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Access to Recovery: Substance Abuse

and Independent Living October 19 and 21, 2006

Richmond, B.C.Centre for Addiction & Mental Health

CAILCToronto Rehabilitation Institute

Canada Drug Strategy

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Learning Objectives

At the end of the workshop, participants will:

 List the most commonly used drugs and their effects Discuss the most current trends in drug use  Understand how these issues affect people with

disabilitiesUnderstand treatment options and how to access the

addiction treatment system,Integrate prevention and health promotion in your workDevelop a plan for working with local communities to

improve awareness of and access to recovery for persons with disabilities

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Agenda DAY 1 9:00 – 4:30

MORNINGWelcome and overview: JenniferIntroduction to Addiction: Keith

Key conceptsModels of addiction

Break Stigma, discrimination & addiction :Jennifer & Keith

Patterns of drug use, with emphasis on use within disability communities: Keith & Jennifer

Lunch

AFTERNOONStages of change and motivational interviewing: Jennifer & Keith Empowerment and self change: Keith

Break

Drug effects, with emphasis on drugs most commonly associated with harm: Keith

Harm reduction: Keith

Q & A’s: Jennifer & Keith

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Agenda DAY 29:00 – 4:30

MORNING

Welcome and overview: Jennifer Health promotion & illness prevention : Keith

Break

Treatment approaches: Keith

The addiction treatment system:Jennifer

Lunch

AFTERNOON

Barriers to access: Keith

Advocacy & systems change: Keith

Break

Making it happen: Jennifer & CAILC participants

Wrap-up

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WELCOME

Agenda overviewGround rules:

Participant led

Introductions:Names Where from and what role is What want to get out of the training

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Society’s most common, serious & neglected problems.

1 in 4 Canadians will experience addiction or mental illness during their lifetime (1/10 in a year).2/3 who need care receive none affect more people than heart disease – more than cancer, arthritis & diabetes combined.Costs Canada $32-billion a year, 14% of the net operating revenue of all Canadian Business (33% of short-term disability claims).20% of Ontario children require help (only 4% currently receive help).

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Why do people use drugs?

Brainstorm a list of reasons people give for using drugs.What are some of the positive, beneficial or desirable effects that people might experience when using drugs

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Some reasons people give for using drugs

Fun/enhance pleasurable activities/intensify feelingsExperiment, explore new experiencesUnwind, cope with stress Escape reality, numb feelingsDeal with emotional pain or discomfortRespond to social pressure or normsMake social contact easierEnhance artistic creativitySpiritual or meditative pursuitsSelf-medicate for anxiety, depression, cognitive dysfunction

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KEY CONCEPTS

What is “addiction”?What is “substance abuse”? What are the causes of addiction?A brief history of the meaning of addiction and substance abuse

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What is “addiction”?

What is first word that comes to mind if you are asked that question?

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The meaning of “addiction”:

• varies widely within and across societies

• is to some degree culturally determined

• is an evolving concept within our society

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Models of addiction

Moral modelsDisease modelsSocial modelsBiopsychosocial models

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Moral models of addiction

The temperance movementThe War on Drugs

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Disease models of addiction

The 12-Step MovementBiology of addiction

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Social models of addiction

The behaviouristsThe Independent Living Movement

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Biopsychosocial models of addictionDeterminants of health & disabilityInclusion of spiritual factors Better understanding of interaction of physical, psychological, social & spiritual factors

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Addiction: An Integrated Model

BIO

PSYCHO

SOCIAL

SPIRITUAL

CULTURAL

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Current concepts in understanding meaning of “substance abuse” and “addiction”

Physical dependenceDrug toleranceWithdrawal

Psychological dependenceHarm

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Physical Dependence

state in which the body has adapted to the presence of the drug at a particular levelwhen the drug concentration falls, withdrawal results

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PHYSICAL DEPENDENCE

Tolerance

the need for an increased amount of a given drug to achieve intoxication or desired effect

or the reduction of a drug’s effect with continued use of the same dose over time

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PHYSICAL DEPENDENCE

Withdrawal

Occurs when a drug is abruptly removed, or dose is significantly decreasedCluster of symptoms often accompanied by directly overt physical signs

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Withdrawal ...cont’d

Withdrawal generally looks opposite to the intoxication.Unpleasantness of withdrawal may be so severe that the individual fearing it may use drug again just to avoid or relieve symptoms

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Psychological Dependence

a state in which stopping or abruptly reducing the dose of a drug produces non-physical symptomscharacterized by emotional and mental preoccupation with the drug’s effects and a persistent craving for the drug

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Harm

Central concept in understanding both addiction and substance abuseTypes of harm:

PhysicalPsychologicalSocial (e.g., family, friends, job, financial, legal system)Spiritual

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Abbreviated List of Criteria for Abuse and Dependence

Preoccupation with substance

Increased use of substance beyond expected

Inability to control use

Withdrawal symptoms

Signs of tolerance

Restricted activities

Impaired functions

Harmful or hazardous use

DSM IV Definitions

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DSM IV

Substance Dependence At least 3 within a 12-month period:ToleranceWithdrawalUnintentional OverusePersistent desire or efforts to control drug useReduction or abandonment of important social, occupational or recreational activitiesContinued drug use despite major drug-related problems

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Substance Abuse: At lease one criterion must apply within a 12 month period

Recurrent use leads to failure to fulfill major role obligations at work, school, or homeRecurrent use in situations which are physically hazardousRecurrent substance-related legal problemsContinued use despite persistent physical, social, occupational, or psychological problems

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Aside from the DSM…“Drug Abuse” is…

a highly complex, value-laden term that does not lend itself to any single definition.Its meaning differs from one society to another

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Review of key points…

Our understanding of the meaning of addiction is evolving. The current model of addiction is called the “___________” model.What are 3 key concepts in our current understanding of addiction & substance abuse?Of these 3 concepts, which one is common to both substance dependence & substance abuse?

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Coffee Break

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Values Clarification Activity

Individually review the list of drug users on the next slide and make note of the first thought, feeling and or image that comes into your mind.As a group discuss and rank the harms associated with the list on the next slide.

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Values Clarification ActivityCoffee drinkerTeen smoker Person on MethadoneCrack addict Person addicted to oxycontin Valium userPregnant heroin userSocial drinkerRaverMarijuana smoker

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STIGMA, DISCRIMINATION & ADDICTION

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What is stigma ? A complex idea that involves beliefs, attitudes,

feelings and behaviour.

Refers to the negative “mark” attached to people who possess any attribute, trait, or disorder that marks that person as different from “normal” people.

This ‘difference’ is viewed as undesirable and shameful and can result in negative attitudes/responses (prejudice and discrimination) from those around the individual.

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Stigmatizing language

AddictSubstance “abuse”/abuserDrunkCrack-headJunkieOthers…

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Legal status of drugs does not reflect harms

Alcohol and tobacco cause more illness and death than all other drugs combinedConsider the ratio of harms to stigma

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CAMH study on stigma & addiction

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PATTERNS OF DRUG USE

within the population at largeamong persons with disabilities

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79% of general population drink, 14% use cannabis. (CAS 2004)

18% exceeded drinking guidelines.14% reported hazardous drinking.Majority of acute problems are the result of average drinkers who drink too much on single drinking occasions. (Rehm 2003)

Alcohol, tobacco and other drugs cost Canadians over $18 billion annually. (Single, 1996)

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Over 90% of the alcohol consumed by males aged 15 to 24 years and over 85% consumed by young females exceeded Canadian guidelines. (Stockwell 2005)Close to 60% of those between 15 and 24 have used cannabis at least once; 38% used cannabis in the past year. (CAS 2004)Over 80% of Grade 12 students drink and almost half of these students report hazardous drinking. (Adlaf 2005)Daily cannabis use has increased significantly and 1 in 5 students report driving after using cannabis. (Adlaf 2005)Although smoking has gone down, 1 in 7 students still smoke. (Adlaf 2005)

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OSDUS 2005 HIGHLIGHTS…The good newsThe following drugs declined in use

cigarettes: from 19.2% to 14.4%alcohol: from 66.2% to 62.0%LSD: from 2.9% to 1.7%PCP: from 2.2% to 1.1%hallucinogens: from 10.0% to 6.7%methamphet: from 3.3% to 2.2%heroin: from 1.4% to 0.9%Ketamine: from 2.2% to 1.3% barbiturates: from 2.5% to 1.7%

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More students in 2005 reportedbeing drug free (including

alcohol and tobacco) during the past

year compared to 2003 (35.9% vs.

31.6%)

OSDUS 2005 HIGHLIGHTS…The good news

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Special Populations

Populations with higher than average levels of substance use:

Homeless Youth & AdultsLesbian, gay, bisexual and transgendered youth and adults Aboriginal people Sex workersPeople in detention centers, jails & prisons Substance Use in Toronto: Issues, Impacts & Interventions, February 2005

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Non-disability factors can be more important predictors of patterns of use than type of disability

Regional differencesCultural differences

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Higher incidence of drug use among people with:

Mental illnessesLearning disabilitiesAcquired brain & spinal cord injuriesPainful conditions

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Primary drugs of concern among people with disabilities

TobaccoAlcoholOpioids MarijuanaBarbiturates & benzodiazipinesPolydrug use

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Alcohol & tobacco

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Opioids

Narcotic analgesicsOpiophobia Issues related to treating chronic pain in people with a histories of drug dependence or abuse

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Marijuana

Medicinal usesRisks

Access to Recovery: Substance Abuse and Independent Living

LUNCH BREAK

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AGENDA DAY 1

AFTERNOONStages of change and motivational interviewing: Jennifer & Keith Empowerment and self change: Keith

Break

Drug effects, with emphasis on drugs most commonly associated with harm: Keith

Harm reduction: Keith

Q & A’s: Jennifer & Keith

Making Changes: Group Activity

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Conte

mplatio

nLapse/Relapse

Maintenance

Action

Preparation

Pre-Contemplation

STAGES OF CHANGESTAGES OF CHANGE

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PRE-CONTEMPLATION

Tasks of Change:Information: Both factual and personalConsider circumstances which indicate a need for changeEngagement of client, create positive relationship

Pre-Contemplation

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CONTEMPLATION

Tasks of Change:

Examine the ambivalenceWeigh and consider alternativesExamine “pros” and “cons” of particular actions

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PREPARATION

Tasks of Change:

Gather information about optionsMake initial contact

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ACTION

Tasks of Change:Understanding factors supporting the behaviourStrategies which will support behavioural changeCommunication with others

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MAINTENANCE

Tasks of Change

Establish support systemPractice behavioural changesAct on relapse prevention plans

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LAPSE/RELAPSE

Tasks of Change:Reconnecting with supportsExamining and learning from lapse experienceReviewing and modifying relapse prevention strategies

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EMPOWERMENT AND SELF CHANGE

Understanding motivationAutonomy Motivational interventions

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Afternoon Break

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DRUG EFFECTS

How do drugs work? What makes one drug more addictive than another?Which drugs are creating the most harm?

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How Drugs Work

the type of drugsize of dosehow drug was takendistribution and absorption metabolizationinteractions

In order to predict the effect of a drug, we need to know:

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Metabolization

blood-brain barrierbody doesn’t distribute all drugs in the same waysome are stored in fat cells and released slowlyothers bind to plasma protein in the blood and move to the brain quickly

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Liver ActionLiver contains enzymes that work to eliminate the drug from the body.

As the liver breaks down the drug it forms metabolites - some may not be psychoactive; others may be more potent than the original drug.

Metabolites eliminated from the body in urine or feces

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Drug Interactions

taking different drugs together creates new effects that are different than those from a drug taken aloneknown as potentiation, its like multiplying the effects of two drugs rather than simply doubling the dosesome drugs cancel the effects of others. This is known as an antagonist effect

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Types of DrugsClassified by Psychoactive Effect

Stimulants

Depressants

Hallucinogens

Antidepressants

Antipsychotics

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Stimulants

increase activity by stimulating the central nervous systemreverse the effects of fatigue and elevate a person’s moodnicotine and caffeine are the most common drugs

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Depressantsslow down body activity by depressing central nervous systeminduce sleep, coma and even deathsleeping pills (barbiturates), tranquilizers (benzodiazepines), antispasmodics and alcohol are most common depressantsopiates such as heroin and morphine can be thought of as a special class of depressants, as can neuroleptics such as neurontin & gabapentin

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Hallucinogenscause user to see hear or feel things that aren’t there yet without causing serious disturbances to CNSLSD (acid), psilocybin (magic mushrooms) and mescaline are common examples of drugsinhalants and marijuana have characteristics of depressants and hallucinogens

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Antidepressants

MAO inhibitersTricyclics, such as amitriptyline, Elavil, imipramine SSRIs, such as Prozac, Paxil, Celexa, ZoloftSSNRIsOthers, such as Wellbutrin, Effexor

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Antipsychotics

Major tranquilizers, such as chlorpromazine, Haldol“Atypical” antipsychotics, such as clozapine, olanzepine, resperidone & Seroquel

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Factors related to addictive & abuse potential of drugs

Biochemical & biologicalCentral Nervous System effectsRout of transmissionRate of absorption/metabolizingRate of eliminationSide effects

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Factors related to addictive & abuse potential of drugs…cont’dPersonal

NeurochemistryDevelopmental historyAspects of personalityExperiences in use of this & other drugsValues, beliefs & expectationsSome types of disorders & disabilitiesAge & health

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Factors related to addictive & abuse potential of drugs… cont’d

EnvironmentalAvailability of drugImmediate social group (e.g., family & peers) and community with whom the person identifiesSocietal norms & sanctions re use of the drug(s) in question

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HARM REDUCTION

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Drugs Cause Real Harms!

Implicit in the term harm reduction is the belief that drugs can cause real harms.These harms are not an inevitable consequence of drug use, and can be prevented or ameliorated through a range of strategies that include but do not invariably require complete cessation from all drug use

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Harm Reduction: Key Concepts

Harm reduction aims to reduce the adverse health, social, and economic consequences of alcohol and drug use without requiring abstinence.Goal is to reduce harms to the individual and the community.

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Harm Reduction- Key Concepts

Focuses on reducing harms and not necessarily on reducing use

Accepts that drug use is universal and brings with it both risks and benefits

Does not judge drug use as good or bad. Morally neutral - does not promote use or

condemn use Non-Coercive

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Harm Reduction: Key Concepts

Acknowledges that quitting drug use may not be realistic or desirable.

Provides practical strategies Public health Human rights approach No person should be denied access to

services because of their drug use.

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Hierarchy of Goals instead of one all or nothing decision.Balances Costs and Benefits Provides accurate information.Attempts to promote & facilitate access to care for addiction & mental health problems.Engage drug users in a continuum of care from which they would otherwise be excluded

Harm Reduction: Key Concepts

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Harm Reduction & Abstinence

Non-use is a viable choiceCan described as overlapping elements within a continuum of care.

Drug holiday – short-term abstinenceAbstinence from one drug but not all drugsLong-term abstinence from all drugs.Abstinence as the goal, but harm reduction strategies used if one relapses.

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WRAP UP & CLOSING

Day 1