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Introduction (approx. 100 words): Provide a logical succinct overview of the main points. Withdrawal management (approx. 500 words): Discuss withdrawal relevant to the main substances in the case study, including onset, signs, symptoms and problems related to poly-substance use. Critically evaluate withdrawal scales you would use to monitor withdrawal. Responding to and managing risks and needs (approx. 500 words): Considering the potential risks of ‘recent release from hospital or residential health setting’, identify and discuss: two (2) physical health-related risks, two (2) mental health-related risks and two (2) psychosocial-related risks related to AOD use that could affect Emily following discharge. Interventions (approx. 300 words): Identify and describe relevant AOD-related or comorbidity-related strategies to manage two of the risks identified above. Justify your choice. Conclusion (approx. 100 words): Present a summary of the main points of the essay. Case Study Emily is a 42-year-old woman, presenting to her local AOD service for her tenth admission for inpatient detoxification/managed withdrawal from heroin, alcohol, and cannabis. Emily has been using heroin since she was 17 years old and has sometimes shared needles. Although heroin has always been her main drug of concern, Emily also drinks heavily and smokes cannabis daily, particularly on days when she cannot obtain heroin. She occasionally uses stimulant drugs but doesn’t particularly like the effect. In addition to her nine previous attempts at inpatient detoxification, Emily has been on a methadone program on three occasions. The first time, she stayed on methadone for 10 years before being imprisoned for her involvement in a break and enter. Emily stayed clean for the duration of her sentence, but returned to use soon after she was released. Emily had also tried going cold turkey, and detoxing by herself numerous times, with the help of non-prescribed benzodiazepines and buprenorphine – none of which were successful. Her longest period of abstinence since she started using was two years after the birth of her first child, who is now 16 years old. Emily has four children, ranging in age from 4-16 years, all of whom are in foster care. Emily relies on the Disability Support Pension to pay the rent on her Department of Housing flat, which she shares with her current boyfriend. There are occasional episodes of domestic violence from him towards her which she does not disclose. She has never been able to hold down a job for more than a few weeks because she often sleeps in and cannot get into a daily routine. Emily is highly motivated to stop using all drugs so that she may have more contact with her children and hopefully one day have them returned to her custody. Emily was coping with withdrawal relatively well until one night when a male client accidentally walked into her room in the detox unit when trying to find the bathroom. Emily was awoken by the feeling that someone was watching her and could hear heavy breathing. His shadowed appearance in the half-light caused her to become hysterical and she lashed out violently. Staff quickly arrived and calmed Emily and removed the male client who was swearing at her and calling her a ‘crazy bitch’. The following morning, the incident was reported during staff handover. The mental health nurse identified seeing Emily as a priority. The mental health nurse told Emily that she had heard about what had happened the previous night and asked whether she was okay. Emily was still a little shaken but said that she was okay now, adding that she was just startled and probably overreacted. She explained that it had reminded her of a time when one of her previous boyfriends had come into their bedroom one night and started beating her. The mental health nurse asked whether she was hurt at the time, to which Emily replied that she was hospitalised and required surgery for internal injuries. Emily appeared reluctant to talk about it. She said that she tried not to think about it and avoided any possibility of running into him again by avoiding areas which he frequented. Despite her efforts to forget about it, she often has bad dreams, flashbacks to the incident, and trouble sleeping, which meant she sometimes needs to take large amounts of benzodiazepines to sleep. She used street benzodiazepines as she had found GPs were reluctant to prescribe them. She found her supplier rather intimidating but had no other source; occasionally he suggested that he could “introduce” her to some people who would pay her well for “services”. While in rehab she had tried to block his number on her phone but he always seemed to use a different one and still got through to her. She thinks he has passed her number on to other people too as she does not recognise some of her missed callers. After this brief talk with Emily, the mental health nurse made a time to see her later in the day. During this session, the mental health nurse asked more questions about how Emily felt after she was beaten and how this had affected her. The mental health nurse assured her that she had done nothing to deserve being treated this way, and that her reactions were completely normal. Emily was shaking as she described the incident in more detail, and later confided that she was also sexually assaulted during this attack – something that she had not previously disclosed. While Emily was an inpatient, the mental health nurse took the opportunity to talk with her a little more about her past trauma, continuing to normalise her symptoms, providing psychoeducation and self-management techniques, and exploring the relationship between her trauma-related symptoms and her substance use. The mental health nurse suggested that Emily might like to try a residential rehabilitation program for women only, where her trauma-related symptoms could also be addressed. Emily had previously been reluctant to enter residential rehabilitation but accepted the prospect of a women-only service. The mental health nurse organised for a telephone assessment with the residential program, and Emily entered the program following her detoxification. While the program was hard, Emily benefited greatly from the trauma-informed approach taken by the service. Importantly, Emily felt safe and over time gradually opened up more about her life. She engaged in a combination of group and individual therapy. Her individual therapy in particular focused on providing integrated treatment for both her PTSD and AOD use. It was during one of these sessions that Emily made a link between the onset of her substance use and previous traumatic events. Unbeknownst to the therapist or any other treatment provider, Emily had been sexually abused by a male relative from the age of 5 to 11 years when she left home to live with her grandparents. Emily drank Pholcodine cough medication when she was little as it made her feel better when she was upset. She also reported using her father’s diazepam. After moving to her grandparents’ house, which also involved a change of schools, she starting hanging out with new friends who liked to drink and smoke cannabis. Her substance use and truancy from school caused continual fights with her grandparents, who told her to leave when she was 16 years old. Emily quit school without getting her Year 10 School Certificate and moved into a shared house with people who introduced her to heroin around age 17. Within a year she had developed a ‘habit’. As Emily’s treatment progressed, she began to open up about numerous assaults, including rape, which had occurred in the context of the drug-using environment, but did not report any PTSD symptoms in relation to these experiences. While she was clean she was also involved in a car accident. She suffered major injuries and was not able to get into a car for 2 1⁄2 years. She reported residual trauma symptoms, and had previously worked with a psychologist on this. Her therapy continued to concentrate on the domestic violence, from which she was currently experiencing the most distress, and later the sexual abuse she experienced as a child. Emily was aware that it would likely take a long time for her to come to terms with what she had experienced. Emily successfully completed the residential rehabilitation program, and continued to receive ongoing psychological treatment for her PTSD and substance use. Her current partner is still using various drugs though at this time Emily remains clean. She is looking for jobs but her criminal record precludes many applications. She has enrolled in an online TAFE course but her boyfriend resents the time she needs to spend studying. She is always on time and present for any meetings arranged with her children by the Department of Child Justice. The rent for her flat has just gone up and her boyfriend is reluctant to pay his full share due to his increasing drug use. Emily values her fortnightly appointments with the psychologist but sometimes wishes she had someone she could talk to more often about how she is feeling. She misses the intense support provided in rehabilitation. She is beginning to feel afraid of her boyfriend and wonders if they will stay together but she does not know how to get him to leave the flat which is in her name. She wishes she could find a sympathetic GP as she has been told that she should have regular LFTs though she is not sure why or what they are. There was no doctor on staff at the rehabilitation centre and the program was officially “drug free” which included all prescribed medication. Suddenly stopping the venlafaxine which she had taken for a year was difficult but she said nothing to staff at the time. She tries to maintain a positive outlook but as the weeks pass it is becoming increasingly difficult.

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