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
1
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
2
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
3
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
AFTERNOON
Barriers to access: Keith
Advocacy & systems change: Keith
Break
Making it happen: Jennifer &
CAILC participants
Wrap-up
Lunch
4
WELCOME
Agenda overview
Ground rules:
Participant led
Introductions:
Names
Where from and what role is
What want to get out of the training
5
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).
6
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
7
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
8
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
9
What is “addiction”?
What is first word that comes to mind if
you are asked that question?
10
The meaning of “addiction”:
•
•
•
varies widely within and across
societies
is to some degree culturally
determined
is an evolving concept within our
society
11
Models of addiction
Moral models
Disease models
Social models
Biopsychosocial models
12
Moral models of addiction
The temperance movement
The War on Drugs
13
Disease models of addiction
The 12-Step Movement
Biology of addiction
14
Social models of addiction
The behaviourists
The Independent Living Movement
15
Biopsychosocial models of
addiction
Determinants of health & disability
Inclusion of spiritual factors
Better understanding of interaction of
physical, psychological, social & spiritual
factors
16
Addiction: An Integrated Model
BIO
PSYCHO
SOCIAL
SPIRITUAL
CULTURAL
17
Current concepts in understanding
meaning of “substance abuse” and
“addiction”
Physical dependence
Drug tolerance
Withdrawal
Psychological dependence
Harm
18
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
19
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
20
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
21
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
22
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
23
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
24
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
25
DSM IV Definitions
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 drugrelated problems
27
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
28
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
29
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?
30
Coffee Break
31
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.
32
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
33
STIGMA, DISCRIMINATION
& ADDICTION
34
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.
35
Stigmatizing language
Addict
Substance “abuse”/abuser
Drunk
Crack-head
Junkie
Others…
36
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
37
CAMH study on stigma &
addiction
38
PATTERNS OF DRUG USE
within the population at large
among persons with disabilities
39
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)
40
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)
41
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%
42
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%)
43
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
44
Non-disability factors can be
more important predictors of
patterns of use than type of
disability
Regional differences
Cultural differences
45
Higher incidence of drug use
among people with:
Mental illnesses
Learning disabilities
Acquired brain & spinal cord injuries
Painful conditions
46
Primary drugs of concern among
people with disabilities
Tobacco
Alcohol
Opioids
Marijuana
Barbiturates & benzodiazipines
Polydrug use
47
Alcohol & tobacco
48
Opioids
Narcotic analgesics
Opiophobia
Issues related to treating chronic pain
in people with a histories of drug
dependence or abuse
49
Marijuana
Medicinal uses
Risks
50
Access to Recovery:
Substance Abuse and
Independent Living
LUNCH BREAK
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
52
Making Changes: Group Activity
STAGES OF CHANGE
PreContemplation
Action
54
PRE-CONTEMPLATION
PreContem
plation
Tasks of Change:
Information: Both factual and personal
Consider circumstances which indicate a
need for change
Engagement of client, create positive
relationship
57
CONTEMPLATION
Tasks of Change:
Examine the ambivalence
Weigh and consider alternatives
Examine “pros” and “cons” of
particular actions
60
PREPARATION
Tasks of Change:
Gather information about options
Make initial contact
63
ACTION
Tasks of Change:
Understanding factors supporting
the behaviour
Strategies which will support
behavioural change
Communication with others
66
MAINTENANCE
Tasks of Change
Establish support system
Practice behavioural changes
Act on relapse prevention plans
69
LAPSE/RELAPSE
Tasks of Change:
Reconnecting with supports
Examining and learning from lapse
experience
Reviewing and modifying relapse
prevention strategies
72
EMPOWERMENT AND SELF
CHANGE
Understanding motivation
Autonomy
Motivational interventions
73
Afternoon Break
74
DRUG EFFECTS
How do drugs work?
What makes one drug more addictive
than another?
Which drugs are creating the most
harm?
75
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
76
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
77
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
78
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
79
Types of Drugs
Classified by Psychoactive Effect
Stimulants
Depressants
Hallucinogens
Antidepressants
Antipsychotics
80
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
81
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
82
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
83
Antidepressants
MAO inhibiters
Tricyclics, such as amitriptyline, Elavil,
imipramine
SSRIs, such as Prozac, Paxil, Celexa, Zoloft
SSNRIs
Others, such as Wellbutrin, Effexor
84
Antipsychotics
Major tranquilizers, such as
chlorpromazine, Haldol
“Atypical” antipsychotics, such as
clozapine, olanzepine, resperidone &
Seroquel
85
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
86
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
87
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
88
HARM REDUCTION
89
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
90
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.
91
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
92
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.
93
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
94
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.
95
WRAP UP & CLOSING
Day 1
96