A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

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1 A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

2 Copyright Matua Raki ISBN: Published May 2012 by Matua Raki The National Addiction Workforce Development Centre P O Box 25056, Panama Street, Wellington 6146, New Zealand Developed with funding from Health Workforce New Zealand, Ministry of Health Recommended citation: Matua Raki. (2012). A Guide to the Addiction Treatment Sector in Aotearoa New Zealand. Wellington: Matua Raki Disclaimer: This Guide to the Addiction Treatment Sector in Aotearoa, New Zealand has been prepared by Matua Raki. It is not intended to be a comprehensive training manual or systematic review of the addiction sector in Aotearoa New Zealand. Matua Raki will not be liable for any consequences resulting from reliance on statements made in this guide. Readers should always seek specialist advise or training before taking (or failing to take) any action on relation to matters covered in this guide.

3 Acknowledgements He waka eke noa: A vehicle for us all Tēnā koe me ngā āhuatanga o te wā, o tātou mate noho mai i roto i te ao wairua. Tātou o te ao ora, kia ora huihui mai tātou. He mihi maioha tēnei kia koutou mo to koutou kaha, ki te mahi tahi ki roto i tēnei kaupapa whakahirahira. Kia kaha, kia u, kia manawanui. No reira, tēna koutou, tēnā koutou, tēnā koutou katoa. Greetings, Kia Ora, Talofa Lava, Malo e lelei, Kia orana, Fakalofa lahi atu, Bula Vinaka, Namaste. This guide extends the scope of the collaborative document Orientation to the Addiction Treatment Field, Aotearoa, New Zealand prepared by the National Addiction Centre and Matua Raki in 2008, which was written primarily for the addiction treatment sector. Its purpose is to provide a navigational guide to help those new to or those interested in working in the addiction sector. We acknowledge the contribution of a number of people in developing this guide, especially Debby Sutton who wrote the initial draft, and the peer reviewers who helped evaluate the usefulness of this resource. This introductory guide attempts to be as accurate as possible at the time of publication and where future change is likely this is indicated. It is anticipated some of the terminology currently used in the addiction sector will change with the release of DSM V in 2013 and that a number of new interventions may become more widely used. This document will be regularly updated to reflect these ongoing changes. The formation on the cover is located in Abel Tasman National Park and is known locally as a navigator rock (photo provided by Raine Berry). It reminds us that, as we traverse the landscape of health and wellbeing, markers (or pou) guide our direction and help position us in time and space while providing us with aspirational goals to achieve. 3

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5 Contents Introduction 7 Continuum of use and addiction related harm 7 Substances and their effects 9 Central nervous system depressants 9 Central nervous system stimulants 10 Hallucinogens 10 Cannabinoids 10 Immediate harms from substance use 11 Harm from long-term substance use 11 Gambling and its effects 12 References and further information 13 Understanding the causes of addiction 14 Medical theories 14 Psychological theories 15 Social theories 15 References and further information 15 Defining problematic substance use and gambling 16 Addiction 16 Diagnosis of substance use disorders 17 Problematic gambling 17 References and further information 18 Assessment and treatment planning 19 Screening for addiction problems (non-specialist settings) 19 Brief screening and assessment (all treatment settings) 19 Comprehensive assessment (specialist treatment settings) 20 Formulation 21 Treatment goals and planning 22 References and further information 23 Interventions used in addiction treatment 24 Pharmacological interventions 24 Psycho-social interventions 25 Public health approach 28 5

6 Contents References and further information 28 Types of support for addiction problems 32 Consumer networks and peer support groups 32 Non-specialist addiction services 33 Specialist AOD treatment services 34 Specialist gambling treatment services 36 References and further information 37 The addiction treatment workforce 38 The culture of the addiction workforce in New Zealand 38 Education in addiction treatment 39 Addiction workforce competencies 39 Addiction practitioners 39 Community support workers 40 Clinical supervisors 40 Consumer and peer roles 40 Cultural specialist roles 41 Nurses 41 Clinical psychologists 41 Medical officers, addiction medicine specialists and psychiatrists 41 Social workers 42 Other professionals 42 Managers and administrators 42 References and further information 42 National organisations 44 Public health organisations 44 Workforce development and professional organisations 45 Treatment stakeholder organisations 47 References and further information 47 National policies and legislation for addiction treatment 48 National drug legislation and policy 48 National gambling legislation and policy 49 References and further information 50 6

7 Introduction Welcome to A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand. This guide aims to enhance the reader s understanding of the addiction treatment sector and reviews: substance use and gambling in New Zealand problematic substance use and problem gambling screening, assessment and treatment services and practitioners and staff who provide addiction treatment in New Zealand the national infrastructure that supports addiction treatment: organisations, resources, policies and relevant legislation. This document has been written for practitioners new to the addiction sector and health and social service professionals from other sectors. Readers of this guide will gain a greater appreciation of the nature and extent of addiction-related problems, how the impacts of addiction-related problems might be minimised and the underpinning rationale for different interventions and approaches. The term addiction is used throughout this document as a generic term to include problematic substance use, problem gambling and nicotine dependence. The focus of this document is predominantly on the problematic use of alcohol and other drugs (AOD) as well as problematic gambling rather than other behavioural addictions because: they are common in New Zealand they are the main focus of public funding, study, research and treatment services the approaches to AOD problems and problem gambling are similar, as are the workforce issues. The term addiction treatment is used in this guide to refer to interventions provided for an AOD or gamblingrelated problem. Continuum of use and addiction related harm Substance use occurs on a continuum of use from no use (abstinence) through to what is known as severe dependence. It is accepted that different levels or intensities of intervention are appropriate depending on the degree of use and related problems. The continuum is also applicable to problem gambling and is represented visually in Figure 1 (over page). A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand 7

8 Introduction Figure 1: Addiction related harm continuum and intervention None Mild Substantial Addiction-related harm (AOD) and problem gambling Severe Specialised interventions Brief and early interventions No or minimal intervention required Adapted from Korn and Shaffer (1999) 8 A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

9 Substances and their effects A psychoactive substance is any chemical that is used recreationally to create a change in mood and/or perception, often referred to as a high. The effects of substances used recreationally will vary and depend on: type of substance taken potency (strength/ concentration/ purity) amount taken and frequency route of administration (commonly either eating and drinking (ingesting), smoking, sniffing, or injecting) individual characteristics of the substance user (previous substance using experiences; and current state both physically, psychologically and socially) environment. Psychoactive substances can be categorised by their effects on the body, although some substances may fit into more than one category. This guide will use the following four categories: Central Nervous System (CNS) depressants; CNS stimulants; hallucinogens; and cannabinoids. Central nervous system depressants Central nervous system (CNS) depressants are substances that slow down brain activity, particularly activity that controls core body functions. Generally, people take depressants to induce feelings of relaxation, calmness and euphoria. In higher doses they have a range of effects including drowsiness, respiratory depression, reduced motor control, disinhibition and sometimes emotional depression. Overdosing on CNS depressants can result in coma and death as key body functions, such as breathing, can shut down. The most commonly used CNS depressant is alcohol, with 85 percent of adults in New Zealand using alcohol (Ministry of Health, 2009a). Other CNS depressants used recreationally include benzodiazepines (e.g. diazepam/valium), barbiturates, opioids (e.g. opium, heroin, methadone, morphine and codeine), gamma hydroxy-butyrate (GHB) and various volatile solvents (e.g. glue, paint, petrol). These substances are used recreationally by fewer people. For example, 1.1 percent of adults use opioids and 0.1 percent use inhalants for recreational purposes. The most common types of opioid used for recreational purposes are prescription painkillers (Ministry of Health, 2010b). When more than one CNS depressant is used together, they can interact and their joint effects are often heightened and unpredictable. A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand 9

10 Substances and their effects Central nervous system stimulants CNS stimulants increase brain activity and the body s state of arousal, as if it is ready for fight or flight. Generally CNS stimulants increase alertness and energy and reduce drowsiness, fatigue and appetite. CNS stimulants often result in euphoria and disinhibition. With high doses of stimulants the user can experience grandiosity, insomnia, irritability, impulsiveness, compulsive actions and nervousness. With some stimulants there is a small possibility of overdose causing convulsions and death through heart attack or brain haemorrhage. With chronic (ongoing) use of high dose stimulants the euphoric feeling is often replaced with emotional depression, agitation, anxiety, hyperactivity and paranoia. One of the most commonly used CNS stimulants is nicotine with 21 percent of New Zealanders being smokers (Ministry of Health, 2010a). A recent survey also found 3.9 percent of adults use other stimulants, of which the most commonly used were MDMA (ecstasy) (2.6 percent), and amphetamines (e.g. methamphetamines or P and speed) (2.1 percent) (Ministry of Health, 2010b). Other CNS stimulants include methylphenidate (ritalin), mephedrone, cocaine and party pills. Many party pills are designed to produce CNS stimulant effects. These initially became popular because they were cheaper than illegal stimulants, such as ecstasy and amphetamines, and because they could be purchased legally. In a survey carried out over percent of adults had tried party pills (Ministry of Health, 2010b). In 2008 the main psychoactive substance in party pills, benzylpiperazine (BZP), was made illegal and since then levels of use of party pills has decreased (Wilkins, Griffiths & Sweetsur, 2010), although party pills made from other chemicals remain legally available. Hallucinogens Hallucinogens can have similar effects to depressants and stimulants, but the main effect that hallucinogens have in common is that they produce sensory distortions. These can involve visual, auditory or tactile hallucinations, heightened emotional experiences (both positive and negative), and distortion of time and space. Harm that arises from hallucinogen use is generally through associated risky behaviours and the exacerbation of mental health problems, such as psychosis. Some hallucinogens, such as datura, are particularly toxic and dangerous to use. 3.2 percent of adults in New Zealand use hallucinogens (Ministry of Health, 2010b). The most commonly used hallucinogen in New Zealand is lysergic acid diethylamide (LSD) and other synthetic hallucinogens (1.3 percent of adults). Other hallucinogens used include psilocybin (magic mushrooms), mescaline (cactus), and datura. Some stimulant drugs such as ecstasy also have hallucinogenic properties as well. Cannabinoids Cannabinoids originate from the cannabis sativa and indica plants. These plants contain over 60 cannabinoid chemicals, such as delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). The psychoactive effect of many of these is still being investigated (McKim, 2003). These substances have been placed in their own category as they produce a complex combination of effects which can include CNS depressant, CNS stimulant and hallucinogenic-like properties. The desired effects usually include feelings of relaxation and calmness. Excessive use is not directly life-threatening, but can create frightening hallucinations, feelings of paranoia and can exacerbate mental health problems. Cannabis can be used as marijuana (dried leaves and flowers); hashish (dried resin harvested from the plant); and hash oil (purified and concentrated oil extracted from both leaves and flowers). Cannabis is commonly used in New Zealand with approximately 14.6 percent of adults reporting they use it on a regular basis (Ministry of Health, 2010b). 10 A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

11 Substances and their effects Immediate harms from substance use Some substances are used recreationally for their desired effects, with very few negative consequences. Other substances, those that are more potent or unpredictable, have risks associated with their use, regardless of whether they have been used before or not. The potential for immediate harm from substance use is related to: effects of intoxication (through associated behaviour or direct effects on the body) substance interactions (effects can be unpredictable) overdose (direct effects on the body of excessive substance use can be dangerous) route of administration (some methods are more risky than others, e.g. injecting can transfer blood borne viruses like Hepatitis C (HCV)). Harm from long-term substance use Most substances will cause harm if used regularly over long periods of time. These harms may be related to: route of administration (e.g. snorting can permanently damage nasal passages) direct impact on the body from ongoing use (e.g. long-term alcohol use can damage the heart, brain, liver and lungs) the development of substance dependence. Substance dependence Many substances, including alcohol, taken frequently over a long enough period will lead to dependence. The development of substance dependence involves physical and/or psychological processes that include tolerance, withdrawal symptoms, cravings and maladaptive behaviours. How quickly dependence develops varies and depends on the specific substance taken and the characteristics of the person taking it. Tolerance When a substance is taken regularly enough, a person s body adjusts to its presence, despite there being a decrease in the desired effect. In order to feel normal the person has to continue using. To create the original desired effect increasing amounts are needed. This is the development of tolerance. Tolerance can involve an adjustment psychologically and/or physically (through changes in brain chemistry and liver processing). After cutting down or withdrawing from a substance a person s tolerance will decrease, so depending on the substance of choice, they have a higher risk of overdose if they consume the amount they were consuming prior to their cutting down or withdrawing. Withdrawal symptoms If use of the substance is reduced or stopped after tolerance has developed, the person will experience withdrawal symptoms. These are a physical response to the reduction of substance use and the resulting chemical changes in the brain and body. These symptoms are often experienced as the opposite effect of the substance. For example, alcohol use produces relaxation and its withdrawal symptoms include anxiety. Withdrawal symptoms can range from being simply uncomfortable through to physical and emotional pain, and can be quickly relieved by taking more of the substance or a similar substance. If no further substances are taken the withdrawal symptoms will continue until the body has excreted (metabolised) all of the substance and re-adjusted back to its normal state. Each substance has a different withdrawal period and the most distressing phase is usually over within two weeks after stopping use, though other less intense but distressing A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand 11

12 Substances and their effects withdrawal effects may be felt for months. Cravings A craving is a strong psychological desire for the effects of a substance that have been previously experienced (McKim, 2003). Cravings motivate people to continue with substance use, even when it has become problematic. How cravings develop is not well understood, but has been explained by the interaction of brain chemistry and psychological learning processes. Although cravings are experienced most frequently in the early stages of withdrawal and abstinence, some people can continue experiencing them occasionally for years afterwards. Cravings can be triggered by being around substances or things associated with the substance and its use (e.g. certain places or people). They re also often triggered by physical or psychological discomfort. People who are severely dependent tend to experience excessive cravings and for longer periods of time. Cravings are a normal part of the process of dependence and withdrawal. Cravings come and go, and the urge to use alcohol or other substances will be stronger at some times than at others. Managing these strong urges can be the hardest part of withdrawal and ongoing recovery for many people, and failure to do so can increase the likelihood of someone returning to substance use. Lapse and relapse At its severest, substance dependence is described as a chronic relapsing disorder. When someone who has been abstinent for a period of time uses substances again it can either be a slip or lapse (a brief, minor return to previous drug use) or a relapse (ongoing, full return to previous problematic substance use). This distinction is important when determining a person s motivation for change and what support should be provided. Long term abstinence is possible but it can be challenging to achieve and may require several attempts. Lapses happen to most people who reduce or stop using a substance and it does not mean the end of the process or that the person has failed (though they may define this as a failure to themselves). Practitioners can help people develop their coping strategies and build their networks so they can learn from the experience and do things differently next time. Gambling and its effects Gambling is a common pastime in New Zealand with 65 percent of adults having gambled in the past 12 months (Ministry of Health, 2008). The increase in gambling over recent years has also been accompanied by an increase in associated problems. It has been estimated that 3 percent of adults in New Zealand (87,000) are negatively affected by their own or someone else s gambling (Ministry of Health, 2008). Harmful effects associated with gambling can include problems with finances, work commitments, relationships, legal issues, substance use and other mental health problems. As with problematic substance use, there is also a chance that if someone gambles regularly over a period of time, they may become dependent on it. With gambling there is euphoria on winning, tolerance on repetition, compulsion, withdrawal and craving (Academy of Medical Sciences, 2008, p. 44). These kinds of issues have been called behavioural addictions. People have become addicted to behaviours such as gambling, shopping, eating, sex, exercise, the internet and electronic entertainment. In fact any behaviour that is reinforcing can become out of balance with other aspects of life, thus creating problems. Explanations for how this occurs are presented in a later section. 12 A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

13 Substances and their effects References and further information Academy of Medical Sciences. (2008). Brain science, addiction and drugs. Great Britain: Academy of Medical Sciences Hulse, G., Cape, G., & White J. (Eds) (2002). The management of alcohol and other drug problems. Oxford: Oxford University Press McKim, W. (2003). Drugs and behavior: An introduction to behavioural pharmacology (5th ed). New Jersey: Prentice Hall Ministry of Health. (2008). A Portrait of Health: Key results of the 2006/07 New Zealand Health Survey. Wellington: Ministry of Health Ministry of Health. (2009a). Alcohol Use in New Zealand: Key results of the 2007/08 New Zealand Alcohol and Drug Use Survey. Wellington: Ministry of Health Ministry of Health. (2009b). A focus on problem gambling: Results of the 2006/07 New Zealand Health Survey. Wellington: Ministry of Health Ministry of Health. (2010a). Tobacco Use in New Zealand: Key findings from the 2009 New Zealand Tobacco Use Survey. Wellington: Ministry of Health Ministry of Health. (2010b). Drug Use in New Zealand: Key results of the 2007/08 New Zealand Alcohol and Drug Use Survey. Wellington: Ministry of Health National Addiction Centre and Matua Raki. (2008). Orientation to the Addiction Treatment Field Aotearoa New Zealand. Christchurch: University of Otago [online] orientation.pdf National Centre for Education & Training on Addiction (NCETA). (2004). Alcohol and other drugs: A handbook for health professionals. Canberra: Australian Government Department of Health and Ageing. Matua Raki. (2012). Substance Withdrawal Management: guidelines for addiction and allied practitioners. Wellington: Matua Raki Matua Raki. (2012). Managing your own withdrawal. Wellington: Matua Raki Wilkins, C., Griffiths, R., & Sweetsur, P. (2010). Recent trends in illegal drug use in New Zealand, Findings from the 2006, 2007, 2008 & 2009 Illicit Drug Monitoring System (IDMS). Auckland: SHORE and Whariki Research Centre A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand 13

14 Understanding the causes of addiction Traditionally abuse and misuse of alcohol and other drugs was seen as a moral issue or a weakness, with the belief that the person needed to develop stronger willpower to change. The church (for moral guidance) and the criminal justice system (for punishment and control) were therefore seen as the most appropriate bodies to address the issue. In the 20th century there was a move away from this judgmental approach to the proposal that alcoholism and, later, drug addiction, were due to a physical disease. There was also a suggestion that there was an addictive personality, that is, people who by virtue of their personality type would have a tendency for addiction. In 1935 Alcoholics Anonymous (AA) began, initiated by two men who had helped each other stop drinking. The Twelve-Step movement that evolved from AA also talks about a disease, but the concept is deliberately broad referring to a bio-psycho-social-spiritual dis-ease rather than a specific and known cause. Gamblers Anonymous (GA), and Narcotics Anonymous (NA) are also based on the Twelve-Step model. Increased study of psychological and social phenomena and neurobiology shows there is no evidence for a single disease or an addictive personality, nor is it an issue of willpower. The causes of these conditions are complex and individually variable. Currently there are a plethora of theories about what causes addiction-related problems from medical, psychological and social perspectives. Although there is not yet one model that integrates all perspectives in a coherent way, it is commonly accepted by most professionals that addiction has roots in bio-psycho-social areas and therefore a holistic and comprehensive intervention is required to address it. The core theories of what causes addiction are briefly described below. Medical theories Within the human brain there is a common reward pathway which, when activated, releases specific chemicals (e.g. dopamine) that create feelings of wellbeing and relaxation (Academy of Medical Sciences, 2008). This neural pathway is activated by behaviours necessary for survival, e.g. eating in response to hunger. This process reinforces these survival behaviours which motivates people to continue them. In the last 30 years, understanding of neurobiology has advanced immensely, although there is still much to explore. A key finding has been that addictive substances trigger activity in the reward pathway mentioned above which reinforces their continued use (Academy of Medical Sciences, 2008). The explanations for why different substances impact some people more strongly than others are still being explored. Some initial findings are that genetics influence the number of receptors for dopamine in the brain. This may be due to a family history of substance dependence or the impact of life events and trauma. For people with fewer receptors it appears that substance use has a greater impact, making it more likely for them to become dependent (Academy of Medical Sciences, 2008). 14 A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

15 Understanding the causes of addiction Research has found other behavioural addictions, such as gambling, also trigger the same reward pathway, even though they are not introducing chemicals directly into the brain (Academy of Medical Sciences, 2008). The mechanism behind this highlights the importance of the interaction between medical and psychological phenomena, which is explained next. Once addiction has been established, the physical processes of tolerance and withdrawal help perpetuate it. Psychological theories There are a range of psychological explanations for addiction that arise from the various psychological approaches, such as psychoanalytic and personality theories. The growing understanding of the neurobiology of addiction has highlighted how it is influenced by, and in turn influences, various psychological processes, including motivation, memory, learning, impulse control and decision-making (Academy of Medical Sciences, 2008). Learning theories have therefore become important to assist with understanding these processes. These theories use concepts from classical conditioning, operant conditioning and social learning theory to explain the physical, psychological and social motivators to start substance use or gambling and how addiction develops and is continued. For example, the ideas about reinforcement and association explain how cravings can be triggered by seemingly unrelated things. These theories also explain how compulsive gamblers have learnt to associate monetary reward with pleasurable feelings and their expectancies about this process releases dopamine in their neural reward pathways (Academy of Medical Sciences, 2008). Social theories Sociological theories understand substance use or problem gambling as societal phenomenon, having largely cultural, social and economic origins. Such causes are often external to the individual, i.e. they are not biological, genetic or psychological traits. Instead, these theories direct our attention away from individuals to both the immediate and more distant social worlds. Social theories suggest factors such as poverty, unemployment, discrimination, colonisation and marginalisation explain why people start and continue to use substances. References and further information Academy of Medical Sciences. (2008). Brain science, addiction and drugs. Great Britain: Academy of Medical Sciences Hulse, G., Cape, G., & White J. (Eds). (2002). The management of alcohol and other drug problems. Oxford: Oxford University Press Orford, J. (2001). Excessive appetites: A psychological view of addictions (2nd ed). Chichester: John Wiley Thombs, D. (2006). Introduction to addictive behaviours (3nd ed). New York: Guilford Press A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand 15

16 Defining problematic substance use and gambling As mentioned in the previous section, many New Zealanders use substances and gamble. It has been found that: 17.7 percent of adults (551,300) drink alcohol hazardously (Ministry of Health, 2008) 3.5 percent of adults (91,200) experience harmful effects from their drug use (Ministry of Health, 2010) 1.7 percent of adults (54,000) experience problematic or moderate risk gambling (Ministry of Health, 2009). A number of these people with problematic use of substances or gambling require professional assistance, and others can and do make changes by themselves with support from friends, family or other non-specialist health and/or social care services. People with more severe problems are more likely to require professional specialist help. The addiction related harm continuum (Figure 1) provides a visual representation of this range of problem behaviour and the type of intervention appropriate at each stage on the continuum. Oakley Browne, Wells, & Scott (2006) found that 2.6 percent of New Zealand adults could be diagnosed with alcohol abuse; 1.3 percent with alcohol dependence; 1.2 percent with drug abuse; and 0.7 percent with drug dependence. For gambling, the Ministry of Health (2008) found that of the people who gambled, 5.4 percent had low risk of problems, 2 percent had moderate risk, and 0.6 percent met criteria for problem gambling. Being able to distinguish the level of problematic use or risk for substance dependence and problem gambling is important in determining the kind of intervention to be provided. The commonly used ways to define problematic use of substances and/or problem gambling are described below. Each of these has limitations that are also discussed. Addiction The term addiction is commonly used by the public but can be problematic as it may be associated with social stigma and usually only refers to more severe problems associated with the use of substances or problem gambling. However, it is one of the few terms that acknowledges the common bio-psycho-social processes that underlie substance dependence and other impulse control issues, such as gambling. This makes it useful as an umbrella term for these kinds of issues. Upper levels for low risk drinking It is recommended that to reduce long-term health risks women should drink no more than two standard drinks a day, and no more than 10 standard drinks a week. Men should have no more than three standard drinks a day and no more than 15 standard drinks a week. 16 A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

17 Defining problematic substance use and gambling It is further recommended that people have at least two non-drinking days every week (ALAC, 2012). While a good measure of low risk drinking, these guidelines do not apply to everyone. For example, it is recommended that pregnant women do not drink alcohol at all and it is likely that older people may find these levels too high due to metabolic changes as they age. Drinking more than these guidelines suggest can lead to long-term health consequences and possible problematic alcohol use. Diagnosis of substance use disorders There are two internationally used systems to diagnose mental disorders (including substance use disorder), the International Classification of Disorders-10 (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) (American Psychiatric Association, 2000). In New Zealand, the DSM system is the main classification system used within addiction treatment settings although knowledge of both classification systems is necessary. The DSM should only be used by those who have received professional training and only to diagnose disorders relevant to the practitioner s scope of practice. For addiction practitioners this may include substance abuse and dependence, and some mood and anxiety disorders, for example. Practitioners can, however, make provisional diagnoses of disorders that are identified in screening and comprehensive assessment that fall outside their scope of practice to ensure treatment for co-existing problems is integrated into treatment for addictive disorders. Diagnoses are not intended to be static and they can change as clients symptoms change to inform treatment planning. The current DSM version, DSM-IV-TR, includes substance use problems as Axis 1 disorders. Axis 1 is part of the DSM multiaxial system for assessment. The DSM has a five axis model designed to provide a comprehensive diagnosis that includes a complete picture of not just acute symptoms but of the entire scope of factors that account for a person s mental health. Axis 1 diagnoses are the most familiar and widely recognised and include disorders such as major depressive episode and panic attacks. Axis 1 describes substance use related problems as follows: substance abuse, which is identified by one (or more) of a set of criteria occurring within a 12-month period. The four criteria relate to: failure to meet role obligations, being physically hazardous, legal problems, and ongoing social problems. substance dependence, which is identified by three (or more) of a set of criteria occurring within the same 12-month period. The seven criteria relate to: tolerance, withdrawal, lack of control, much time spent on substance using, other activities are reduced, and continued use despite associated problems (American Psychiatric Association, 2000). In 2013 the DSM-V will be released and it is expected that the current system of diagnosing problematic substance use will be changed. Problematic gambling The DSM IV-TR includes gambling problems as an Axis 1 impulse control disorder and diagnoses severe gambling problems as pathological gambling. Pathological gambling is identified when persistent and recurrent problematic gambling behaviour meets five (or more) of a set of criteria. The 10 criteria listed relate to symptoms such as preoccupation, lying to others about their gambling and illegal acts to finance gambling. Problematic gambling can be diagnosed as pathological as long as it cannot be accounted for by a manic episode. In the new DSM V it is anticipated that problem gambling will sit in the same classification as substance use disorders and be classified as an addictive disorder. A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand 17

18 Defining problematic substance use and gambling The EIGHT gambling screen developed in New Zealand by Sullivan (2007) is also widely used to screen for problem gambling. Please see Screening, Assessment and Evaluation: alcohol and other drug, smoking and gambling (Matua Raki, 2011:42-43) for more information. References and further information Alcohol Advisory Council (ALAC). (2012). Low Risk Alcohol Drinking Advice [online] [accessed 8 March 2012] American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. (4th ed). Text Revision. Washington DC: American Psychiatric Association. Coynash, N., & Harrison, G. (1987). Drinking continuum. Living with alcohol: Managing the problems. Wellington: Alcohol Liquor Advisory Council. Korn, D., & Shaffer, H. (1999). Gambling and the health of the public: Adopting a public health perspective. Journal of Gambling Studies 15: 4 Matua Raki. (2011). Screening, Assessment and Evaluation: alcohol and other drug, smoking and gambling. Wellington: Matua Raki Ministry of Health. (2008). A Portrait of Health: Key results of the 2006/07 New Zealand Health Survey. Wellington: Ministry of Health Ministry of Health. (2009). A focus on problem gambling: Results of the 2006/07 New Zealand Health Survey. Wellington: Ministry of Health Ministry of Health. (2010). Drug Use in New Zealand: Key results of the 2007/08 New Zealand Alcohol and Drug Use Survey. Wellington: Ministry of Health Oakley Browne, M., Wells, J.E., & Scott, K. (Eds). (2006). Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health Sullivan, S. (2007). Don t let an opportunity go by: Validation of the EIGHT gambling screen. International Journal of Mental Health and Addiction, 5 (4): A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

19 Assessment and treatment planning Following welcoming, engagement and building a rapport with people who present for services, all treatment for addiction-related problems should be preceded by an assessment. An assessment is the process of collecting, integrating and analysing information provided by the person so that an understanding can be reached and a formulation developed about the presenting issues and the client s desired goals. This then forms the basis for a treatment plan. An assessment can be much more than an information collection process. When done skilfully and empathically assessments can also be therapeutic. This is particularly the case when there is collaboration with the client and the practitioner uses therapeutic techniques to enhance the client s motivation for change. Different assessment processes are used, depending on the treatment setting as well as the severity and type of issue with which the client presents. The main types of assessment used are described below. Screening for addiction problems (non-specialist settings) The impact of problematic substance use or problem gambling can have a wide ranging impact on a person s life. They may present in primary care settings including health, social services and criminal justice services. Staff in these settings can play a valuable role in identifying whether a person s presenting issues could be improved by addressing problematic substance use or gambling related problems. The recommended approach is to screen people who attend services for problematic substance use and/or gambling problems. Screening tools are designed to identify people who may have a problem and positive results indicate further assessment should be carried out to confirm its severity. This can be followed up by a referral to specialist addiction treatment services and/or a brief intervention (see the Interventions section for further explanation). Brief screening and assessment (all treatment settings) Non-specialist settings In services for health, social and criminal justices issues, it may be appropriate for staff to follow up the use of screening tools with a brief assessment. Once a possible problem has been identified by a screening tool, further information could be gathered from the client regarding their substance use and/or gambling through an interview. The key information to be gathered would include: a description of current substance use and/or gambling (type, quantity and frequency) problems associated with this use (physical, social, legal, responsibilities) identification of associated harms (either current or potential) to themselves and/or others A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand 19

20 Assessment and treatment planning previous experience of substance use and/or gambling and treatment clients concerns and desire for change. Once completed, this assessment information can be used to provide a brief intervention and/or make a referral to a specialist treatment service. Specialist addiction treatment settings Brief screening and assessment can also be used by specialist treatment services. Screening tools may be used initially as an efficient way to identify the range of substances that someone may have issues with and any coexisting problems. Once identified, further information is gathered through an interview process similar to the content as described for the non-specialist services. A brief assessment completed by specialist services would differ to non-specialist services in the following ways: greater depth of information gathered specific information gathered to identify whether a provisional clinical diagnosis is appropriate regarding the clients substance use and or co-existing problems therapeutic relationship developed using client-centred counselling and motivational approaches. Whether specialist services provide brief assessment or a more comprehensive one will depend on the service delivery model they are providing, how long clients engage with them and the severity or complexity of the client s problems. For example, a telephone helpline service may only have a few minutes to work with a client and so needs to complete a brief assessment and provide some intervention during this time. This can be compared with a residential treatment service where clients live-in for eight weeks or longer. A longer intervention allows more time for a more comprehensive and ongoing assessment process. Comprehensive assessment (specialist treatment settings) A comprehensive assessment is a more in-depth holistic assessment of the person s bio-pyscho-social and spiritual background and current functioning and can include medical, psychological and biochemical testing. The aim of a comprehensive assessment is to determine the aetiology (cause) of the substance use problem, contributing and perpetuating co-existing problems and the person s strengths, in order to develop an appropriate treatment plan. Please see Screening, Assessment, and Evaluation: alcohol and other drug, smoking, gambling (Matua Raki, 2012) and Te Ariari o te Oranga: The Assessment and Management of People with Co-existing Mental Health and Substance Use Problems (Todd, 2010) for more detailed information regarding comprehensive assessments. As well as gathering information through client self-reports by assessment tools and interview, collateral information can be gathered through: information from friends, family or whānau information from referral sources (e.g. general practitioners, probation officers or employers) physical examination by a medical practitioner biochemical measures of the presence of substances and their metabolites (e.g. through breath, hair, blood or urine tests) biochemical measures of physical damage from long term substance use (e.g. through blood tests that measure liver function). 20 A Guide to the Addiction Treatment Sector in Aotearoa, New Zealand

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