Access to Recovery: Substance Abuse and Independent Living : 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


Learning Objectives: 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


Agenda DAY 1 9:00 – 4:30: Agenda DAY 1 9:00 – 4:30 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 & A’s: Jennifer & Keith


Agenda DAY 29:00 – 4:30: Agenda DAY 2 9:00 – 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


WELCOME: WELCOME Agenda overview Ground rules: Participant led Introductions: Names Where from and what role is What want to get out of the training


Society’s most common, serious & neglected problems.: 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).


Why do people use drugs?: 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


Some reasons people give for using drugs: 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


 KEY CONCEPTS  : 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


What is “addiction”?: What is “addiction”? What is first word that comes to mind if you are asked that question?


The meaning of “addiction”:: The meaning of “addiction”: varies widely within and across societies is to some degree culturally determined is an evolving concept within our society


Models of addiction: Models of addiction Moral models Disease models Social models Biopsychosocial models


Moral models of addiction: Moral models of addiction The temperance movement The War on Drugs


Disease models of addiction: Disease models of addiction The 12-Step Movement Biology of addiction


Social models of addiction: Social models of addiction The behaviourists The Independent Living Movement


Biopsychosocial models of addiction: Biopsychosocial models of addiction Determinants of health & disability Inclusion of spiritual factors Better understanding of interaction of physical, psychological, social & spiritual factors


Addiction: An Integrated Model: Addiction: An Integrated Model CULTURAL


Current concepts in understanding meaning of “substance abuse” and “addiction”: Current concepts in understanding meaning of “substance abuse” and “addiction” Physical dependence Drug tolerance Withdrawal Psychological dependence Harm


Physical Dependence: 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


PHYSICAL DEPENDENCETolerance: 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


PHYSICAL DEPENDENCE Withdrawal: 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


Withdrawal ...cont’d: 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


Psychological Dependence: 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 drug’s effects and a persistent craving for the drug


Harm: 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


Abbreviated List of Criteria for Abuse and Dependence: 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: DSM IV Definitions


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


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


Aside from the DSM…“Drug Abuse” is…: 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


Review of key points…: 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?


Coffee Break: Coffee Break


Values Clarification Activity : 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.


Values Clarification Activity: 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


STIGMA, DISCRIMINATION & ADDICTION: STIGMA, DISCRIMINATION & ADDICTION


What is stigma ? : 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.


Stigmatizing language: Stigmatizing language Addict Substance “abuse”/abuser Drunk Crack-head Junkie Others…


Legal status of drugs does not reflect harms: 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


CAMH study on stigma & addiction: CAMH study on stigma & addiction


PATTERNS OF DRUG USE: PATTERNS OF DRUG USE within the population at large among persons with disabilities


Slide40: 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)


Slide41: 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)


OSDUS 2005 HIGHLIGHTS…The good news: OSDUS 2005 HIGHLIGHTS… The 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%


OSDUS 2005 HIGHLIGHTS…The 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%) OSDUS 2005 HIGHLIGHTS…The good news


Special Populations: 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


Non-disability factors can be more important predictors of patterns of use than type of disability: Non-disability factors can be more important predictors of patterns of use than type of disability Regional differences Cultural differences


Higher incidence of drug use among people with:: Higher incidence of drug use among people with: Mental illnesses Learning disabilities Acquired brain & spinal cord injuries Painful conditions


Primary drugs of concern among people with disabilities: Primary drugs of concern among people with disabilities Tobacco Alcohol Opioids Marijuana Barbiturates & benzodiazipines Polydrug use


Alcohol & tobacco: Alcohol & tobacco


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


Marijuana: Marijuana Medicinal uses Risks


Access to Recovery: Substance Abuse and Independent Living : Access to Recovery: Substance Abuse and Independent Living LUNCH BREAK


AGENDA DAY 1 : 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 & A’s: Jennifer & Keith


Making Changes: Group Activity: Making Changes: Group Activity


Slide54: STAGES OF CHANGE


Slide55: Stages of Change


PRE-CONTEMPLATION Characteristics: : PRE-CONTEMPLATION Characteristics: “No problem” See no reason to change Lack of awareness


PRE-CONTEMPLATION Tasks of Change:: PRE-CONTEMPLATION Tasks of Change: Information: Both factual and personal Consider circumstances which indicate a need for change Engagement of client, create positive relationship


Slide58: Stages of Change


CONTEMPLATIONCharacteristics:: CONTEMPLATION Characteristics: Ambivalence Fear of change Wishful thinking Interest in “the problem”


CONTEMPLATIONTasks of Change:: CONTEMPLATION Tasks of Change: Examine the ambivalence Weigh and consider alternatives Examine “pros” and “cons” of particular actions


Slide61: Stages of Change


PREPARATIONCharacteristics:: PREPARATION Characteristics: Readiness to consciously engage in change process Temporal imminence of change


PREPARATION Tasks of Change:: PREPARATION Tasks of Change: Gather information about options Make initial contact


Slide64: Stages of Change


ACTION Characteristic:: ACTION Characteristic: Change in behaviour


ACTIONTasks of Change:: ACTION Tasks of Change: Understanding factors supporting the behaviour Strategies which will support behavioural change Communication with others


Slide67: Stages of Change


MAINTENANCECharacteristics:: MAINTENANCE Characteristics: Consolidation of changes Need for support Skills development


MAINTENANCETasks of Change: MAINTENANCE Tasks of Change Establish support system Practice behavioural changes Act on relapse prevention plans


Slide70: Stages of Change


LAPSE/RELAPSE Characteristics:: LAPSE/RELAPSE Characteristics: Initial return to use Re-establishing previous pattern


LAPSE/RELAPSE Tasks of Change:: LAPSE/RELAPSE Tasks of Change: Reconnecting with supports Examining and learning from lapse experience Reviewing and modifying relapse prevention strategies


EMPOWERMENT AND SELF CHANGE: EMPOWERMENT AND SELF CHANGE Understanding motivation Autonomy Motivational interventions


Afternoon Break: Afternoon Break


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


How Drugs Work: How Drugs Work the type of drug size of dose how drug was taken distribution and absorption metabolization interactions In order to predict the effect of a drug, we need to know:


Metabolization: Metabolization blood-brain barrier body doesn’t 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


Liver Action: 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


Drug Interactions: 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


Types of DrugsClassified by Psychoactive Effect: Types of Drugs Classified by Psychoactive Effect Stimulants Depressants Hallucinogens Antidepressants Antipsychotics


Stimulants: Stimulants increase activity by stimulating the central nervous system reverse the effects of fatigue and elevate a person’s mood nicotine and caffeine are the most common drugs


Depressants: 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


Hallucinogens: Hallucinogens cause user to see hear or feel things that aren’t 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


Antidepressants: Antidepressants MAO inhibiters Tricyclics, such as amitriptyline, Elavil, imipramine SSRIs, such as Prozac, Paxil, Celexa, Zoloft SSNRIs Others, such as Wellbutrin, Effexor


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


Factors related to addictive & abuse potential of drugs: 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


Factors related to addictive & abuse potential of drugs…cont’d: Factors related to addictive & abuse potential of drugs…cont’d Personal Neurochemistry Developmental history Aspects of personality Experiences in use of this & other drugs Values, beliefs & expectations Some types of disorders & disabilities Age & health


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


HARM REDUCTION: HARM REDUCTION


Drugs Cause Real Harms!: 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


Harm Reduction: Key Concepts: 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.


Harm Reduction- Key Concepts: 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


Harm Reduction: Key Concepts : 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.


Slide94: 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


Harm Reduction & Abstinence: 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.


WRAP UP & CLOSING Day 1: WRAP UP & CLOSING Day 1