Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan

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1 Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan

2 Acknowledgements The Ministry would like to acknowledge the Adult, and Child and Youth Provincial Standing Committees, the Regional Directors of Mental Health and Addictions, the Project Reference Group, and the Drug Treatment Funding Program Steering Committee for their contribution to document development. The Ministry would also like to acknowledge John McCallum and Greg Drummond for project facilitation and document development, and Health Canada for project funding under the Drug Treatment Funding Program. December 2012

3 Table of Contents Intended Audience... 3 Introduction... 3 Clinical Principles Summary... 4 Clinical Principles Detailed Description... 7 Clinical Principle 1: Alcohol and drug misuse, abuse and dependence are shaped by biological, social and other factors, which may include family, environment, and other extra therapeutic factors... 7 Clinical Principle 2: Alcohol and drug dependence is a chronic condition... 8 Clinical Principle 3: The patterns of youth alcohol and drug misuse are different from those of adults and require specialized treatment responses... 9 Clinical Principle 4: Treatment programs need to be knowledge or evidence-informed Clinical Principle 5: The needs of special populations are recognized and responded to appropriately and with sensitivity Clinical Principle 6: Mental health and alcohol and drug services are integrated for clients with concurrent alcohol and drug misuse and mental health issues Clinical Principle 7: Programs exist for clients and the community that reduce the short and long term impacts of alcohol and drug misuse Appendix A References

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5 Intended Audience The clinical principles for Alcohol and Drug Misuse Services in Saskatchewan have been developed by the Ministry of Health in partnership with the Health Regions Mental Health and Alcohol and Drug Misuse Services. Building upon the emergence of evidence based research and practice, the principles are intended to provide a basis for maintaining and developing evidence informed practice and programs. These principles build upon and are supported by the Framework for Mental Health and Alcohol and Drug Misuse, and linked to supporting documents of that Framework. Introduction The Saskatchewan Model for Recovery Services (SMRS) has been the treatment model employed in Saskatchewan since the 1980s. At the time there was little clinical research data on treatment effectiveness and the SMRS was developed based on a consensus of what was considered effective clinical practice at the time. Since then there have been numerous studies on treatment effectiveness and services need to reflect the new evidence, e.g. motivational interviewing, relapse prevention, cognitive behaviour therapy, and cooccurrence with mental health issues. In general, there is an increasing understanding that alcohol and drug misuse is a health condition that requires a communitybased primary health response. More than 30 years of research have demonstrated that treatment can work. Behavioural therapies can engage people, help change their attitudes and behaviours related to alcohol and drug misuse, and increase their life skills. Medications are now available to treat opioid, alcohol dependence while others are under development. Alcohol and drug misuse treatment exists on a continuum of interventions from creating supportive environments and building community capacity to health promotion and prevention, to outreach services that reduce the impacts of alcohol and drug misuse, and treatment. Interventions include strengthening community action, creating supportive environments, and building healthy public policy, all targeted towards reducing the harms associated with alcohol and drug misuse and promoting well-being. To support the Ministry s and Health Regions alcohol and drug initiatives, the need to develop a more flexible treatment model was identified. This model has as its aim, to meet individual unique needs and circumstances, especially for those with multiple problems, to build capacity across sectors and within communities, to reduce fragmentation of services and to reflect known best practices. The model builds on the Saskatchewan Model of Recovery Services. It will serve as a basis for establishing the best care pathways for different client groups. The principles are also informed by the recent changes in patterns and complexity of drug and alcohol use, the increasing levels of harm associated with these and the recognition of the need for a community response to provide a continuous and seamless system of intervention and support. The collaboration and cooperation across service providers, including Métis, First Nations and Community Based Organizations in addition to Health Regions is critical in providing a seamless service. The following clinical principles are informed by the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs in Canada, A Systems Approach to Alcohol and Drug Use Problems in Canada (National Treatment Strategy), and Saskatchewan Mental Health and Alcohol and Drug Misuse:Integration. They are guided by the Saskatchewan Mental Health and Alcohol and Drug Misuse Services Framework Document. A complete description and discussion of principles along with references to the Federal and Provincial frameworks are contained in the body of this document. Outlined below is summary outline of these principles. 3

6 Clinical Principles Summary Clinical Principle 1: Alcohol and drug misuse, abuse and dependence are shaped by biological, social and other factors, which may include family, environment, and other extra therapeutic factors. Alcohol and drug abuse and dependency are significantly affected by and linked to social factors such as socio-economic status, culture, gender and education and by the impact of life altering events or conditions such as violence, cultural dislocation and mental illness. This requires that interventions must address the multiplicity of conditions beyond the immediate alcohol and drug misuse issues and that clients need to be linked to other services along the continuum (e.g. mental health, medical services, social supports, housing, community supports and self-help). Interventions require strong partnerships, collaboration and coordination of services across sectors. Services need to be provided using a holistic approach within an integrated and collaborative model of service delivery. The alcohol and drug misuse worker must be adept at identifying and providing direction to address these extra-therapeutic factors. Clinical Principle 2: Alcohol and drug dependence is a chronic condition. While alcohol and drug abuse can be episodic it may lead to alcohol and drug dependency. Interventions and recovery plans should be client-centered, recognizing the unique nature of that person s condition (genetic, biological, familial and social factors). As with other chronic conditions alcohol and drug dependency or alcohol and drug misuse is shaped by social and other factors. Some clients will achieve abstinence while others will achieve a goal of drug/alcohol use reduction or safer use of harmful alcohol and drugs. For all clients the goal is to return to or attain an optimal quality of life. As with all chronic conditions the affected person must take some responsibility for their self- management, within their capability and with appropriate supports from the health system. Clinical Principle 3: The patterns of youth alcohol and drug misuse are different from those of adults and require specialized treatment responses. Alcohol and drug treatment services to adolescents recognize the developmental and social factors that require different approaches to intervention for the young person affected by alcohol or drug misuse. In adolescents, family factors, stressful life circumstances including factors associated with academic and peer functioning, as well as a history of physical or sexual abuse are major determinants of heavy alcohol and drug use. Additionally it is recognized that youth in rural areas and involved with street gangs present a greater challenge in providing care. Interventions directed to the identified youth and family with alcohol and drug misuse issues considers all of these factors and provides an interdisciplinary approach through outreach, mobile services and community supports, provided in nontraditional venues and outsideregular working hours. As with all services, programming occurs along a continuum from least to most intrusive. Interventions need also consider the youth s support system including family, school and community. 4

7 Clinical Principle 4: Treatment programs need to be knowledge or evidence-informed. The core approaches to the treatment of alcohol and drug misuse are well supported by clinical research. Motivational Interviewing honours the client s perspective and strengths. It provides a focused and goal directed approach to exploring and resolving ambivalence within an empathic and client centered relationship. The Trans theoretical Model of Change progresses through six stages from pre contemplation to contemplation, preparation, action, maintenance, and termination. The relationship of client and clinician matches the stage of change and changes as the client progresses towards termination. As with other chronic conditions relapse is anticipated and interventions must include preparation in planning for relapse within the treatment continuum. Relapse prevention helps identify high risk situations and early warning signs of relapse as well as interventions to help the person re-engage in the treatment process when relapse has occurred. Cognitive Behaviour Therapy or CBT has been shown as an effective therapeutic intervention in treating alcohol and drug misuse as well as mental health conditions such as depression and anxiety. This approach supports other models of drug and alcohol treatment in helping the client recognize situations that place them at risk to use and identify strategies to minimize those risks. Clinical Principle 5: The needs of special populations are recognized and responded to appropriately and with sensitivity. It is recognized that individual populations need specific forms of engagement, including specific forms of assessment and interventions, based on their unique needs. Understanding of the impact of specific social and cultural factors e.g. First Nations//Métis, women, seniors, immigrants, are necessary to successfully engage these populations. Interventions need to be delivered in a manner that recognizes the unique aspects of their needs. Clinical Principle 6: Mental health and alcohol and drug services are integrated for clients with concurrent alcohol and drug misuse and mental health issues. In the delivery of mental health and alcohol and drug misuse treatment and services, it is now known that the rates of co-occurring mental health issues and alcohol and drug misuse are high. It is imperative therefore that the services of Mental Health and Alcohol and Drug Misuse is organized and delivered in such a way as to identify and provide remediation when the co-existing conditions exist. In an integrated Mental Health and Alcohol and Drug Misuse Services the system takes a population health approach that also addresses the determinants of health and is collaborative with other health and social programs so that interventions address the full continuum of needs. When concurrent mental health and alcohol and drug misuse issues are present, both conditions are primary i.e. neither takes precedence over the other, and interventions need to address the existence of both. Clinicians should have the ability to screen and triage for mental health and alcohol and drug misuse issues if not fully able to assess and treat both conditions. In assessing and treating persons with concurrent mental health and alcohol and drug misuse issues, it is critical that there be an agreed upon and well communicated treatment plan. 5

8 Clinical Principle 7: Programs exist for clients and the community that reduce the short and long term impacts of alcohol and drug misuse. Programs and services to prevent and reduce the harmful effects of alcohol and other drugs are targeted to identified clients, families and the community. Services will include programs (e.g. methadone, needle exchange, detox and safe driving) directed to those identified and experiencing harmful alcohol and drug abuse and to those unable or unwilling to identify their risks. Interventions are flexible and targeted to the individuals readiness for change. In the community interventions can include education and policy directions (e.g. issues of access), that reduce the risks associated with drugs and alcohol. Prevention initiatives are targeted to the community/population reflecting their culture and acknowledging broader issues affecting the health of their community. 6

9 Clinical Principles Detailed Description The clinical principles provide a framework for the development of evidence-based treatment services in Saskatchewan. They are informed by several developments in the field over recent years: increasing awareness of different levels of harm in various population groups (e.g., higher thanaverage rates of alcohol and drug use related harm among Aboriginal people) changing patterns of alcohol and drug use (e.g., use of prescription and non-prescription opioids, inhalants and methamphetamine) increasing complexity of problems, including high rates of co-occurring mental health problems (e.g., depression, posttraumatic symptoms) and physical health problems (e.g., hepatitis C and B, HIV/AIDS) decreasing social supports among people seeking help (e.g., limited housing, employment) the increasing acceptance of a continuum of approaches aimed at reducing the impacts of alcohol and drug use In addition to the National Treatment Strategy principles, the following principles and guidelines are proposed to guide the Saskatchewan clinical model: building capacity across health and human service sectors increased clarity/agreement within the alcohol and drug misuse field no wrong door approach applies to all human services system is designed for the clients, rather than expecting the client to fit the system information sharing reduces fragmentation services are trauma informed developed care pathways for clients holistic approach programs are gender and diversity informed practice is culturally informed pharmacological treatment needs are integrated into counselling continuous quality improvement to improve outcomes Clinical Principle 1: Alcohol and Drug, misuse abuse and dependence are shaped by biological, social and other factors, which may include family, environment, and other extra therapeutic factors. The understanding that alcohol and drug misuse is shaped by social and other factors dictates that addressing problematic alcohol and drug use requires a population health approach that considers and addresses the potential risk and protective influence of socio-economic status, culture, gender, housing, education, geography, family, law and policies, and other factors. This approach recognizes how stigma, trauma, discrimination, violence and cultural dislocation can contribute to problematic alcohol and drug use. It understands that problematic alcohol and drug use often co-occurs with other conditions such as mental health issues s gambling problems or tobacco addiction. In the treatment context, this indicates that more emphasis is required in addressing factors that were considered extra-therapeutic in traditional clinical models. The research treatment literature has concluded that 40% of client changes are due to extra-therapeutic influences, 30% are due to the quality of the therapeutic relationship, 15% are due to expectancy effects, and 15% are due to specific techniques. 1 Extra-therapeutic influences include client motivation, resources and supports and the severity of the problem. This implies that treatment needs to address multiple domains beyond the immediate alcohol and drug use issues in order for the treatment effect to be maximized and that clients need to be linked to other services and supports across a continuum. Research has revealed that addiction affects the brain circuits involved in reward, motivation, memory, and 1 Lambert (1992) 7

10 inhibitory control. No single factor determines whether someone will or will not become addicted to drugs, however prolonged drug abuse changes the brain in fundamental ways that reinforce drug taking that can lead to addiction. Chronic exposure to drugs disrupts the way critical brain structures interact to control and inhibit behaviours related to drug abuse. Just as continued abuse may lead to tolerance or the need for higher drug dosages to produce an effect, it may also lead to addiction, which can drive an abuser to seek out and take drugs compulsively. Drug addiction erodes a person s selfcontrol and ability to make sound decisions, while increasing the impulse to take drugs. Research has led to the identification of several potential medications for drug addiction. In addition to already approved medications for treatment of opiate addiction (e.g., methadone, buprenorphine), new approaches that target different aspects of addiction are also being developed. Pharmaceutical treatment for addiction to alcohol (disulfiram, naltrexone, and acamprosate), opioids (naloxone, clonidine, and phenobarbital), cocaine (topiramate, modafinil) can be used in conjunction with motivational interviewing, cognitive behavioural therapy, and adjunct supports to improve treatment outcomes. Drug and alcohol availability is the single prerequisite for the development of alcohol and drug misuse. However other factors, including having a history of physical or sexual abuse, witnessing violence, or experiencing other kinds of stressors often play a major role. Important within these are adverse childhood events including recurrent and severe physical abuse, recurrent and severe emotional abuse, sexual abuse, and growing up in a household with an alcoholic or drug user, a member being imprisoned, a mentally ill member, the mother being treated violently or both biological parents not being present. Families can increase risk, or provide protective factors in alcohol and drug misuse, but rarely play a neutral role. Family members are in turn affected by alcohol and drug misuse and need to be considered and/or included in treatment wherever possible. Clinical Principle 2: Alcohol and drug dependence is a chronic condition. Alcohol and drug abuse and dependence emerge from multiple, interacting influences. There is wide variation in onset, progression and outcome. It is important to identify populations that comprise the multitude of varying patterns of alcohol and drug abuse and dependence and develop increasingly sophisticated tailored treatment responses to address the needs of each population. As a chronic condition, alcohol and drug dependence (or addiction) shares a similar aetiology to other chronic conditions in that they are not completely caused by genetic or biological factors but are shaped also by social and other factors. Alcohol and drug dependency or addiction have similar relapse rates to other chronic conditions and are not always progressive as symptoms can remain stable, but enduring over time. Deceleration of alcohol and drug use to non-problematic levels is less likely for those with patterns of severe and persistent alcohol/drug problems. Alcohol and drug abuse is more typically episodic in nature and is a condition that may lead to alcohol and drug dependence. With this understanding it is important to develop client-centered recovery plans that respond to the individual s progression through alcohol and drug abuse and dependence. For some clients this will mean abstinence. For others the goal may be reduced or safer use. For all clients recovery means the return or attainment of the best possible level of functioning and the attainment of optimal achievable health. 1) Alcohol and Drug Dependence DSM-IV-TR defines the disorder of substance dependence as a collection of cognitive, behavioural and physiological features that together signify continued use despite significant alcohol and 8

11 drug-related problems. It is a pattern of repeated self-administration that can result in tolerance, withdrawal and compulsive drug taking behaviour. In order to cross the threshold of Substance Dependence the client must exhibit three or more behaviours from a set of seven criteria over a 12-month period. The ICD-10 Classification of Mental and Behavioural Disorders define dependence syndrome due to psychoactive substance use as a cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco. There may be evidence that return to alcohol and drug use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals. 2) Alcohol and Drug Abuse DSM-IV-TR describes substance abuse as continued use despite significant problems caused by the use in those who do not meet the criteria for alcohol and drug dependence. To meet a criterion, a alcohol and drug-related problem must have occurred repeatedly or persistently during the same 12- month period and does not include tolerance, withdrawal or compulsive use. A model to successfully manage chronic conditions such as alcohol and drug abuse and dependency requires that the client, once returned to best possible health and education level concerning self care, take a certain degree of responsibility to manage their own health. The responsibilities are to undertake preventative and stabilizing tasks; manage their own health, recognize their own vulnerability to their condition, act proactively, to prevent new outbreaks, recognize the presence of the condition and act decisively to arrest and manage the condition. Health services can support the client s journey to self management by matching the client to the appropriate level of services and supports across the continuum of care. Clinical Principle 3: The patterns of youth alcohol and drug misuse are different from those of adults and require specialized treatment responses. Youth alcohol and drug use differs from that of adults not only in general patterns of use and alcohol and drugs used but in the meaning of and factors associated with use. There are difficulties in defining what constitutes an alcohol and drug use problem among youth when adolescence itself is characterized by change related to the achievement of significant developmental tasks. Adolescence is a phase of transition to independence. Youth behaviour is characterized by heightened novelty seeking and exploration, increased social behaviour, and, relative to other ages, higher levels of sensation seeking, risk taking and recklessness. In addition, adolescents display an increase in negative affect (e.g., anxiety and depression), and tend to experience anhedonia (an inability to experience pleasure). Such responses may predispose adolescents to seek new reinforcements through risk taking and novelty seeking, for example, through alcohol and drug use. In contrast to adults who generally demonstrate a progression from abuse to dependence, adolescent abuse symptoms do not always precede dependence symptoms. In some cases, adolescents exhibiting clinically significant problems with alcohol may not qualify for a diagnosis of alcohol use disorder. Similarly, symptoms of alcohol withdrawal tend to be experienced infrequently by adolescents until late in the course of their alcohol use disorders. In addition, 9

12 health complications are often chronic in nature and are therefore more frequently experienced by adults than by adolescents. Tolerance to alcohol and drugs has been identified as a predictor of dependency in adults, but has had less applicability for youth. Adolescents have a wider variety of symptoms of alcohol and drug abuse and their presentation of tolerance may be different from that of adults. However, they frequently experience significant impairment in family functioning and interpersonal relationships, as well as disruptions in school attendance and academic performance as a result of alcohol and drug misuse. The issues the youth may be facing may have existed prior to involvement with alcohol and drug misuse or they may have arisen from the alcohol and drug misuse. Youth who experience problems with alcohol and/or drugs typically display changes in mood, sleep changes, family conflict and a decrease in academic functioning. Typically they engage in conflict with their parents as a method to project their problems on to their parents. Involving the family and school personnel typically enhances the effectiveness of intervention with youth who are abusing drugs and alcohol. Research indicates that peer association and family factors including inadequate social conditions, stressful life events, societal pressures and physical or sexual abuse are major factors in the development of heavy alcohol and drug use by adolescents (Health Canada 1999). Since youth differ from adults, caution should be used when trying to use the DSM-IV-TR and ICD- 10 to diagnosis youth alcohol and drug abuse and dependence because the criteria used within these tools was normed on adult populations and some youth tend to mature out of alcohol and drug abuse. Use patterns in adolescence may not be predictive of longterm alcohol and drug use problems (Health Canada 2001). Identification of youth with alcohol and drug misuse issues include the assessment of the level and intensity of alcohol and drug use; the impact of the use on personal, social and family relationships, and on their own health (Health Canada 2001). Interdisciplinary methods of intervention tend to focus on addressing physical, psychological and interpersonal issues in conjunction with harm reduction and relapse prevention. Two populations of youth that provide special challenges are youth residing in rural communities and street involved youth. The size of this population in Saskatchewan is constantly changing and is difficult to determine. Street involved youth are the most at risk and difficult to reach because of their transient nature and lack of connection to community supports. Therefore, outreach, mobile treatment services, community support services, drop in services and services located in non-traditional venues and during non-traditional hours become increasingly important to reach at risk youth. Youth residing in rural areas may not have access to alcohol and drug misuse services. Outreach and transportation have been identified as important for connecting with youth in more remote locations. Outreach can also use mobile services (e.g. a van) to make contacts in a variety of places or reach youth in rural or more isolated areas. Rural youth are often concerned that confidentiality is difficult to ensure. Stigma and the possibility of encountering someone familiar while accessing mental health and alcohol and drug misuse services increase reluctance to seek out services. Sex-trade workers and injection drug users may be less visible in rural areas than in urban centres. Some of these issues can be addressed by providing services on an outreach basis by meeting with clients in their natural settings and developing rapport with them through multiple contacts. Approaches that first seek to engage youth and reduce the risk and impacts of alcohol and drug misuse are the most effective and responsive to youth needs and stage of life (Health Canada 2001). Programming should occur on a continuum beginning with the least intrusive means first based on appropriate assessment and treatment matching. This may include outreach, drop-in services, outpatient services, or community orders, then moving to more structured, intensive or intrusive means of treatment including voluntary or mandated inpatient services. The option of secure youth detoxification should be used only as a last resort in cases of severe alcohol and drug abuse. Clinicians experiences suggest that youth benefit most from programming which offers flexible, individualized approaches that incorporate family therapy, behavioural skills counselling, school availability, vocational counselling, recreation services, sexuality counselling, involvement of family or support people and continuing 10

13 care (Health Canada 1999). Asset and resiliency-based approaches are indicated for youth. Intervention methods must be relevant to the developmental age of the youth and focus on the youth s strengths, skills and interests. Youth should be considered within a system and whenever possible family, peers, community and other organisations involved with the youth should be included in the planning and treatment process. Families need to be involved wherever possible especially for younger youth, including engagement of family members when the alcohol and drug affected youth is not willing to participate. Clinical Principle 4: Treatment programs need to be knowledge or evidence-informed For alcohol and drug misuse services the core approaches that are well-supported by clinical research evidence are: 1. Motivational Interviewing Motivational Interviewing (MI) is a brief clinical method that addresses motivational struggles in behaviour change. The spirit of MI is characterized by a counselling style in which a partnership is established between the client and counsellor that honours the client s perspective and strengths. Counselling is client-centred, empathetic and built on reflective listening that conveys the counsellor s acceptance of the client. The client is viewed as possessing the resources and motivation for change and the counsellor s task is to bring out that motivation in the client. Change comes about by focusing on the differences between current behaviour and important goals and values. MI is a directive, client-centered counseling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. Compared with nondirective counselling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counsellor is intentionally directive in pursuing this goal. Guidelines: Expression of Empathy Support of Self-Efficacy Rolling with resistance Development of Discrepancy 2. Transtheoretical Model of Change The Transtheoretical Model of Change approach has demonstrated that individuals are able to achieve lasting behaviour change without treatment as well as with professional help. A wide range of health behaviours have been investigated using this paradigm, including smoking, drinking, eating disorders, and illicit drug use. The Transtheoretical Model of Change conceptualises behaviour change as a process that unfolds over time and involves progression through a series of six stages: pre-contemplation, contemplation, preparation, action, maintenance, and termination. The alcohol and drug misuse field has added the concept of relapse to the Model of Change. At each stage of change, different processes of change optimally produce progress. Matching change processes to the respective stages requires that the therapeutic relationship be matched to the client s stage of change. Furthermore, as clients progress from one stage to the next the therapeutic relationship also progresses. 3. Relapse Prevention As with any chronic condition, there are periods of relapse, which are to be expected and to be prepared for by relapse preparation planning included in treatment models. Relapse prevention is empirically based and has been found to be an effective intervention in the treatment of various addictive behaviour problems in treatment outcome studies. Relapse prevention has two primary goals: (a) to help clients prevent relapse and maintain treatment goals (abstinence or moderation) by assessing high-risk situations for relapse, recognizing and coping with early warning 11

14 signals, coping with urges or cravings to use, and establishing lifestyle balance; and (b) to help clients who are experiencing relapse to get back on track, by identifying relapse triggers and reactions (relapse debriefing), and by viewing the lapse as an opportunity for learning new coping strategies rather than as a sign of personal failure. 4. Cognitive Behavioural Therapy Cognitive Behavioural Therapy (CBT) addresses the learning processes that play a critical role in the development of alcohol and drug misuse, abuse and addiction. CBT clients learn to identify and change problematic behaviours through the development of skills that can be used to stop susbstance misuse and other problems that often accompany it. CBT helps clients anticipate problems and enhances self-control by helping clients develop effective coping strategies. Techniques include exploring the positive and negative consequences of drug use, self-monitoring to recognize cravings, identifying high risk situations, and developing strategies for coping with cravings and high-risk situations. Clinical Principle 5: The needs of special populations are recognized and responded to appropriately and with sensitivity. Specific populations or groups within Saskatchewan and Canada benefit from special attention due to their unique characteristics to meet their needs. Populations may be identified by their structural or functional characteristics. Structural characteristics are those based on population, demographic or developmental characteristics. Functional characteristics are those social, clinical or legal conditions which are shared by a group of people. An individual may possess several structural or functional characteristics that need to be recognized and may need to be accounted for in treatment planning and programming (Health Canada 1999). Their needs can be addressed through cultural competency and the ability to provide effective treatment based on the knowledge of and respect for each person s circumstances. Special populations may include but are not limited to: First Nations/Metis/Inuit Peoples Ethno-cultural Peoples Lesbian, Gay, Bisexual, Transgender Women Seniors Youth People with Concurrent Disorders People with HIV/AIDS/Hepatitis Those residing in isolated or rural communities Homeless People Street or Gang Involved People Offenders Families Those with medical conditions or disabilities including hearing/visual impairments, mobility issues, cognitive disabilities, FASD, acquired brain injuries etc. See Appendix A for further information regarding special populations. 12

15 Clinical Principle 6: Given the high correlation between mental health issues and alcohol and drug misuse problems, mental health and alcohol and drug services need to be integrated for clients with concurrent alcohol and drug misuse and mental health issues. The prevalence of co-occurring mental health and alcohol and drug misuse is high in the treatmentseeking populations and needs to be considered in planning, implementing and evaluating both mental health and alcohol and drug misuse services. Alcohol and Drug misuse and mental health co-morbidity changes the course, cost and outcome of care and presents significant challenges for screening, assessment, treatment/support and outcome monitoring. When mental health and alcohol and drug misuse issues coexist, both should be considered primary, and integrated dual primary treatment is required. However, if either issue is so severe that it compromises the individual s life, or critical aspects of functioning, treatment should be first targeted to the most important issue and once it is stabilized then treatment should be simultaneous in an integrated program or system (Health Canada 2002). Successful treatment requires most importantly the creation of welcoming, empathetic, hopeful, continuous treatment relationships, in which integrated treatment and coordination of care are sustained through multiple treatment episodes. There is no single correct dual diagnosis intervention. Interventions need to be individualized, according to the subtype, specific diagnosis, phase of recovery/stage of change, and level of functional capacity or disability. The treatment of co-occurring mental health and alcohol and drug misuse issues can be especially challenging to clinicians because few have the familiarity or expertise in the treatment of both and therefore, some clinicians tend to focus on the treatment of the condition they are most familiar. While expertise in both mental health and alcohol and drug misuse is recommended, if this is not possible, clinicians should develop capacity to screen and triage for mental health and alcohol and drug misuse and consult with other professionals who possess the expertise. Strong partnerships and communication is necessary in the establishment and implementation of the treatment plan. Critical features of integration include that there be an agreed upon and well-communicated treatment plan and a consistent and well-coordinated implementation of that plan. This reduces the possibility of individuals receiving inconsistent messages regarding their treatment. Clinicians in an integrated program or system should provide specific services concurrently or sequentially, depending on the particular combination of concurrent issues and other individual factors. It is recommended that all people seeking help for alcohol and drug misuse be screened for co-occurring mental health issues as well. With a positive screen for either alcohol and drug use or mental health issues, a comprehensive assessment is recommended to: Establish diagnoses; Assess the level of psychosocial functioning and other condition-specific factors; and Develop a treatment plan that enables interaction between alcohol and drug misuse and mental health issues facing the client (Health Canada 2001). Interventions should be provided on a continuum beginning with the least intrusive measures and being either stepped up or down based on the results from ongoing outcome monitoring. The use of psychotropic medications should not form the basis upon which to exclude a client from an abstinence based treatment program. Within this integrated approach, intervention should focus on medical and nutritional management to stabilize the individual; educational and behavioural strategies to effect change in the mental health and alcohol and drug misuse behaviours, strength based capacity building while improving the client s quality of life; psychotherapy (cognitive-analytical, family, 13

16 cognitive-behavioural) to address psychological issues; psychopharmacology for severe symptomatology; individual and group therapy (examining self-esteem, feelings, trauma, life skills, positive self-talk and motivation); and after care (Health Canada 2002, Government of Canada 2006). Services need to be trauma-informed and holistic in nature. It is important to assist an individual with co cooccurring mental health and alcohol and drug misuse issues to expand and enhance their network of psychosocial supports. This may include connecting people to housing, employment or education services, recreation, and social networks (Health Canada 2001). The Framework recommends that mental health and alcohol and drug misuse services take a population health approach that addresses the social determinants of health and improves the coordination of community based supports. To improve system delivery response, effective collaboration of alcohol and drug misuse and mental health interventions needs to take place across the full spectrum of services. Clearly defined entry and transition points are necessary to establish where integration needs to occur. A further requirement is the adoption of a tiered/ stepped care model for organizing services and supports that address alcohol and drug use and mental health needs. Clinical Principle 7: Programs that reduce the short and long term impacts of alcohol and drug misuse benefit clients and the broader community. Successful responses to reduce the harms associated with alcohol and other drugs and alcohol and drugs address the full range of health promotion, prevention, treatment, enforcement, and programs that reduce the impacts of alcohol and drug misuse. Preventing and reducing the harms associated with alcohol and other drugs and alcohol and drugs require integrated, culturally appropriate, comprehensive, and balanced responses to ensure a range of appropriate activities, programs, and policies that include a combination of population-based approaches and targeted interventions. Some programs focus on people who are already experiencing harm due to alcohol and drug use but are not contemplating treatment or abstinence. Outreach interventions initially focus on reducing use or encouraging safer use, while informing clients of the availability of treatment services. These programs help reduce the harmful consequences of alcohol and drugs use (e.g. reduced crime and public disorder), in addition to the benefits that accrue from the inclusion into mainstream life of previously marginalized members of society. The improved health and functioning of individuals and the net impact on harm to the community are notable indicators of the early success of these programs This is one approach in a broad spectrum of clientcentered care. From a treatment perspective it is a proactive early engagement of clients while they are still in active alcohol and drug use and is often embedded in outreach services. Individuals must be engaged in self-management so that they may be capable of anticipating risky situations and generating viable, preferred alternatives that are suited to the situation at hand and reflect their own considered goals. An awareness of clients readiness for change is crucial to developing appropriate treatment and support services. Clients goals are prioritized emphasizing immediate and realizable goals. Programs need to remain flexible, recognizing individual differences and goals, and provide a maximum range of options for interventions and treatment. Reflecting the client s motivation and readiness for change treatment goals need to span the continuum from abstinence to reduced use to safer use. 14

17 Appendix A 1. FIRST NATIONS / METIS Many First Nations / Métis people are suffering not simply from specific diseases and social problems, but also from depression of spirit from 200 years or more of damage to their cultures, language, identities and self respect. Consequently, healing in First Nations / Métis communities often refers to personal and societal recovery from the lasting effects of this damage. Healing and good health are often depicted in imagery as being in a state of balance and harmony involving body, mind, emotions and spirit. It links each person to family, community and the earth in a circle of dependence and interdependence. To work effectively with First Nations / Métis people and communities it is important to find out how closely individuals, families and communities identify with First Nations / Métis values. There is considerable variation in First Nations / Métis beliefs, values and traditions from one community to another. There is no one set of clinical practices that will work for all First Nations / Métis clients but the following can be applied and adjusted to fit a variety of First Nations / Métis clients. Cross-cultural awareness is essential when working with First Nations/ Métis individuals, families and communities. Cross cultural awareness can be obtained in many different ways through attending organized sessions, initiating contact with First Nations / Métis individuals, tribal councils and Métis locals and First Nations / Métis service organizations. Counsellors need to be aware of the cultural groups that reside in their service area/health region and to seek out the specific information relevant to the history of the people, as well as past and current practices. Successful healing programs make extensive use of Elders. Elders can provide individual and group counselling and support and advise on the overall structure of the healing programs. It is important to note that not all Elders have the same role and function. Elders need to be carefully screened and their on going participation in the healing program carefully monitored. Elders may be members of the staff or they may operate independently. First Nations / Métis are quite often perceived in the context of their family. Family consist of parents, children, grandparents, aunts and uncles and cousins who may be viewed as siblings. When working with First Nations / Métis families it is important to include the extended family members. It is helpful to arrange sessions for the parents and the children at the same time. In this instance, parents would attend sessions relevant to adults and the children would attend sessions specific to their developmental level. It is very helpful to make services easily accessible for parents. This includes being able to access programs in the same location, at the same time and providing child care and transportation. Counsellors need to be aware that when English is a second language for their First Nations / Métis clients, the client may have difficulty reading and comprehending English. The use of clinical jargon or other language may be unfamiliar to First Nations / Métis clients and should be avoided. Some clients may prefer to express themselves through art, crafts and music. First Nations / Métis people are often reserved about entering government/health region offices. They may meet stigma and discrimination that can be overt or very subtle. This includes body language, willingness to listen and the manner is which directions are given. Some communities or families have acceptable practices that may seem different or strange in another setting. It is important for the clinician to present as welcoming and accepting. As counsellors identify and increase awareness of their own views and biases, they are better able to ensure that these are not imposed on the clients. Office settings present as more supportive when they display First Nations / Métis art, posters and pamphlets. When working with First Nations / Métis communities there is a need for a community- 15

18 based approach in healing the community. Building community empowerment is the key to helping communities heal. A key aspect of healing communities is the recapturing of community values, rebuilding the family, respecting the wisdom of elders in sharing essential teachings, allowing women and children to voice their opinions, and recreating a strong nation. References Alberta Alcohol and Drug Abuse Commission. Alberta Alcohol and Drug Abuse Commission (2006). Developments: Addiction Treatment with an Aboriginal Focus. Industry/View.aspx?id=25211&p=1d28 Government of Canada (2006). The Human Face of Mental Health and Mental Illness in Canada Ottawa: Minister of Public Works and Government Services. Health Canada (2001). Best Practices: Treatment and Rehabilitation for Youth with Substance Use Problems. Ottawa: Minister of Public Works and Government Services. Health Canada (1998). Literature Review: Evaluation Strategies in Aboriginal Substance Abuse Programs: A Discussion. alt_formats/fnihb-dgspni/pdf/pubs/ads/literary_examen_review_e.pdf Health Canada. Treatment Centre Directory. National Native Alcohol and Drug Abuse Program / National Youth Solvent Abuse Program. gc.ca/fnih-spni/substan/ads/nnadap-pnlaada_dir-rep_e.html National Aboriginal Health Organization (NAHO). Croweshoe, Chelsea (2005). Sacred Ways of Life: Traditional Knowledge. TraditionalKnowledgeToolkit-Eng.pdf National Native Alcohol and Drug Abuse Program (NNADAP) - General Review Final Report. Thatcher, Richard Fighting Firewater Fictions: Moving Beyond the Disease Model of Alcoholism in First Nations. Toronto: University of Toronto Press Incorporated. 2. WOMEN Women who have problems with alcohol and drug use differ from men in their patterns and onset of drug use. Sensitivity to gender differences and needs is important when developing and delivering treatment services for women with alcohol and drug use problems. Due to differences in the metabolism of alcohol, women are more affected than men by the same amount of alcohol, even after correcting for body weight. Women often describe their alcohol and drug use as having a sudden and heavy onset, often following a traumatic event. Women may use alcohol and drugs to numb emotional pain from abuse, grief over the death of loved ones, or guilt over injury to loved ones, especially children. Relational issues are intricately connected with the onset and progression of alcohol and drug use problems in women. Families can either help or hinder treatment seeking, but they rarely have a neutral impact. Women with children may forgo or postpone treatment entry because they do not have someone they trust to care for their children in their absence (Health Canada 2006). It is important to consider barriers to alcohol and drug misuse services for women and to provide women a range of modifications and support services to address those personal, interpersonal, program and geographic barriers to treatment. Barriers to women accessing alcohol and drug misuse services include the following: Pregnant or parenting women (isolation, child care issues, fear, stigma); Women experiencing concurrent disorders (isolation, lack of collaboration between mental health and alcohol and drug misuse services); First Nations women (language barriers, lack of culturally sensitive or specific programming); Ethno-cultural minority women (language barriers, lack of culturally sensitive or specific programming); 16

19 Women residing in rural communities (isolation, transportation issues, stigma, lack of privacy, lack of community services); Women residing in institutional facilities including correctional facilities (lack of services, restricted accessibility, lack of trust, lack of continuity between facilities and programming); Women who are transient or homeless (basic needs unmet, isolated, hard to reach); and Women with medical issues including HIV, AIDS, Hepatitis C, etc. (medical issues, stigma, fear, isolation, feelings of hopelessness); (Health Canada 1996, 1999, 2001, 2006). Best practice research indicates women are better served through early intervention, outreach and community linkages (Health Canada 2006). Best practice literature also includes elements of the following when working with women with alcohol and drug misuse issues: Gender sensitivity; Establishing strong linkages with community organisations serving women and their families; Developing trust; Direct outreach services; Development of services that are not all directly related to alcohol and drug misuse treatment which may include recreation, vocational training, life and parenting skills training, therapy for victimisation and assertiveness training; Utilisation of harm reduction approaches as a tool of engagement; Culturally sensitive, appropriate and available interventions; Women/client and family-centred therapy and support; Easily accessible, flexible, individualized and convenient services; and Establishment of supportive services to facilitate engagement and retention of women in support services including transportation and childcare (Health Canada 1996, 1999, 2001, 2006). When examining optimum alcohol and drug misuse treatment approaches for women, those approaches should focus on women s spiritual, physical, personal and interpersonal issues while connecting women to positive outreach and community supports. References Centre for Addiction and Mental Health and AWARE (Action on Women s Addictions - Research & Education) Women and Alcohol. Toronto: Centre for Addiction and Mental Health. WomenAlc_ENG.pdf Health Canada: Office of Alcohol, Drugs and Dependency Issues Horizons Two - Canadian Women s Alcohol and Other Drug Use: Increasing Our Understanding. Ottawa: Minister of Public Works and Government Services. Health Canada: Office of Alcohol, Drugs and Dependency Issues Immigrant Women and Substance Use: Current Issues, Programs and Recommendations. Ottawa: Minister of Public Works and Government Services. Health Canada: Office of Alcohol, Drugs and Dependency Issues Rural Women and Substance Use: Issues and Implications for Programming. Ottawa: Minister of Public Works and Government Services. Health Canada: Office of Alcohol, Drugs and Dependency Issues Health Canada Best Practices Substance Abuse Treatment and Rehabilitation. Ottawa: Minister of Public Works and Government Services. bp_alcohol and drug_abuse_treatment_e.pdf Health Canada: Office of Alcohol, Drugs and Dependency Issues Health Canada Best Practices Treatment and Rehabilitation for Women with Substance Use Problems. Ottawa: Minister of Public Works and Government Services. Health Canada: Office of Alcohol, Drugs and Dependency Issues Best Practices - Early Intervention, Outreach and Community Linkages for Women with Substance Use Problems. Ottawa: Minister of Public Works and Government Services. adp-apd/early-intervention-precoce/early-intervention-precoce_e.pdf Health Canada: Office of Alcohol, Drugs and Dependency Issues Summary Report Treatment and Rehabilitation for Women with Substance Use Problems Workshop on Best Practices June 6 and 7, Ottawa: Minister of Public Works and Government Services. alt_formats/hecs-sesc/pdf/pubs/adp-apd/treatment-traitement/treatment-traitement_e.pdf Pederson, Ann (ed) Centres of Excellence for Women s Health Research Bulletin Volume 5 Number I Spring Ottawa: Centres of Excellence for Women s Health Bureau of Women s Health and Gender Analysis Health Canada. Saskatchewan Health. Focus Sheet. 17

20 3. SENIORS The proportion of seniors in Canada is increasing. With this demographic shift, effective alcohol and drug misuse services are needed for seniors. With aging, there is a reduction in the proportion of body water, resulting in an increased potency of alcohol and drugs in seniors (Health Canada 2002). Slower metabolisms in seniors result in prolonged effects on the central nervous system and increase susceptibility to problematic alcohol and drug use (Health Canada, 2002). As well, the use of intoxicating alcohol and drugs may result in adverse medical interactions if the senior is taking prescription medication for a physical or psychological condition (AADAC 2003). For seniors, the alcohol and drug use problems most frequently observed are with alcohol and prescription medications. Although illicit drugs are not currently a major problem for seniors, it is anticipated that problems with their use will emerge as baby boomers enter their senior years. Symptoms of alcohol and drug use can resemble symptoms of chronic conditions. Both professionals and the general public need increased education on alcohol and drug use issues. Early-onset drinkers comprise approximately twothirds of senior problem drinkers, and late-onset drinkers comprise one-third. Early-onset drinkers tend to have fewer social supports than late-onset drinkers. Family, physicians and pharmacists should monitor medication use and be aware of concurrent use of alcohol and other prescription medication, over-the-counter medications, or herbal remedies. Instructions for prescription medications should be clear, taking into account potential declines in hearing, and difficulties reading small fonts on labels or understanding terminology. Seniors risk factors include multiple losses, such as loss of health, independence and family or social network. These losses may contribute to social isolation and loneliness. The development of relationships and social networks are important aspects of treatment. Age-specific interventions are beneficial for seniors; at times a slower pace may be required. Brief interventions that promote awareness and encourage motivation to change are beneficial for seniors experiencing mild to moderate difficulties with alcohol use. Seniors benefit from outreach services that adopt a harm reduction, client-centred, holistic treatment approach that aims to improve overall quality of life (Health Canada 2002). References Alberta Alcohol and Drug Abuse Commission ABC s of Alcohol and Seniors. Alberta Alcohol and Drug Abuse Commission Beyond the ABC s, Alcohol-Medication Interactions. alcohol_medical_interaction.pdf Frederic C. Blow, Ph.D. Substance Abuse Among Older Adults Treatment Improvement Protocol (TIP) 26. Rockville, MD: U.S. Department of Health & Human Services and alcohol and drug Abuse and Mental Health Services Administration National Clearinghouse for Substance Abuse Related Information. Health Canada Best Practices - Treatment and Rehabilitation for Seniors with Substance Use Problems. Ottawa: Minister of Public Works and Government Services. St. Philip, Elizabeth and White, Patrick. May 14, Number of drug-addicted seniors to surge as boomers retire. Toronto: Globe and Mail. theglobeandmail.com/servlet/story/rtgam wxlseniors14/bnstory/specialscienceandhealth/home 4. IMMIGRANTS Given the occurrence of immigrant alcohol and drug misuse, services need to be culturally sensitive. Issues facing immigrants who are trying to utilise alcohol and drug misuse services include language barriers, separation from family and social networks, concurrent disorders, stress and traumatising 18

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