Download Clinical Principles for Alcohol and Drug Misuse

Clinical Principles for
Alcohol and Drug Misuse
Services in Saskatchewan
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
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................................................. 11
Clinical Principle 5:
The needs of special populations are recognized and responded to
appropriately and with sensitivity...................................................................................................................... 12
Clinical Principle 6:
Mental health and alcohol and drug services are integrated for clients
with concurrent alcohol and drug misuse and mental health issues................................................ 13
Clinical Principle 7:
Programs exist for clients and the community that reduce the short
and long term impacts of alcohol and drug misuse................................................................................... 14
Appendix A...................................................................................................................................................................... 15
References....................................................................................................................................................................... 24
1
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.
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.
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
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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
4
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.
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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.
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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.
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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.
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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.
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.
In the treatment context, this indicates that more
emphasis is required in addressing factors that were
Research has revealed that addiction affects the brain
circuits involved in reward, motivation, memory, and
Lambert (1992)
1
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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
8
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
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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,
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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 ICD10 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.
10
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
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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,
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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
14
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.
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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. http://aadac.andornot.com/
Alberta Alcohol and Drug Abuse Commission (2006). Developments: Addiction Treatment with an Aboriginal Focus. http://www.industrymailout.net/
Industry/View.aspx?id=25211&p=1d28
Government of Canada (2006). The Human Face of Mental Health and Mental Illness in Canada 2006. Ottawa: Minister of Public Works and Government
Services. http://www.phac-aspc.gc.ca/publicat/human-humain06/pdf/human_face_e.pdf
Health Canada (2001). Best Practices: Treatment and Rehabilitation for Youth with Substance Use Problems. Ottawa: Minister of Public Works and
Government Services.
http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/youth-jeunes/youth-jeunes_e.pdf
Health Canada (1998). Literature Review: Evaluation Strategies in Aboriginal Substance Abuse Programs: A Discussion. http://www.hc-sc.gc.ca/fnih-spni/
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. http://www.hc-sc.
gc.ca/fnih-spni/substan/ads/nnadap-pnlaada_dir-rep_e.html
National Aboriginal Health Organization (NAHO). http://www.naho.ca
Croweshoe, Chelsea (2005). Sacred Ways of Life: Traditional Knowledge. http://www.naho.ca/firstnations/english/documents/FNCTraditionalKnowledgeToolkit-Eng.pdf
National Native Alcohol and Drug Abuse Program (NNADAP) - General Review 1998 - Final Report. http://www.hc-sc.gc.ca/fnih-spni/alt_formats/fnihbdgspni/pdf/pubs/ads/1998_rpt-nnadap-pnlaada_e.pdf
Thatcher, Richard. 2004. 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
16
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);
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
• 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). 2007. Women and Alcohol. Toronto: Centre
for Addiction and Mental Health. http://www.camh.net/About_Addiction_Mental_Health/Drug_and_Addiction_Information/Women_and_Alcohol/
WomenAlc_ENG.pdf
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 1995. 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. 1996. Immigrant Women and Substance Use: Current Issues, Programs and
Recommendations. Ottawa: Minister of Public Works and Government Services. http://dsp-psd.pwgsc.gc.ca/Collection/H39-356-1996E.pdf
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 1996. Rural Women and Substance Use: Issues and Implications for Programming. Ottawa:
Minister of Public Works and Government Services. http://dsp-psd.pwgsc.gc.ca/Collection/H39-364-1996E.pdf
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 1999. Health Canada Best Practices Substance Abuse Treatment and Rehabilitation.
Ottawa: Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp-mp-abuse-abus/
bp_alcohol and drug_abuse_treatment_e.pdf
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 2001. Health Canada Best Practices Treatment and Rehabilitation for Women with
Substance Use Problems. Ottawa: Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adpapd/bp_women-mp_femmes/women-e.pdf
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 2006. Best Practices - Early Intervention, Outreach and Community Linkages for Women
with Substance Use Problems. Ottawa: Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/
adp-apd/early-intervention-precoce/early-intervention-precoce_e.pdf
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 2002. Summary Report Treatment and Rehabilitation for Women with Substance Use
Problems Workshop on Best Practices June 6 and 7, 2002. Ottawa: Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/
alt_formats/hecs-sesc/pdf/pubs/adp-apd/treatment-traitement/treatment-traitement_e.pdf
Pederson, Ann (ed). 2006. Centres of Excellence for Women’s Health Research Bulletin Volume 5 Number I Spring 2006. Ottawa: Centres of Excellence for
Women’s Health Bureau of Women’s Health and Gender Analysis Health Canada. http://www.cewh-cesf.ca/PDF/RB/bulletin-vol5no1EN.pdf
Saskatchewan Health. Focus Sheet. http://www.health.gov.sk.ca/drug_awareness_pub/alcohol_and_drugs_women_in_recovery_services.pdf
17
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
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. 2003. ABC’s of Alcohol and Seniors. http://www.aadac.com/documents/abcs_alcohol_and_seniors.pdf
Alberta Alcohol and Drug Abuse Commission. 2003. Beyond the ABC’s, Alcohol-Medication Interactions. http://www.aadac.com/documents/beyond_abcs_
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. http://
www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.48302
Health Canada. 2002. Best Practices - Treatment and Rehabilitation for Seniors with Substance Use Problems. Ottawa: Minister of Public Works and
Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/treat_senior-trait_ainee/treat_senior-trait_ainee_e.pdf
St. Philip, Elizabeth and White, Patrick. May 14, 2007. Number of drug-addicted seniors to surge as boomers retire. Toronto: Globe and Mail. http://www.
theglobeandmail.com/servlet/story/RTGAM.20070514.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
18
alcohol and drug misuse services include language
barriers, separation from family and social networks,
concurrent disorders, stress and traumatising
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
experiences prior and post migration, lowering of
socio-economic status post migration, and racial
discrimination (Health Canada 1996).
Prevailing best practice in treating individuals of an
ethno-cultural minority background need to focus
on alcohol and drug misuse interventions that are
individualized, inclusive and community driven,
encompassing community outreach, language
and cultural sensitivity (Health Canada 1996, 2001).
Language barriers and cultural variances may be
addressed through a representative workforce or
by individuals having access to translation services.
Individuals should have access to culturally specific
and culturally appropriate programming and
outreach services thereby providing individuals who
are isolated or lack social networks access to needed
services and programming.
References
Cultural Competence In Substance Abuse Treatment, Policy, Planning, and Program Development: An Annotated Bibliography.
http://www.attc-ne.org/pubs/ccsat.pdf
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 1996. Immigrant Women and Substance Use: Current Issues, Programs and
Recommendations. Ottawa: Minister of Public Works and Government Services. http://dsp-psd.pwgsc.gc.ca/Collection/H39-356-1996E.pdf
Health Canada. 2001. Best Practices: Treatment and Rehabilitation for Youth with Substance Use Problems. Ottawa: Minister of Public Works and Government
Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/youth-jeunes/youth-jeunes_e.pdf
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 2001. Best Practices: Treatment and Rehabilitation for Women with Substance Use Problems.
Ottawa: Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp_women-mp_
femmes/women-e.pdf
5. ACQUIRED BRAIN INJURY
An acquired brain injury (ABI) is defined as damage
to the brain, which occurs after birth, which may
be caused traumatically, by a medical problem or a
disease process. A Toronto study estimated that 25
to 30% of people sustaining an acquired brain injury
are intoxicated at the time of their injury; more than
half of the adults admitted to acquired brain injury
rehabilitation programs have a history of alcohol
and drug misuse; and 20% of people who did not
have a alcohol and drug use problem prior to the
injury become vulnerable to alcohol and drug abuse
after the injury and using alcohol and drugs greatly
increases the chances of a second injury.
An acquired brain injury results in a variety of
symptoms of varying severity including:
• memory loss;
• difficulty concentrating;
• difficulty performing more than one task at a
time;
• difficulty with abstract reasoning;
• difficulty with communication;
•seizures;
• issues with balance and/or mobility;
• vision problems;
•headaches;
• increased anxiety;
• depression and/or mood swings;
• altered personality characteristics;
• impulsive behaviour;
• behavioural changes.
It has been recommended that people with
acquired brain injuries not consume alcohol or
non-medicinal drugs because alcohol and drug use/
abuse impairs or inhibits physical, emotional and
cognitive functioning and rehabilitation increases
the risk of another brain injury or seizure, leads
to medication interactions, and creates conflict
between the individual with an acquired brain injury
and their needed support systems. Although it is
recommended that people with an acquired brain
injury discontinue alcohol and non-medicinal drug
use, it is evident that many people who have an
ABI have misused alcohol and drugs either prior to
or post injury, and some will require alcohol and
drug abuse treatment and rehabilitation. Treatment
strategies for individuals with ABI must be reflective
of the individual’s complex needs, which may
include spiritual, physical, personal and interpersonal
needs. Therefore, strength-based, individualized,
19
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
multidisciplinary, and collaborative approaches to
treatment and support are required.
An educational, non-confrontational intake
interview and motivational interviewing principles
can facilitate an acquired brain injured individual’s
recognition of the need for alcohol and drug misuse
services. Individual needs because of the ABI will
need to be accommodated in the continuum of
services that are provided to the individual. Experts
in brain injury rehabilitation recommend that
practitioners determine an acquired brain injured
individual’s unique learning and communication
styles; accommodate for those specified styles and
offer individuals direct feedback.
Accommodations may include:
• frequent session breaks and/or shortened
sessions;
• providing concrete examples;
• reframing abstract ideas;
• using repetition, especially for important
concepts;
• summarize session at end and check-in for
retention of concepts;
• review previous sessions at the beginning of the
new session;
• conducting individual and group therapy in
rooms free from distractions.
Utilising pictures to convey concepts, role-playing
and memory aides have also been useful tools. For
people with ABIs, treatment providers should begin
thinking of aftercare options early in the treatment
process and include those social and formal supports
to facilitate the transference of treatment from the
therapeutic setting to the non-therapeutic setting.
Aftercare and outreach is key.
References
Brain Injury and Substance Abuse the Cross Training Advantage. http://abinetwork.ca/downloads/bisa_manual.pdf
Community Head Injury Resource Services of Toronto (CHIRS). http://www.chirs.com/CHIRS/Public/BrainInjury.aspx
International Brain Injury Association. http://www.internationalbrain.org/
Moore, Dennis (Ed) (1998). Substance Use Disorder Treatment for People with Physical and Cognitive Disabilities Treatment Improvement Protocol (TIP)
Series 29. Rockville, MD: U.S. Department of Health & Human Services and Substance Abuse and Mental Health Services Administration National
Clearinghouse for Substance Abuse Related Information. http://ncadi.samhsa.gov/govpubs/bkd288/default.aspx
National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2005). Module 101: Disabilities and Alcohol Use Disorders. http://pubs.niaaa.nih.gov/
publications/Social/Module10IDisabilities/Module10I.html
Ohio Valley Center for Brain Injury Prevention and Rehabilitation. http://www.ohiovalley.org/abuse/index.html
Prevention Institute. http://preventioninstitute.sk.ca/
Saskatchewan Brain Injury Association. http://www.sbia.ca/
Saskatchewan Health Provincial Acquired Brain Injury Education and Prevention.
http://www.health.gov.sk.ca/rr_abi_alcohol_and_drugs.html
http://www.health.gov.sk.ca/ps_abi_pub_alcoholdrugs.pdf
Saskatchewan Health and SGI. Acquired Brain Injury Partnership Project Programs and Services. http://www.health.gov.sk.ca/ps_abi_directory.pdf
Substance Use/Brain Injury Project (SUBI). Brain Injury: Now What? and Substance Use/Brain Injury Project Client Workbook. Downloadable with
nonmonetary membership. http://www.subi.ca/
Toronto Acquired Brain Injury Network. http://www.abinetwork.ca/home.htm
6. EATING DISORDERS
Given the high co-correlation between mental
health issues including eating disorders such as
anorexia nervosa, bulimia nervosa, compulsive
eating, binge eating and alcohol and drug misuse
problems, Mental Health and Alcohol and Drug
Misuse Services need to be integrated for clients
20
with concurrent alcohol and drug misuse and mental
health issues (Skinner 2005, Health Canada 2002).
Given the higher than expected prevalence of eating
disorders in men and women with alcohol and drug
misuse problems, it is important for individuals to
be routinely screened for the presence of an eating
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
disorder when presenting with alcohol and drug
misuse issues regardless of the persons sex, physical
appearance and weight. This assessment should
focus on current and past symptoms and may be
completed through informal direct questioning and
standardized diagnostic criteria such as the DSM-IV
to ensure a reliable measurement (Health Canada
2002).
Prevailing best practice in treating concurrent
eating disorders and alcohol and drug misuse issues
focuses on interventions that are individualized,
planned and implemented concurrently. However,
if either disorder is so severe that it compromises
the individuals’ life, or critical aspects of functioning,
treatment should be first targeted to the critical
disorder and once the critical disorder is stabilized
then treatment of the two disorders should be
treated simultaneously in an integrated program or
system (Health Canada 2002). 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 eating and alcohol and drug misuse
behaviours; psychotherapy to address psychological
issues; psychopharmacology for severe
symptomatology; individual and group therapy
(examining body image, media, self-esteem, feelings,
trauma, life skills, positive self talk and motivation);
and after care (Health Canada 2002, Government of
Canada 2006).
References
Fast Facts About Eating Disorders. http://www.health.gov.sk.ca/rr_eating_disorders.html
Government of Canada. 2006. The Human Face of Mental Health and Mental Illness in Canada 2006. Ottawa: Minister of Public Works and Government
Services. http://www.phac-aspc.gc.ca/publicat/human-humain06/pdf/human_face_e.pdf
Health Canada. 2002. Health Canada Best Practices Concurrent Mental Health and Substance Use Disorders. Ottawa: Minister of Public Works and
Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp_disorder-mp_concomitants/bp_concurrent_mental_
health_e.pdf
Saskatchewan Department of Health Joint Committee on Eating Disorders (1995). Services for individuals with eating disorders / compiled by the Joint
Committee with Representation from Saskatchewan Health, District Health Boards and Milden Venture Corporation.
Saskatchewan Health. 2005. Supporting Mental Well-Being and Decreased Substance Use and Abuse. Regina: Saskatchewan Health Population Health
Branch. http://www.health.gov.sk.ca/mc_dp_supp_mental_wellbeing.pdf
Skinner, W.J. Wayne (ed). 2005. Treating Concurrent Disorders: A Guide for Counsellors. Toronto: Centre for Addiction and Mental Health.
The International Association of Eating Disorder Professionals Foundation. http://iaedp.com/
The National Eating Disorder Information Centre (NEDIC). http://www.nedic.ca/index.shtml
U.S. Department of Health and Human Services. 2006. Screening, Assessment, and Treatment Planning for Persons with Co-Occurring Disorders, Overview
Paper 2. Rockville, MD: Substance Abuse and Mental Health Services Administration and Centre for Mental Health Services. http://coce.samhsa.gov/
cod_resources/PDF/ScreeningAssessment(OP2).pdf
7. OFFENDERS/MANDATED CLIENTS
(i.e. Drug Treatment Court, Driving While Impaired, Offender programs in correctional settings)
Health Canada (1999) suggests that treatment as
opposed to incarceration or in conjunction with
incarceration may represent a cost effective and
rehabilitative means to reduce individual and
societal harms associated with alcohol and drug
misuse. As well, drinking and driving literature does
show small but significant positive effects of a mixed
educational and treatment model (Health Canada
1999).
In Saskatchewan, up to 93% of provincial offenders
are identified as having alcohol and drug abuse
problems and alcohol and drug abuse is recognized
as one of the contributing factors in recidivism for
a significant number of individuals in conflict with
the criminal justice system (Head 2001). Moreover,
Health Canada (2001) cites 48% of street youth and
36% of non-street youth were on probation/parole/
bail or awaiting trial and 30% of street youth and
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
16% of non-street youth had been in a correctional
facility in the past six months.
It is important to consider barriers to alcohol and
drug misuse treatment for offenders and to provide
those individuals a range of treatment options
and support services to address those personal,
interpersonal and program barriers to treatment.
Barriers in accessing alcohol and drug misuse
treatment and rehabilitation services may include
the following:
• Inconsistent assessment and treatment
programming available amongst facilities;
• Staffing issues or a lack of supportive
environments for program delivery;
• Restricted accessibility to programming within
the facility;
• Lack of knowledge, collaboration and linkages
of community supports for post-institutional
settings;
• Closed culture of offenders which make group
treatment difficult given the lack of trust with
correctional officials, levels of secrecy and group
loyalty;
• Individuals experiencing concurrent disorders
(isolation, lack of collaboration or cross-training
between mental health and alcohol and drug
misuse services);
• Language barriers, lack of culturally sensitive or
specific programming, lack of a representative
workforce for First Nations, Metis and ethnocultural people;
• Medical issues including cognitive disabilities,
HIV, AIDS, Hepatitis C, etc. (medical issues,
stigma, fear, isolation, feelings of hopelessness);
(Health Canada 1996, 1999, 2001, 2006; Erickson
2005).
Intensive intervention services should be reserved
for individuals who are assessed as “high risk” for
further criminal behaviour. “High risk” cases respond
better to intensive services whereas “low risk” cases
respond better to less intensive services (CCSA 2004,
Health Canada 2004). Effective treatment of alcohol
and drug misuse and criminological mindsets and
behaviours including other intervention modalities
(marital therapy, social skills training, stress/anger
management intervention, etc.) is associated with
reduced re-offending.
References
Head, D. 2001. Alcohol and drugs: A perspective from Corrections in the Province of Saskatchewan. Forum on Corrections Research, 13, 10-12.
Canadian Centre on Substances Abuse. 2004. Substance Abuse in Corrections FAQs. Ottawa: Canadian Centre on Substances Abuse.
8.FAMILIES
When someone in a family (a parent, youth or
extended family member) has an alcohol or other
drug problem, everyone is impacted and affected
and can have a lasting impact on their lives. The
effect on family members varies from person to
person and family to family.
Alcohol and drug misuse often creates an unstable
family environment. Parents may not effectively
discipline their children or provide them with
training in basic life skills. Children may feel insecure
or unloved. They may also begin to take on adult
responsibilities that are not appropriate to their age.
Children in families where alcohol and drug misuse
is present are more likely to display difficulties
22
with peers and others in the home, school and
community.
When a family member misuses alcohol and drugs,
the whole family usually develops ways of coping
with the problems associated with the misuse.
Often, there is less communication; the family avoids
talking about the issue, avoids expressing emotions,
and may keep the alcohol and drug misuse secret
from the community. Some family members may
take on some of the responsibilities abandoned by
the addicted person. While these coping strategies
may help the family to operate more smoothly
and get along better, they may also support the
continuation of the problem. Unfortunately, family
Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
members may also use alcohol, drugs or gambling
themselves as a way of coping with the problems
in their family. Family membersoften experience
loneliness, frustration, fear, anger and shame.
Family members may have different ideas about the
alcohol and drug use and how best to deal with the
alcohol and drug use. Family members may struggle
with their feelings regarding the alcohol and drug
use, which may profoundly impact relationships.
Health Canada (2001) reviews several treatment
approaches and methods to address interpersonal
including peer and family issues. Some of these
treatment approaches and methods include:
• Relational Models-support to build healthy peer
and family relationships
• Individual, couple and family therapy
•
•
•
•
•
•
Life skill education and development
Parenting skill groups and development
Mental Health services for adults and youth
Exploration of identity and co-dependency
Self-help groups
Outreach(CAMH, AADAC and Health Canada
2001)
Involvement of a spouse, family members and
or significant others in the therapeutic process
may improve implementation of the case plan,
communication, problem solving and other skills in
the family with the goal of supporting the client and
family in the treatment process to modify alcohol
and other drug use by the client and minimise
the impact of the alcohol and drug misuse on the
members of the family.
9. LESBIAN, GAY, BISEXUAL, TRANSGENDER
When compared with the general population,
Lesbian, Gay, Bisexual, Transgender (LGBT) people
have higher rates of alcohol and drug abuse, and are
more likely to continue problem drinking into later
life.
Some LGBT individuals find it uncomfortable in
accessing treatment services. Alcohol and Drug
misuse programs are often not equipped to meet
their needs. Staff members may lack information
about LGBT issues, may be lack sensitivity in dealing
with LGBT clients, or may wrongly believe that sexual
identity causes alcohol and drug abuse or can be
changed by therapy.
Counselors need to respect clients’ frame of
reference and recognize the importance of
cooperation and collaboration with clients.
Maintaining professional objectivity, recognizing
the need for flexibility and a willingness to adjust
strategies in accordance with client characteristics
are particularly important in treating LGBT clients
References
SAMHSA. 2001. A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals. Rockville: SAMHSA.
http://www.kap.samhsa.gov/products/manuals/pdfs/lgbt.pdf
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
References
CCSA. 2006. Guiding Principles for Substance Abuse Policy. Ottawa: CCSA.
Health Canada. Straight Facts About Drugs and Drug Abuse. http://www.hc-sc.gc.ca/hl-vs/pubs/adp-apd/straight_
facts-faits_mefaits/what_drug-drogue_e.html#what_drug
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 1999. Health Canada Best Practices Substance
Abuse Treatment and Rehabilitation. Ottawa: Minister of Public Works and Government Services. http://www.hc-sc.
gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp-mp-abuse-abus/bp_substance_abuse_treatment_e.pdf
Health Canada. 2001. Health Canada Best Practices Concurrent Mental Health and Substance Use Disorders. Ottawa:
Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/
adp-apd/bp_disorder-mp_concomitants/bp_concurrent_mental_health_e.pdf
Health Canada. 2002. Best Practices - Treatment and Rehabilitation for Seniors with Substance Use Problems. Ottawa:
Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/
adp-apd/treat_senior-trait_ainee/treat_senior-trait_ainee_e.pdf
Introduction
Saskatchewan Health. March 2001. Meeting the Challenges: A Saskatchewan Model of Recovery Services.
National Treatment Strategy Working Group. (2008). A Systems Approach to Substance
Use in Canada: Recommendations for a National Treatment Strategy. Ottawa: National Framework for Action to
Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada
Clinical Principles
Canada. Fall 2005. National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs
and Substances in Canada. Ottawa: Health Canada and Canadian Centre on Substance Abuse. http://www.
nationalframework-cadrenational.ca/uploads/files/TOOLS%20English/NatFra_1stEdition_chart_eng.pdf
National Treatment Strategy Working Group. (2008). A Systems Approach to Substance Abuse
Use in Canada: Recommendations for a National Treatment Strategy. Ottawa: National Framework for Action to
Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada
Clinical Principle 1
Addiction: “Drugs, Brains, and Behavior - The Science of Addiction” (NIDA , August 2010)
Addiction Science: From Molecules to Managed Care (NIDA)
Butt, Dr Peter, “The Journey to and Through Addiction”, Presentation to the 4th Annual Aboriginal HIV/AIDS & HCV
Conference, Saskatoon, November, 2010
Lambert, M.J. 1992. Implications of Outcome Research for Psychotherapy Integration. In J.C. Norcross and M.R.
Goldstein (eds), Handbook of Psychotherapy Integration (pp. 94-129). New York: Basic Books.
Lambert, M.J. 1992. Implications of Outcome Research for Psychotherapy Integration. Cited In Mark Hubble, Barry
Duncan and Scott Miller. 1999. The Heart and Soul of Change: What Works in Therapy. Washington: American
Psychological Association.
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
Clinical Principle 2
American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision. Arlington, VA: American Psychiatric Association.
World Health Organization. 1992. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions
and Diagnostic Guidelines. Geneva: World Health Organization.
Clinical Principle 3
Health Canada. 2001. Best Practices: Treatment and Rehabilitation for Youth with Substance Use Problems. Ottawa:
Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/
adp-apd/youth-jeunes/youth-jeunes_e.pdf
Health Canada. 2001. Preventing Substance Use Problems Among Young People - A Compendium of Best Practices.
Ottawa: Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/
pdf/pubs/adp-apd/prevent/young-jeune_e.pdf
Health Canada. 2001. Treatment and Rehabilitation for Youth with Substance Use Problems. Ottawa: Minister of
Public Works and Government Services. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/
youth-jeunes/youth-jeunes_e.pdf
Health Canada. November 2001. Workshop on Best Practices in Treatment and Rehabilitation for Youth with
Substance Use Problems. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/treatment_youthtraitement/treatment_youth-traitement_e.pdf
Self, B., and Peters, H. (2005). Street outreach with no streets. Canadian Nurse, 101(1), 21–24.
Health Canada, 2008, Best Practices - Early Intervention, Outreach and Community Linkages for Youth with Substance
Use Problems
Clinical Principle 4
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 1999. Health Canada Best Practices Substance
Abuse Treatment and Rehabilitation. Ottawa: Minister of Public Works and Government Services.http://www.hc-sc.
gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp-mp-abuse-abus/bp_substance_abuse_treatment_e.pdf
Valasquez, Mary, Maurer, Gaylyn, Crouch, Cathy and DiClemente, Carlo. 2001. Group Treatment for Substance Abuse:
A Stages of Change Therapy Manual. New York: The Guilford Press.
National Institute on Drug Abuse (NIDA), Cognitive-Behavioral Therapy (Alcohol, Marijuana, Cocaine,
Methamphetamine, Nicotine), http://www.drugabuse.gov/publications/principles-drug-addiction-treatmentresearch-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral
Clinical Principle 5
Health Canada: Office of Alcohol, Drugs and Dependency Issues. 1999. Health Canada Best Practices Substance Abuse
Treatment and Rehabilitation. Ottawa: Minister of Public Works and Government Services. http://www.hc-sc.gc.ca/
hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp-mp-abuse-abus/bp_substance_abuse_treatment_e.pdf
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Clinical Principles for Alcohol and Drug Misuse Services in Saskatchewan
Clinical Principle 6
Government of Canada. 2006. The Human Face of Mental Health and Mental Illness in Canada 2006. Ottawa: Minister
of Public Works and Government Services. http://www.phac-aspc.gc.ca/publicat/human-humain06/pdf/human_
face_e.pdf
Health Canada. 2001. Best Practices: Concurrent Mental Health and Substance Use Disorders. Ottawa: Minister of Public
Works and Government Services Canada.
Minkoff, K. CCISC Model: Comprehensive, Continuous, Integrated System of Care Model. http://kenminkoff.com/ccisc.html
Mental Health and Integrated Service Delivery Task Group, Saskatchewan
Mental Health & Addiction Services - Integrated Service Delivery Framework, December, 2010
Provincial Working Group, The Adolescent Motivational Assessment Process, December, 2007
Clinical Principle 7
Dell, Colleen. June 2007. Harm Reduction Policies and Programs for Persons of Aboriginal Descent. Ottawa: Canada
Centre for Substance Abuse. http://www.ccsa.ca/NR/rdonlyres/9D021396-587C-4327-8FB7-42DDABCEED2E/0/
ccsa0115152007.pdf
Health Canada. 2002. Methadone Maintenance Treatment. Ottawa: Minister of Public Works and Government Services
Canada. http://www.hc-sc.gc.ca/hl-vs/alt_formats/hecs-sesc/pdf/pubs/adp-apd/methadone-bp-mp/methadonebp-mp_e.pdf
Poulin, Christine. August 2006. Harm Reduction Policies and Programs for Youth. Ottawa: Canada Centre for Substance
Abuse. http://www.ccsa.ca/NR/rdonlyres/D0254373-5F2B-459D-BB79-6EE7C22CC303/0/ccsa113402006.pdf
Saskatchewan Health. 2004. Methadone Assisted Recovery Guidelines: For Saskatchewan Addiction Counsellors. http://
www.health.gov.sk.ca/mc_dp_methadone_guide.pdf
Thomas, Gerald. May 2005. Harm Reduction Policies and Programs for Persons Involved in the Criminal Justice System.
Ottawa: Canada Centre for Substance Abuse. http://www.ccsa.ca/NR/rdonlyres/B092A5D6-C627-4503-8F218A1AB8923B3A/0/ccsa0039002005.pdf
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