Access to Recovery: Substance Abuse and Independent Living

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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
• CAILC
• Toronto 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
  disabilities
• Understand treatment options and how to access
  the addiction treatment system,
• Integrate prevention and health promotion in
  your work
• Develop 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 1 900 430

• MORNING
• Welcome and overview Jennifer
• Introduction to Addiction Keith
• Key concepts
• Models of addiction
• Break
• Stigma, discrimination addiction Jennifer
  Keith
• Patterns of drug use, with emphasis on use within
  disability communities Keith Jennifer
• Lunch

• AFTERNOON
• Stages 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 As Jennifer Keith

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Agenda DAY 2900 430

• MORNING
• Welcome and overview Jennifer
• Health promotion illness prevention Keith
• Break
• Treatment approaches Keith
• The addiction treatment systemJennifer
• 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 overview
• Ground rules
• Participant led
• Introductions
• Names
• Where from and what role is
• What want to get out of the training

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Societys 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
  feelings
• Experiment, explore new experiences
• Unwind, cope with stress
• Escape reality, numb feelings
• Deal with emotional pain or discomfort
• Respond to social pressure or norms
• Make social contact easier
• Enhance artistic creativity
• Spiritual or meditative pursuits
• Self-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 models
• Disease models
• Social models
• Biopsychosocial models

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Moral models of addiction

• The temperance movement
• The War on Drugs

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Disease models of addiction

• The 12-Step Movement
• Biology of addiction

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Social models of addiction

• The behaviourists
• The Independent Living Movement

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Biopsychosocial models of addiction

• Determinants of health disability
• Inclusion of spiritual factors
• Better understanding of interaction of physical,
  psychological, social spiritual factors

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Addiction An Integrated Model
CULTURAL
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Current concepts in understanding meaning of
substance abuse and addiction

• Physical dependence
• Drug tolerance
• Withdrawal
• Psychological dependence
• Harm

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Physical Dependence

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

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PHYSICAL DEPENDENCETolerance

• the need for an increased amount of a given drug
  to achieve intoxication or desired effect
• or the reduction of a drugs 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 decreased
• Cluster of symptoms often accompanied by directly
  overt physical signs

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Withdrawal ...contd

• 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 symptoms
• characterized by emotional and mental
  preoccupation with the drugs effects and a
  persistent craving for the drug

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Harm

• Central concept in understanding both addiction
  and substance abuse
• Types of harm
• Physical
• Psychological
• Social (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

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DSM IV Definitions
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DSM IV Substance Dependence
At least 3 within a 12-month period

• Tolerance
• Withdrawal
• Unintentional Overuse
• Persistent desire or efforts to control drug use
• Reduction or abandonment of important social,
  occupational or recreational activities
• Continued 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 home
• Recurrent use in situations which are physically
  hazardous
• Recurrent substance-related legal problems
• Continued use despite persistent physical,
  social, occupational, or psychological problems

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Aside from the DSMDrug 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 Activity

• Coffee drinker
• Teen smoker
• Person on Methadone
• Crack addict
• Person addicted to oxycontin
• Valium user
• Pregnant heroin user
• Social drinker
• Raver
• Marijuana 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

• Addict
• Substance abuse/abuser
• Drunk
• Crack-head
• Junkie
• Others

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Legal status of drugs does not reflect harms

• Alcohol and tobacco cause more illness and death
  than all other drugs combined
• Consider 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 large
• among 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 HIGHLIGHTSThe good news

• The 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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OSDUS 2005 HIGHLIGHTSThe good news

• More students in 2005 reported
• being drug free (including alcohol
• and tobacco) during the past year
• compared to 2003 (35.9 vs. 31.6)

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Special Populations

• Populations with higher than average levels of
  substance use
• Homeless Youth Adults
• Lesbian, gay, bisexual and transgendered youth
  and adults
• Aboriginal people
• Sex workers
• People 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 differences
• Cultural differences

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Higher incidence of drug use among people with

• Mental illnesses
• Learning disabilities
• Acquired brain spinal cord injuries
• Painful conditions

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Primary drugs of concern among people with
disabilities

• Tobacco
• Alcohol
• Opioids
• Marijuana
• Barbiturates benzodiazipines
• Polydrug use

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Alcohol tobacco
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Opioids

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

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Marijuana

• Medicinal uses
• Risks

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Access to Recovery Substance Abuse and
Independent Living

• LUNCH BREAK

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AGENDA DAY 1

• AFTERNOON
• Stages 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 As Jennifer Keith

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Making Changes Group Activity
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STAGES OF CHANGE

• Relapsing back to problem use

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Stages of Change
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PRE-CONTEMPLATION Characteristics

• No problem
• See no reason to change
• Lack of awareness

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PRE-CONTEMPLATION Tasks of Change

• Information Both factual and personal
• Consider circumstances which indicate a need for
  change
• Engagement of client, create positive relationship

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Stages of Change
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CONTEMPLATIONCharacteristics

• Ambivalence
• Fear of change
• Wishful thinking
• Interest in the problem

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CONTEMPLATIONTasks of Change

• Examine the ambivalence
• Weigh and consider alternatives
• Examine pros and cons of particular actions

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Stages of Change
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PREPARATIONCharacteristics

• Readiness to consciously engage in change process
• Temporal imminence of change

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PREPARATION Tasks of Change

• Gather information about options
• Make initial contact

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Stages of Change
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ACTION Characteristic

• Change in behaviour

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ACTIONTasks of Change

• Understanding factors supporting the behaviour
• Strategies which will support behavioural change
• Communication with others

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Stages of Change
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MAINTENANCECharacteristics

• Consolidation of changes
• Need for support
• Skills development

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MAINTENANCETasks of Change

• Establish support system
• Practice behavioural changes
• Act on relapse prevention plans

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Stages of Change

• Relapsing back to problem use

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LAPSE/RELAPSE Characteristics

• Initial return to use
• Re-establishing previous pattern

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LAPSE/RELAPSE Tasks of Change

• Reconnecting with supports
• Examining and learning from lapse experience
• Reviewing and modifying relapse prevention
  strategies

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EMPOWERMENT AND SELF CHANGE

• Understanding motivation
• Autonomy
• 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
In order to predict the effect of a drug, we need
to know

• the type of drug
• size of dose
• how drug was taken
• distribution and absorption
• metabolization
• interactions

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Metabolization

• blood-brain barrier
• body doesnt distribute all drugs in the same way
• some are stored in fat cells and released slowly
• others bind to plasma protein in the blood and
  move to the brain quickly

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Liver Action

• Liver 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 alone
• known as potentiation, its like multiplying the
  effects of two drugs rather than simply doubling
  the dose
• some 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 system
• reverse the effects of fatigue and elevate a
  persons mood
• nicotine and caffeine are the most common drugs

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Depressants

• slow down body activity by depressing central
  nervous system
• induce sleep, coma and even death
• sleeping pills (barbiturates), tranquilizers
  (benzodiazepines), antispasmodics and alcohol are
  most common depressants
• opiates 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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Hallucinogens

• cause user to see hear or feel things that arent
  there yet without causing serious disturbances to
  CNS
• LSD (acid), psilocybin (magic mushrooms) and
  mescaline are common examples of drugs
• inhalants and marijuana have characteristics of
  depressants and hallucinogens

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Antidepressants

• MAO inhibiters
• Tricyclics, such as amitriptyline, Elavil,
  imipramine
• SSRIs, such as Prozac, Paxil, Celexa, Zoloft
• SSNRIs
• Others, 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 biological
• Central Nervous System effects
• Rout of transmission
• Rate of absorption/metabolizing
• Rate of elimination
• Side effects

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Factors related to addictive abuse potential of
drugscontd

• Personal
• Neurochemistry
• Developmental history
• Aspects of personality
• Experiences in use of this other drugs
• Values, beliefs expectations
• Some types of disorders disabilities
• Age health

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Factors related to addictive abuse potential of
drugs contd

• Environmental
• Availability of drug
• Immediate social group (e.g., family peers) and
  community with whom the person identifies
• Societal 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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Harm Reduction Key Concepts

• 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

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Harm Reduction Abstinence

• Non-use is a viable choice
• Can described as overlapping elements within a
  continuum of care.
• Drug holiday short-term abstinence
• Abstinence from one drug but not all drugs
• Long-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