Access to Recovery: Substance Abuse and Independent Living

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Access to Recovery Substance Abuse and
Independent Living

• Day 2
• Oct 21,2006
• Centre for Addiction Mental Health
• Toronto Rehabilitation Institute
• CAILC

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Welcome to Day 2

• Debrief Day 1
• Check in
• Review ground rules and
• Review expectations
• Review agenda

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Agenda DAY 2900 400

• MORNING
• Welcome and overview Jennifer
• Health promotion illness prevention Jennifer
• Break
• Treatment approaches Keith
• Canadas treatment systemJennifer
• Lunch

• AFTERNOON
• Barriers to access Keith
• Advocacy systems change Keith Jennifer
• Break
• Making it happen Jennifer CAILC participants
• Wrap-up

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HEALTH PROMOTION ILLNESS PREVENTION
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(No Transcript)
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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,Contd

• 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)
Community Families Schools, post-sec Care settings Clubs, bars, dance venues Street Work place
Universal
Selective
Indicated
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Canadas Drug Strategy

• 4 key pillars
• Prevention
• Treatment
• Enforcement
• Harm reduction

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Canadas 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
  problem-solving 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 consumers
  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 TREATMENTSYSTEM IN CANADA
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The Risk Continuum
NO DRUG RELATED DRUG RELATED CONSEQUENCES
CONSEQUENCES
Moderate Risk
MODERATE RISK
NO RISK
LOW RISK
HIGH RISK
No Risk
Low Risk
High Risk
Health Enhancement
Risk Avoidance
Risk Reduction
Early Intervention
Treatment Rehabilitation
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Continuum of Alcohol Treatment Services
Levels of Treatment Intensity
Highly Intensive
Minimally Intensive
Facilitate Recovery without Treatment
Short-term Outpatient Self-Change Oriented Interve
ntions
Residential Social Model
Extended Outpatient Interventions
Long-term Residential
Prevention
Custodial Care
Residential Hospital-Based
Day Treatment
Brief Community Interventions (e.g.., self-help
manuals, physicians advice)
Short-term Outpatient Therapist- Directed Interven
tions
Mild to Moderate
Substantial To Severe
Severity of Alcohol Problems
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Matching Clients to Treatment
Severity of Use
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The Addictions Treatment Continuum
Detox Centres
Assessment Referral

• Residential
• Short Term
• Long Term

• Outpatient
• 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 off-site.
• 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
  in-house.
• 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 contd
Social context issues

• Ethnicity and cultural diversity
• Sexual orientation diversity
• Invisible/visible disabilities
• Pregnancy
• Child welfare
• Vocational issues
• Violence
• Underlying psychopathology

• Stigma
• Health concerns
• Mental health Dx (Anxiety, Depression, Trauma,
  Suicidality)
• Legal problems
• Family problems
• Social problems
• Housing
• Language
• Age issues (youth, older persons)

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Potential Barriers contd

• 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