Treatment Resources

PRE-1940
• Moralism
1940-1960
• Influence of AA
1970s
• Proliferation
1980s
HISTORY • Diversification
1990s
• Consolidation
21st Century
• Harm Reduction
• Concurrent Disorders
• Housing First
• Responding to the Oppression of Addiction
Barriers to Access

 Waitlists
 Stringent admission requirements
 Stigma
 Existence of private treatment
 Cost for private treatment
 Anxiety of attending treatment program
► As few as one in three able to access treatment in Canada
Treatment Resources

 Canadian federal government responsible for dealing with addiction on two fronts:
1. Direct responsibility for specific groups: military personnel, veterans, federal
penitentiary inmates, the RCMP, and First Nations, Métis, Inuit, and Innu
2. Providing national strategy for dealing with addiction, including transferring funds to
provincial governments for data collection, research, and treatment
Entry into the
Addiction Continuum
of Care
Four Pillar
Model
Entry Points into Continuum of Care

 Withdrawal management (detoxification services)

 Assessment
 Ongoing case management often required but not always available
Continuum of Care
Withdrawal Management: Detox & Daytox

► Often a first step in the treatment process

► Often requires detox from ALL substances, including tobacco and prescribed medications,
can cause severe problems for those with mental health issues or concurrent conditions
► Effects of withdrawal can be mild to severe and even life-threatening
► Centres are predominantly non-medical
► Residential settings
► Daytox or outpatient settings
Rapid/Ultra-Rapid Detox

 One-night residential stay

 withdrawal precipitated by opioid antagonists, either naltrexone or naloxone
 Discomfort avoided by sedating for rapid detox or anaesthetizing in ultra-rapid
detox
 Effective in the short-term but users often return to use patterns, particularly if no
counselling component provided post-treatment
Assessment

 Services use specific instruments and processes to determine the major issues, as well as the
strengths and supports of the person with a substance issue
 Typically includes history of use, age of onset, duration, patterns, consequences of use, family
use, physical health, environment supports, accommodation, employment, legal problems,
sexual orientation
 Develop individualized plans for assistance
Assessment Centres should Provide

 in-depth knowledge of effects of alcohol and/or other psychoactive drugs on physical

and mental health, employment, financial, and legal difficulties; marital and family
relationships; and social, religious, and cultural identity
 in-depth knowledge of treatment resources available to deal with service users’
problems, including resources specific to treating alcohol and other drug issues
 knowledge of assessment tools specific to identifying drinking and/or drug-using
activities
 access to psychological testing to determine the extent of damage from alcohol and/or
drugs and thus the ability of service users to respond to treatment and interact in a
treatment community
Assessment Centres should Provide

 ability to assess strengths and resources that would be a base for service users to begin to
resolve their situation
 ability to identify environmental factors that might adversely effect treatment
 ability to prioritize service users’ treatment needs
 ability to work co-operatively with service users and other stakeholders in the treatment
system to design an appropriate treatment plan
 attitudes and specialized knowledge regarding needs of particular groups, such as youth,
women, elderly, Indigenous peoples, and minority and newcomer groups
 specialized knowledge of resources directed specifically to the above groups
Case Management

 Service user-focused strategy to improve coordination and continuity of care

 Service user designated worker who performs ongoing assessment, treatment plan adjustment,
coordination of required services, monitoring and support, development of discharge plan
 Counsellor facilitates and advocates for service user ensuring assessment is accurate and up to
date, linked with appropriate addiction treatment resources and adjunct services to meet
underlying and instruments needs
 Expedites the use of resources available in the community, consistent with an overall
treatment plan through a single consistent point of contact
 Without case management the potential for inefficient utilization of limited resources
increases which has been the case historically throughout Canada
Tasks of a Case Manager

 providing continuity of care for the alcohol/drug-dependent person

 facilitating contact with appropriate treatment resources
 assisting the service user in entering the appropriate treatment centre
 monitoring service users’ changing needs and problems
 periodic assessment of service users’ progress in terms of the agreed-upon treatment plan
 providing crisis intervention and ongoing support to service users and their families in
solving immediate problems
Tasks of a Case Manager

 encouraging service users who leave treatment prematurely to return for

further appropriate assistance
 facilitating, within the bounds of confidentiality, information sharing with all
concerned parties, including other agencies, family, the Employee Assistance
Program, and/or family physician
 providing aftercare or follow-up care after discharge from treatment to ensure
that service users receive continuing encouragement and, where necessary,
additional services
 assessing the risk of reoccurrence
Addiction-
Specific
Resources
  Community-based (outpatient) treatment
 Day treatment
Continuum of  Harm reduction
 Concurrent disorder programs
Care  Short-term residential treatment
 Recovery homes
 Alternative living environment and therapeutic
communities
 Addiction supportive housing (ASH): housing
first
 Managed alcohol programs: non-abstinence
residential programs—the “wet shelter”
 Drug treatment courts
Community Based (Outpatient
Counselling)

 Least intrusive; client still has some degree of support system in place
 Take knowledge from counselling and apply directly into issues of daily living
 Individual and group counselling options
 Less disruptive of life (childcare, work, education, etc.)
 Therefore fewer barriers and better access
 Good for individuals who are free from significant medical problems; are self-
motivated; have support systems in place (family, friends, work); live within easy
access to facility; have not had personal or work life extensively affected by use
Day Treatment

 More intensive, structured non-residential treatment

 Typically four or five days/evenings per week, 3-4 hours per session
 Involves group activities ranging from formal sessions to education to
recreational activities
 Home environment just be stable and have support
 Appropriate for those who are able to maintain social competence
 Aim to develop sense of community support and responsibility
Harm Reduction

1. Drug Substitution: Maintenance Programs

2. Drug Substitution: Treatment Programs
3. Heroin-Assisted Treatment
4. Needle Exchange Programs
5. Supervised Injection Sites
6. Supervised Consumption Sites
Concurrent Disorder Programs

 Specialized form of community-based counselling

 For service users with both addiction and mental health issues
 Services offered by psychologists, psychiatrists, social workers, and nurses
 Provide counselling to address depression, psychosis, loneliness, suicidal ideation
and attempts, paranoia, and violent behaviours
 Short-Term Residential Treatment

 Early programs - The Minnesota Model:

 Alcoholism is an involuntary, primary, chronic, progressive biopsychosocial, spiritual disease.
 Recovery is contingent upon abstinence from all non-medical drugs.
 Recovery is best achieved through the Twelve Steps of AA and immersion in a community of
shared experience, strength, and hope.
 Focus of the residential rehabilitation process should be on the direct treatment of the disease.
 Addiction needs to be treated in an environment of dignity and respect.
 Motivation, or lack of motivation, at point of intake is not a predictor of outcome success, and
motivation is as much the responsibility of the treatment setting as the individual
Residential Programming

 1. Hospital-based medically run but  2. Social programs following 12-step

primarily staffed by counselling traditions staffed by those in recovery
professionals
Short-Term Residential Treatment

 Current average program length: 21-28 days

 Medically oriented or community based following Minnesota Model
 Almost all programs provide aftercare support: reoccurrence prevention, alumni
groups, family information nights
 Much more expensive than day treatments
 Services include: medical evaluation, assessment, detox, vocational guidance,
employer involvement
Recovery Homes (Social Model Recovery/Sober
Living Houses)

 Gender specific homes to provide safe,

supportive therapeutic program of addiction
education
 Life & Social skills focused
 Strong AA emphasis – Oxford House
Approach
 Stays range from 3-6 months
 Bridge between initial intensive treatment
and returning to community
Recovery Homes (Social Model Recovery/Sober
Living Houses)

 Offer group and individual counselling focusing on physical, emotional, educational,

and employment objectives
 Sessions can include: education on process of dependency; exercise, nutrition
counselling, and information pertaining to health issues; problem solving and
decision-making skills; information on retraining and job search skills; appropriate use
of leisure time; goal setting; communication and assertiveness; stress management;
avoiding reoccurrence
 Cost often income-geared and subsidies often available
Alternative Living Environment and
Therapeutic Communities

 Provide protective living environment for people whose substance use is major life disruptor
 Community-led living and learning environments to promote social, psychological, and
behavioural change
 Individuals live together and are encouraged to confront and un-learn addiction-related and
anti-social patterns and behaviours
 Uses community as an agent of change
Addiction Supportive Housing: Housing First
Addiction Supportive Housing: Housing First

► recognizes the importance of safe and sustainable housing in the recovery process
► Programs provide longer stays than short-term programs or recovery homes
► Goal to develop long-term skills to maintain own residence
► Substance misuse primary predictor of homelessness
► Increases probability that the marginally housed or homeless will follow through
with addiction treatments
► Component of harm reduction approach
Addiction Supportive Housing: Housing First

► In Ontario, two options available to service users who have completed addiction
treatment program but are at risk of homelessness
1. Transitional house: gender-specific communal living; required to attend house
meetings, a community support program, participate in chores and upkeep
2. Independent living: must attend weekly one-on-one counselling session, other
requirements more individualized
► Both options see improvements in health and functioning, reductions in substance
use, emergencies, hospital admissions, encounters with criminal justice system
Managed Alcohol Programs: Non-
Abstinence Residential Programs

 Created as a response to alcoholics avoiding shelters at risk of having their alcohol

confiscated/held leaving many to the streets during harsh Canadian winters
 Primary purpose to offer continuing health and housing services for individuals
with history of homelessness and alcohol use along with chronic health issues, and
who are often deemed to be near the end of their lives and remain unwilling or
unable to participate in an abstinence-based residential program
 Integrates social support with individualized humane treatment
Managed Alcohol Programs: Non-
Abstinence Residential Programs

 Nursing, medical, and rehabilitation care provided

 Users provided with regular but limited amount of alcohol
 Care plans individualized and include recreational components and access to
primary health care
 Overall goal to improve quality of life and allowing residence in respectful,
supportive environment
 Leads to fewer emergency and hospital admissions, detox episodes, police contact
Risks and Benefits of Managed Alcohol Programs

Single Heavy Drinking Non-Beverage Alcohol Drinking in Unsafe Chronic High-Volume Alcohol
Risk Episode Consumption Settings Consumption
violence, injury,
violence, injury, poisoning, exacerbate chronic freezing, conflict with cirrhosis, cancer, housing and
Potential Harms seizures, legal issues diseases, poisoning the law social problems

shelter from cold,

smooth drinking pattern, fewer protected supply of housing security, reduced
injuries and seizures, secure reduced consumption of alcohol, personal consumption, improved
MAP Benefits housing, improved relationships non-beverage alcohol safety, food nutrition

increased ethanol
higher blood alcohol consumption if drinking
concentration if drinking continues outside of less exercise and fewer days of abstinence
MAP Risks continues outside of program program weight gain contribute to liver disease risk
Drug Treatment Courts

► Aim to reduce substance use and provide rehabilitation to

persons who resort to criminal activity to support addictions
► Inaugural Canadian drug treatment court opened in 1998
► Premised on theory that substance use and criminal behaviour
perpetual vicious cycle
► Treatment and rehabilitation outside of traditional prison
system required
Drug Treatment Courts

► Principles and objectives of drug treatment courts:

 increase public safety
 help participants reduce or eliminate their drug use
 help participants reduce or eliminate criminal behavior
 reunite participants with families
 help participants become active members of society
 have participants experience an overall improvement in personal well-being
Drug Treatment Courts Guidelines

 Integrating addiction treatment services with justice system case processing

 Using a non-adversarial approach to allow prosecution and defence counsels to promote
public safety while protecting participants’ Charter rights
 Identifying eligible participants early in their contact with the criminal justice system so
that they can be placed in the drug treatment court program as promptly as possible
 Providing access to a continuum of drug, alcohol, and other related treatment and
rehabilitative services
 Monitoring compliance by frequent drug testing
Drug Treatment Courts Guidelines

 Developing a coordinated strategy governing drug treatment court responses

to participants’ compliance and non-compliance
 Applying both sanctions and rewards, swiftly, certainly, and consistently, for
both non-compliance and/or compliance
 Ongoing judicial interaction with each drug treatment court participant
 Monitoring and evaluating the achievement of program goals and gauging
their overall effectiveness
Drug Treatment Courts Guidelines

 Continuing interdisciplinary education promoting effective drug treatment court

planning implementation, and operations
 Forging partnerships among courts, treatment and rehabilitation programs, public
agencies, and community-based organizations to generate local support and enhances
program effectiveness
 Ongoing case management providing the social support necessary to achieve social
reintegration
 Being appropriately flexible in adjusting program content, including incentives and
sanctions, to better achieve program results with particular groups, such as women,
indigenous people, and racialized minorities.
Drug Treatment Courts

 Participation has modest though statistically significant impact on decreasing

recidivism
 Regular court proceedings = 50% recidivism
 Drug court proceedings = 37.5% recidivism
 Provide intensive treatment services, case management, judicial supervision
 Participants released with strict bail conditions, rules for curfew, living arrangements,
and limitations on who they can interact with
 Requires provision of random drug tests
Family Drug Treatment Courts

 Also recognize role of trauma in addiction and child welfare contexts

 Aim to improve outcomes for children by assisting parents whose substance use puts
children at risk
 Although goal is improved family relations and family reunification, court does not
always reunite families, depending on parent progress
 More than half of children still placed into permanent non-parental care
Inpatient vs. Community-Based
Outpatient Care

 In-hospital alcoholism programs of a few weeks to a few months duration

show no greater success in producing abstinence than do periods of brief
hospitalization of a few days
 The great majority of alcohol-dependent persons seeking treatment for
alcohol withdrawal can be safely detoxified without pharmacotherapy and in
non-hospital-based units
 Detoxification with pharmacotherapy on an ambulatory basis has been
demonstrated to be a safe alternative at one-tenth the cost
 Inpatient vs. Community-Based
Outpatient Care

 Partial hospitalization (day treatment) programs have been found to have equal
or superior results to in-patient hospitalization in producing abstinence among
individuals at one-half to one-third the cost
 Controlled trials have demonstrated that community-based outpatient programs
can produce comparable results to in-patient programs. One estimate placed the
cost saving at $3,700 CAD per person (1984 dollars) compared with the typical
course of medical in-patient treatment
Adjunct
Resources
Adjunct Resources

 Budgeting and Financial Counselling

 Employment Assistance/Vocational Training
 Legal Assistance
 Marital and Family Counselling
 Medical Services
 Mutual Aid/Self-Help Groups
 Recreational/Leisure Programs
 Social Assistance
Reoccurrence (Relapse) Prevention

 Goal to provide continuing encouragement, support, and additional services as

needed
 Relapse treated not as a failure but as a learning opportunity
 Goals of treatment: functional analysis, determining triggers, consequences of use,
and skill building
 Relapse is not a one time event but rather a complex, circular process
 

Marlatt & Witkiewtiz Cognitive-Behavioural Model of Relapse