1 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

2 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  U nderstand 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

3 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

4 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

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

6 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).

7 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

8 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

9 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

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

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

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

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

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

15 Social models of addiction The behaviourists The Independent Living Movement

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

17 Addiction: An Integrated Model BIO PSYCHO SOCIAL SPIRITUAL CULTURAL

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

19 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

20 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

21 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

22 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

23 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

24 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

25 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

27 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

28 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

29 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

30 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?

31 Coffee Break

32 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.

33 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

34 STIGMA, DISCRIMINATION & ADDICTION

35 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.

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

37 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

38 CAMH study on stigma & addiction

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

40 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)

41 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)

42 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%

43 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

44 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

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

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

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

48 Alcohol & tobacco

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

50 Marijuana Medicinal uses Risks

Access to Recovery: Substance Abuse and Independent Living LUNCH BREAK

52 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

54 Contemplation Lapse/Relapse Maintenance Action Preparation Pre- Contemplation STAGES OF CHANGE

55 Pre- Contemplation Stages of Change

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

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

58 Contemplation Pre- Contemplation Stages of Change

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

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

61 Preparation Contemplation Pre- Contemplation Stages of Change

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

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

64 Action Contemplation Preparation Pre- Contemplation Stages of Change

65 ACTION Characteristic: Change in behaviour

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

67 Maintenance Contemplation Action Preparation Pre- Contemplation Stages of Change

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

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

70 Lapse/Relapse Contemplation Maintenance Action Preparation Pre- Contemplation Stages of Change

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

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

73 EMPOWERMENT AND SELF CHANGE Understanding motivation Autonomy Motivational interventions

74 Afternoon Break

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

76 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:

77 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

78 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

79 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

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

81 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

82 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

83 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

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

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

86 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

87 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

88 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

89 HARM REDUCTION

90 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

91 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.

92 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

93 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.

94 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

95 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.

96 WRAP UP & CLOSING Day 1