Transcript FUNDAMENTALS OF ADDICTION Day 2

Access to Recovery: Substance Abuse
and Independent Living
Day 2
Oct 21,2006
Centre for Addiction & Mental Health
Toronto Rehabilitation Institute
CAILC
1
Welcome to Day 2
Debrief Day 1
Check in
Review ground rules and
Review expectations
Review agenda
2
Agenda
DAY 2
9:00 – 4:00
MORNING
Welcome and overview: Jennifer
Health promotion & illness
prevention: Jennifer
Break
Treatment approaches: Keith
Canada’s treatment
system:Jennifer
AFTERNOON
Barriers to access: Keith
Advocacy & systems change: Keith
& Jennifer
Break
Making it happen: Jennifer &
CAILC participants
Wrap-up
Lunch
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HEALTH PROMOTION &
ILLNESS PREVENTION
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5
Health, illness & disability depend
upon a variety of determinants
Age & gender
Income & income distribution
Social environment
Education & literacy
Physical environment
Personal health practices
Health services
Biology & genetics
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Many determinants of health fall
outside the health services sector
Finance
Social services
Housing
Justice
Education
Employment
Transportation
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Key Principles for Effective
Prevention
Ensure an overarching policy framework and
supportive environment;
Implement comprehensive programs, that:
Combine policy and targeted interventions
Are of sufficient intensity and duration
Involve multiple sectors, and settings
Are evidence-based
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Principles,Cont’d
Implement comprehensive programs, that:
Involve target group/audience directly
Address risk and protective factors, and
determinants of health
Have realistic goals
Include accurate information, credible messages
Are sustainable and can be evaluated
Address all three levels of prevention –
universal, selective, indicated.
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Primary ( or Universal Prevention)
Primary :
Targeted at the whole population (e.g. all
students in grades 5 and 6);
Aims to promote the health of the population, or
prevent or delay onset of substance use;
Children, youth, as well as parents and families
are often the audience;
Schools are common settings for universal
programs.
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Secondary (or Selective) Programs
Targeted at individuals «at risk » (e.g. youth
with problems in school, dysfunctional families,
poverty, history of substance abuse);
Aimed at modifying these risks and reducing
problems associated with substance use;
Selective prevention programs tend to have
more efficacy than universal programs in the
literature.
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Tertiary (or Indicated)
Targeted at individuals who are « at high
risk » who use alcohol and/or other drugs
on a regular basis;
Aims to help them reduce harms related
to their lifestyle;
Can be successful with appropriate target
group, however, recruiting and
maintaining staff are key challenges.
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Ideally
A combination of universal, selected
and indicated programs should be
implemented and adapted within
communities
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Prevention Supported By
Evidence
Societal:
Attention to social determinants
Policy, regulations for legal substances
Community:
Developmental prevention
Systems approaches
Multi-component programs
Community action
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Licensed Establishments:
Policies
Responsible Service Programs
Environmental changes
Recreational Settings:
Policies
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Families:
Intensive postnatal case mgmt / home
visiting
Family skill-building programs
Schools:
Interactive approaches
Social influence/normative approaches
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Care Settings:
Brief interventions
Workplace:
Policies
Environmental change
Programs
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The Prevention Arena
(settings X prevention level)
Commun Families
ity
Schools,
post-sec
Care
Clubs,
settings bars,
dance
venues
Stree
t
Work
place
Universal
Selective
Indicated
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Canada’s Drug Strategy
4 key pillars:
Prevention
Treatment
Enforcement
Harm reduction
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Canada’s Drug Strategy is founded on a
population-based approach to health
promotion & illness prevention
“Health” does not equate to the absence of
disease/illness – includes concepts of
“wellness”, well-being & quality of life.
A population health approach focuses on the
interrelated conditions that affect health.
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Types of prevention initiatives
Primary prevention
Secondary prevention
Tertiary prevention
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Harm reduction serves as the
guiding principle for many
secondary prevention initiatives
related to substance abuse
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Why Harm Reduction?
We will never have a drug-free society
Abstinence is not desired or achievable by
everyone
Enforcement is limited in its ability to contain the
supply of many substances
People will continue to use drugs and get sick or
even die.
We can reduce the numbers of deaths and the
amount of harm that people experience.
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Drug Specific Harm Reduction
Strategies/Programs
Needle Exchange
Methadone
Wet Shelters
Extended liquor store hours
Heroin Maintenance
User Groups
Safe injection rooms
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Individual strategies for reducing risks
related to substance use
Change the route of administration –e.g,THC
capsules, vaporizer, nicotine gum & patches
Use safe injection sites.
Substitute drug of choice for a safer
alternative.
Reduce frequency or intensity of use.
Never use alone.
Do a “tester” - 1/3 to 1/2 of normal.
Drink lots of water to avoid dehydration.
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More individual strategies
Always use a clean needle - how are you going to do
this?
Eat well - especially prior to use.
Seek help if you feel your use is getting out of
control.
Call 911 if someone overdoses.
Work with finances to manage your commitments.
Discuss the risks & benefits of mixing drugs.
Substance Use Management (SUM).
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Target Audience
Harm reduction can be aimed at
recreational drug users. (light drinkers,
pot smokers, club drug users)
Harm reduction can be used with
injection drugs users or heavy users of
heroin, crack or other street drugs.
The strategy should be appropriate to
the duration & intensity of use & harms.
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Break
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TREATMENT APPROACHES
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Addiction Treatment Models
Traditional
12-Step consumer support groups
residential programs, including therapeutic communities,
based on a disease model
Talk therapies – individual or group, inpatient or outpatient
Pharmacotherapies
Integrated Models, including concurrent disorder programs
Brief interventions
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Traditional or Disease Model
Substance dependence (alcoholism,
addiction) is a disease characterized by
denial
Counsellor must break down denial
Consumer must accept that powerless
in the ability to change & relinquish
control to a higher being.
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“Talk” Therapies
Group or individual formats
Inspire, persuade, provide emotional support
Facilitate personal/emotional growth through self
exploration
Educate re drug effects, triggers for using, refusal
skills, relapse prevention skills
Provide training in coping skills, such as problemsolving & decision-making, stress management,
relationship skills)
Address underlying emotional/psychological issues
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Pharmacotherapies
making drug of choice have adverse
effect
eliminate rewarding effect of drug
substitute a “lesser harm”
wean from dependence
treat underlying problems
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Integrated Model
Based on the concept of a continuum of drug
use and dependence. Accepts legitimacy of
non-abstinence goals.
Broad spectrum range of services aimed at
addressing individual needs and learning
styles.
Attempts to match intervention to consumer’s
readiness for change & treatment goals.
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Brief interventions
Motivational interviewing
Screening & early intervention
Psycho-educational interventions
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Alternative therapies &
interventions
religious conversion
complimentary therapies such as
Native Sweat Lodges, acupuncture,
mindfulness meditation, herbal
remedies
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Abstinence vs. moderation as treatment
goals
Source of controversy between advocates of
disease vs. social learning models of addiction
Moderation accepted as legitimate treatment
goal by increasing number of treatment
services
Development of consumer support groups
who accept moderate drinking as an
alternative to abstinence
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Abstinent vs. moderate drinking
outcomes
Severely dependent individuals, when
successful, are most often abstinent
Problem drinkers, when successful, are most
often drinking in moderation
Use of a specific treatment goal seems to
have no long term effect on either group -i.e. severely dependent persons gravitate
toward abstinence and problem drinkers
toward moderation, no matter what goal is
presented in treatment
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Addiction treatment settings
Medical & non-medical detoxes
Hospital-based inpatient & outpatient
programs
Non-medical residential treatment programs
Outreach programs & services provided in
home
Primary care facilities
Other settings such as colleges, vocational
rehab services & physical rehab programs
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THE ADDICTION
TREATMENT
SYSTEM IN CANADA
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The Risk Continuum
NO DRUG RELATED
DRUG RELATED
CONSEQUENCES
NO
No RISK
Risk
Health
Enhancement
LOW
RISK
Low
Risk
Risk
Avoidance
CONSEQUENCES
MODERATE
Moderate
RISK
Risk
Reduction
Risk
HIGHRisk
RISK
High
Early
Intervention
Treatment
Rehabilitation
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Continuum of Alcohol Treatment
Services
Prevention
Mild to
Moderate
Highly
Intensive
Levels of Treatment Intensity
Minimally
Intensive
Facilitate
Recovery
without
Treatment
Short-term
Outpatient
Self-Change
Oriented
Interventions
Brief
Community
Interventions (e.g..,
self-help manuals,
physician’s advice)
Extended
Outpatient
Interventions
Short-term
Outpatient
TherapistDirected
Interventions
Residential
Social
Model
Day Treatment
Long-term
Residential
Residential
Hospital-Based
Severity of Alcohol Problems
Substantial
To Severe
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Matching Clients to Treatment
Severity of
Use
Problem Social Support
& Stability
Multiplicity
Brief Outpatient
Lo
Lo
Hi
Outpatient
Lo-Hi
Lo-Hi
Mod-Hi
Day Treatment
Mod-Hi
Mod-Hi
Mod
Residential
Mod-Hi
Mod-Hi
Lo
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The Addictions Treatment Continuum
Detox Centres
Assessment &
Referral
Residential:
Outpatient:
•Short Term
•Long Term
•Day Programs
•Weekly Programs
•Individualized
Continuing Care
Recovery Homes
Self Help
NOTE: Entry can occur at any point other than continuing care. However the main
points of entry are Detox and Assessment/Referral Centres
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Initial Assessment/Treatment
Planning
provide consistent and continuous
assessment and treatment planning to
individuals and significant others.
match clients to services based on
specific needs, goals, characteristics,
problems and/or stage of change.
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Case Management
ongoing assessment
ongoing adjustment to treatment plan
linking & coordination of services
monitoring & support
discharge planning &
advocating for client
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Community & Residential
Withdrawal Management
provide withdrawal management.
provide discharge planning
provide early recovery education
provide 24 hour crisis services
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Community & Residential
Treatment Services
To provide a range of outpatient
therapeutic services in individual, group
and family formats
To provide a structured scheduled
program of addiction treatments while
they reside in house
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Residential Support
Level I/Level II
To provide 24-hour access to support.
To provide a stable, supportive
environment prior to, during or following
treatment which may be accessed offsite.
To provide appropriate supportive
services.
To provide housing and accommodation
in safe setting (level II).
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Community Medical/Psychiatric
Treatment
To provide appropriate
medical/psychiatric treatment services
to clients that include substitution and
alternative therapies.
To provide non-residential services to
clients with concurrent disorders and/or
other presenting conditions
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Residential Medical/Psychiatric
Treatment
To provide 24-hour access to
medical/psychiatric treatment.
To provide a structured scheduled program
of addictions treatment and/or rehabilitation
activities for clients while they reside inhouse.
To provide a range of therapeutic services
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Entry
DART - Drug & Alcohol Registry of
Treatment
province-wide, free, bilingual info & referral
1-800-565-8603 or www.dart.on.ca
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Addiction Clinical Consultation
Service (ACCS)
1-800 720-ACCS
Or 416-595-6968
Puts Ontario health and social service
professionals in touch with experts on
addictions, concurrent disorder and
medication related questions.
(You call with question and an expert will call
you back with an answer)
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Lunch
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BARRIERS TO ACCESS
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Potential Barriers Faced by Someone Seeking
Treatment
General Issues
Uncertainty about the process
Fear of the unknown
Feelings of despair and hopelessness
Loss of control
Fear of failure
Fear of the future
Potential loss of social network
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Potential Barriers… cont’d
Social context issues
Stigma
Health concerns
Mental health Dx (Anxiety,
Depression, Trauma,
Suicidality)
Legal problems
Family problems
Social problems
Housing
Language
Age issues (youth, older
persons)
Ethnicity and cultural
diversity
Sexual orientation diversity
Invisible/visible disabilities
Pregnancy
Child welfare
Vocational issues
Violence
Underlying psychopathology
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Potential Barriers… cont’d
Systemic issues
Long wait times
Physical accessibility
Unable/unwilling to make required accommodations
in programs to meet special needs in areas such as:
Personal care
Translation
Learning needs
Pacing and timing of services
Policies that are discriminatory – e.g., medications
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Advocacy & systems change
Community development and
networking exercise
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Community development and
networking
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Supporting and encouraging
consumers in your community
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Wrap Up and Evaluation
Thank you!
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MAKING IT HAPPEN
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