate the symptoms of mental illness. Most young people do not voluntarily attend mental health services and, when they do, they are often told to address their drug use before receiving attention for their mental illness.
The National Survey of Mental Health and Well-Being 1997, conducted by the Australian Bureau of Statistics, found that almost one in five Australians aged 18 years or more met criteria for a mental disorder at some time during the 12 months prior of the survey, but that only 38 per cent of people with a mental disorder had used health services. This suggests a large unmet need for mental health services, and among this group young Australians are the most highly represented. The mental health needs of young adults are more significant because young adulthood is a complex transitional period, marked by reduced dependence on parents and peers, and the commencement of long-term relationships, careers and families.
Because adolescence and early adulthood is usually a time of new discovery, unlimited energy and increased independence and perceived self-indestructibility, young people are the group least likely to recognise or acknowledge their own mental illness. There are many understandable factors which prevent them from seeking assistance from mental health professionals, and even from their own local general practitioner.
As an additional barrier, existing mental health services are rarely designed to be ‘youth friendly’, with the dominant influence being an authoritative medical model, transposed from a hospital setting into the local community-based services. Formal clinical settings, with fixed role relationships and appointment schedules that demand consistency and punctuality, are limited in their ability to engage young people needing mental health care.
The existence of a mental disorder is an often unidentified factor in the complex task of responding to the health needs of young people using illicit drugs, especially heroin. When their need for assistance escalates and they finally seek treatment from drug and alcohol services, they are told that such services are not equipped to deal with their mental health needs. If they eventually approach mental health services, they are referred back to drug and alcohol services, with the specific instructions that they must first get their drug usage under control before they can profitably receive treatment for their mental health needs. Many young Australians are now in this catch-22 situation because our existing health services do not have the capacity to respond to the needs of young people in a holistic way, or to build relationships with clients still engaged in the youth culture.
The National Co-morbidity Survey (1997) in the U.S., indicated the early onset of both substance-related and mental health disorders. Many such disorders are seen to develop in childhood and early adolescence, and tend to become persistent and disabling if not treated early. But the focus of treatment programs has almost always tended to be on adults. Opportunities for secondary prevention, by preventing an existing disorder from worsening, or a second disorder such as drug misuse from developing, have not been grasped.
Such U.S. research provides growing evidence of the sequential growth of mental illness and substance abuse in much of the population that share this form of ‘dual disability’. Typically, the mental illness sets in several years before the substance use disorder. There is clear evidence that the substance abuse constitutes an attempt to relieve the pain and anxiety caused by the mental illness. This knowledge presents a window of opportunity for intervention in the lives of mentally ill adolescents; if their mental illness is diagnosed and treated sufficiently early, they may be prevented from becoming involved with either alcohol or other drugs which may, in turn, also prevent the accentuation of their mental disorder.
In Victoria the dimensions of the incidence of concurrent mental illness and problematic drug and/or alcohol use matches international and national research at between 30-70- per cent. About 300 agencies report that they provide services to these clients. However, the ‘service’ is usually assessment and referral, or just referral (most often the latter) and the referral is most often for assistance for the ‘other problem’ (i.e. the problem with which the referring agency has no expertise). This approach has led to what has been referred to as ‘ping pong’ therapy, where service systems and agencies maintain, rather than modify, existing services and therefore will refer on those who fail to meet strict program criteria. However, their study also indicated that between 200 and 300 people with a dual diagnosis who contact Victorian agencies each week receive no service whatsoever.
Policy makers at all levels of government have many reasons to be interested in those with dual disability. This population, with the compounding of their mental health needs with a drug use disorder, is prone to homelessness and eventual incarceration within criminal justice institutions. Evidence from the United States indicates that a majority of the exploding numbers of incarcerated individuals have co-occurring substance-related and mental health disorders.
In 1972, the total population of those incarcerated in the United States was about 200,000. Including those awaiting trial in jail or in prison, this figure has now reached beyond two million, representing about one in 200 American citizens in custody! In 1990, the National Institute of Mental Health estimated that 82 per cent of American prison inmates had a history of mental health disorder and 81.6 per cent of this group also had a substance-related disorder. In 1991, a study of inmates at the Chicago Cook County Jail indicated that 85 per cent of prisoners who were severely mentally ill also abused alcohol, and 58 per cent abused illicit drugs. The comparable numbers for those who were not severely mentally ill were only 48 per cent and 30 per cent.
Based on such studies, it is a simple calculation to estimate that more than one million prisoners have co-occurring substance-related and mental disorders, representing about half of the United States prison population. There is every indication that the same pattern applies to the Australian prison population. The high level of co-morbidity of the modern prison population could readily explain the 48 per cent increase in the Australian prison population since 1986.
At the present time, it is estimated that less than 10 per cent of the Australian prison population obtains any form of drug treatment or behaviour change therapy. Yet, almost without exception, all are eventually released back into the community which then has to bear the repeated burden of their offending behaviour. It may be high time for Australian authorities to reconsider the punitive focus of our imprisonment policies and objectives, away from containment and warehousing (achieved at great expense in order to provide some form of temporary public protection), to a treatment model focused on the health needs of the current prison population.
The experience of Jesuit Social Services’ staff working with young people with dual disability (through the Brosnan Centre and Connexions programs) demonstrates a high incidence of trauma in the lives of these clients. Examination of case notes reveals that it is as high as 90 per cent. A recent report on the prevalence of mental disorders among homeless young people in Sydney revealed a similarly high incidence of trauma, confirming anecdotal evidence within Jesuit Social Services of both the prevalence of trauma among marginalised young people and the need to create an appropriate response.
The trauma experienced by young people in our programs varies in severity and intensity. Experiences range between one-off rapes to prolonged sexual abuse; from one-off physical attacks that leave indelible damage in memory and psyche to prolonged periods of severe physical abuse; from one-off emotional abuse to prolonged periods of emotional neglect and violence. The vast majority of clients at Connexions have suffered severe, repeated abuse which has lead to the development, in most cases, of symptoms of post-traumatic stress disorder and diagnosis of borderline personality disorder.
Many of the clients, both male and female, have been sexually, physically and emotionally abused at young ages. The fact that they are also suicidal as well as self-mutilating is no surprise. A recent study found that there were high correlations between having been sexually abused, particularly early in life, self-mutilation and suicide attempts. There is a cycling of trauma, whereby the mind and body are overwhelmed by the stress and trauma, so that the person cannot think their way out of it and break the cycle. The following case study illustrates the effects of trauma on an individual’s behaviour.
‘Christie’ who was repeatedly sexually abused by her stepfather from a young age repeats the cycle throughout her relationships with men by choosing partners who repeat the abuse on her. In fact she has very little real choice, she ‘goes for what she knows’. However horrendous, she is deeply acclimatised to abuse, which seems normal to her because it is what she has experienced from a very young age. Consequently, she does not have a framework of self-care and respect, nor any experience of sexual partnership as non-violent. Nor does she have the experience to be able to sense danger and protect herself from such situations, as they are normal for her. Thus Christie, who has significant post-traumatic stress disorder, is in a constant state of hyper-vigilance and anxiety from which she switches off by using heroin. While this serves to contain the overwhelming emotions she feels, it limits her cognitive capacity to discover new and better choices and situations and locks her in a destructive cycle.
Jesuit Social Services, through the Brosnan Centre and Connexions, has developed a new paradigm of service for young people who suffer from mental illness and problematic drug use. Based on years of experience of working with young people from within the correctional system who suffered from dual diagnosis, staff saw the benefit of providing a community-based service staffed by youth workers (including outreach workers) and counselors, rather than a service based on traditional mental health and drug treatment practice. This latter approach is dualistic and defines the young person in relation to either or both of these issues. In contrast, this holistic approach perceives individuals as greater than the sum of their parts and considers all parts or aspects (physiological, psychological, social, emotional, mental and spiritual) as intrinsically related. Holism recognises that drug and alcohol misuse directly relates to and impacts upon one’s mental health and vice versa. It eschews treatment models that ignore or arbitrarily attempt to separate out one from the other, believing that this approach splits and further fragments the already fragile and complex client.
The youth work focus places a high value on human relationships and staff are employed specifically for their capacity to forge emotionally authentic relationships. In addition, the importance of being able to understand and work with every young person in their particular familial, social and economic context is well understood. Addressing basic needs such as food, shelter, warmth and human companionship are often necessary precursors to any intervention. Staff develop significant experience of young people and how they are affected by past experiences. Family abuse and neglect, particularly sexual and physical abuse, are commonly understood as central to how young people’s subsequent relationships develop. Workers aim, therefore, to better understand the precursors to difficult behaviours and assist young people to develop more constructive and mutually supportive relationships. The culture at the programs attempts to facilitate the growth of such relationships by creating an environment that is informal, not solely appointment based, and which is interactive and non-judgmental. This is a direct response to consultations with young people who reported that their experiences with mental health and drug treatment services had often been alienating and humiliating where they felt health professionals were judgmental, often did not listen, and spoke down to them.
These programs work within a harm minimisation framework. As young people become more stable, it is possible to respond to therapeutic windows that occur and conduct brief amounts of trauma work. This can begin to build a positive experience of dealing with the trauma, which then lays the ground for later constructive trauma work. Our clients may not address all their issues, but a ‘good taste’ of therapy, even if things are left unfinished, is more healing and keeps open the inner door to further exploration if and when the time is again right for the client.
Our programs have two main aims. These are to improve the quality of life of the young people who access the programs and to improve the quality of care provided to these young people. Within this context, the more specific goals for our clients are to achieve stability of accommodation, less drug use, fewer admissions to hospital for self-harming incidents, and use of mainstream health and welfare services. Feedback from participants indicates that the Connexions environment is one that encourages participation, and by contrast to young people’s previous experiences within the health and welfare system, engages them positively and respectfully in a partnership, rather than simply providing a service. One young woman at Connexions commented:
One thing I can say about Connexions that is different from any other organisation I’ve ever gone in, and that’s been seven years of organisations, is they actually treat you as an individual, you’re not just a case number … you’re not just a file, you’re actually a human person with a living heart that can feel…
Many young people are using drugs to deaden the pain of crisis, trauma and mental illness. While services remain one-dimensional in their approach, young people will continue to ‘fall through the gaps’ between services and not receive the treatment they require. The wider community needs to understand that young people misusing drugs are doing so in response to pain, suffering and isolation, not because they deliberately choose to behave in a self-destructive manner.

Peter Norden, AO

Paper published in May 2001