Working with

Problematic Substance

Use: Adults

ANZASW Webinar

Anna Nelson

Learning outcomes

• Recognise the discrimination, stigma and

marginalisation of substance users

• Recognise the prevalence of substance use (including

alcohol)

• Recognise the signs and symptoms of problematic use

• Understand screening and brief interventions

• Be able to take a motivational approach to supporting

behaviour change

Historical background: Key points

• The normalisation of substance use

• Health and social concerns

• The medicalisation of substance use

• The criminalisation of drug use

• Alcohol and tobacco regulation

Anti-discriminatory practice

An understanding of the historical and

socio-political context, coupled with a

commitment to self-reflection and notions

of justice, equality and partnership will

support the social work practitioner in

being anti-oppressive and anti-

discriminatory in the work they do.

(Nelson, 2012: 22)

Power of language • Language has more impact than is often acknowledged

and language and power are inextricably linked. As

Thompson (2003) states, “Language not only reflects

reality it constructs reality.” Williams (1998, cited in

Thompson, 2003) further elaborates with “Common

language in use reflects a worldview and in itself can

reproduce relations of dominance and subordination”.

Language is a key medium through which dominating

groups reinforce their superiority and prescribe the

inferior status of minority groups.

Terminology

• Addiction

• Substance

◦ Use

◦ Abuse

◦ Misuse

◦ Problematic substance use

◦ Dependence

◦ Use Disorders

• Pathological Gambling - Gambling Disorder

• Alcohol and Other Drug (AOD)

• Recovery

Continuum of substance use and

gambling No Use or Gambling

Moderate Use or Gambling

Problematic Use or Gambling

Hazardous Use or Gambling

Harmful Use or Gambling

Moderate to Severe Disorder

Using substances or gambling without problems

There are some occasional negative consequences

There is a risk of future physical , social and or mental health damage

There is some apparent physical , social and or mental health damage

Loss of ability to control use or gambling despite significant consequences

Social use or gambling

Risky use or gambling DSM4: Substance Abuse

Problem Gambling

DSM4: Substance Dependence or

Pathological Gambling

DSM5 Substance Use or Gambling Disorder

Spectrum of Addiction

Addiction related harm and intervention continuum

Adapted from Korn and Shaffer, 1999

Thinking about causes of addiction

• The Moral Model-it is a personal failing and lack of willpower • The Disease Model-it is because of a disease • Psychological-it’s because of trauma or anxiety or depression • Genetic-it’s because of family history and vulnerability • Social Learning-it’s because of peer groups and norms • Socio-cultural-it’s because of poverty, colonisation and

disempowerment • Neurobiological-substances and pleasurable behaviours effect

the brain and are more rewarding and the brain adapts to them and start to need them to feel normal

The four L’s

• Liver

• Lover

• Law

• Livelihood

AOD Classification

◦ Depressants-are drugs that slow down the central

nervous system (CNS) and because of this they are

sometimes called downers. They make people feel

sleepy, relaxed and calm

◦ Stimulants-these substances increase activity in the

CNS. They speed users up, makes users feel more

energised and alert and give users a sense of

wellbeing. They may also cause anxiety, restlessness

and insomnia.

◦ Hallucinogens-produce a sensory experience of

something that does not exist outside the mind (a

hallucination).

Kava

Alcohol Inhalants/Solvents

Opiates & Opioids

Amyl / Butyl Nitrite

Benzodiazepines

GHB, GBL, 14B

Ketamine

Caffeine

Nicotine

Cocaine Khat

Amphetamines (Speed)

Methamphetamine ( ‘P’)

Mephedrone (bath salts)

Diet Pills

Ecstasy

Cannabis (Marijuana, Hash )

New Psychoactive substances

LSD Datura Mescaline Magic

Mushrooms

(Psilocybin &

Psilocin)

Common substances

Dependence

• Physical and psychological dependence-false

dichotomy?

• Psychological habituation – a compulsion to

take the substances periodically or continuously

to have a good time or to avoid reality.

• Physical dependence-user’s body has become

dependent, without the substance the person

will experience symptoms of withdrawal.

Tolerance

• Depends on the substance

• Person requires more and more of the

substance to get the same effect

• Usually also physically dependent

For more factual and correct

info see

http://www.drugfoundation.org.nz/drug-

information

http://alcoholdrughelp.org.nz/

Reality check…

The evidence suggests that a majority of people

who use drugs are able to use them without

harming themselves or others. They are able, in

that sense, to manage their drug use…The

harmless use of illegal drug use is possible,

indeed common. (RSA, 2007: 11)

Social construction

• Legal substances in NZ-caffeine, alcohol

and nicotine

• Illegal substances

• ‘There is not much difference between

horse riding and ecstasy’ Professor David

Nutt

Age Drug 16-17 18-24 25-34 35-44 45-54 55-64 Total Cannabis 24.8 31.4 21.3 10.6 7.9 3.3 14.6%

Ecstasy 2.3 6.9 5.3 1.4 0.4 0 2.6%

Stimulants (includes methamphetamine)

3.7 10.1 7.7 2.5 1 0 3.9%

LSD + synthetic hallucinogens

1 4.4 1.9 0.6 0.3 0 1.3%

Opiates 0.1 0.2 0.2 0.2 0.1 0 0.1%

Prescription sedatives

1 1.7 1.5 1 0.6 0.7 1%

Injected drugs 1.2 0.6 0.1 0.2 0.3 0 0.3%

A snapshot of drug use in New Zealand

Illegal drugs – Past year use rate (Ministry of

Health, 2010)

NZ Adults who are hazardous drinkers 2013/14 (score 8 or more on the AUDIT)

Hazardous drinking rates are highest in young people

one in six adults (16%) has a hazardous drinking pattern, down

from 18% in 2006/07.

Hazardous drinking rates peak in the 18–24-year age group.

One-third of 18–24-year olds (33%) are hazardous drinkers; an

improvement on 2006/07 (when the equivalent figure was

43%).

Men are twice as likely to have hazardous drinking patterns as

women (the rates are 22% and 11% respectively).

(Ministry of Health, 2014).

Standard drinks (adults) The standard drinks measure is a simple way to work out how

much alcohol you are drinking. It measures the amount of pure

alcohol in a drink. One standard drink equals 10 grams of pure

alcohol.

• Amount of drink in litres (Vol) x Percent by volume of

alcohol (%) x Density of ethanol at room temperature

(0.789)

• Example:

• 500ml of beer which is 5 percent alcohol by volume.

• 0.5 x 5 x 0.789 = 1.97 (approx 2 standard drinks)

• Making people aware of this is a ‘brief intervention’.

www.hpa.org.nz

Standard drinks

Low risk drinking (adults)

How much?

• Reduce your long-term health risks by drinking no more than:

• 2 standard drinks a day for women and no more than 10 standard drinks a week

• 3 standard drinks a day for men and no more than 15 standard drinks a week

• AND at least two alcohol-free days every week.

• Reduce your risk of injury on a single occasion of drinking by drinking no more than:

• 4 standard drinks for women on any single occasion

• 5 standard drinks for men on any single occasion

Low risk drinking (adults)

Advice for pregnant women or those planning to get pregnant

• no alcohol

• There is no known safe level of alcohol use at any stage of pregnancy.

Advice for parents of children and young people under 18 years

• For children and young people under 18 years, not drinking alcohol is the

safest option.

• Those under 15 years of age are at the greatest risk of harm from

drinking alcohol and not drinking in this age group is especially

important.

• For young people aged 15 to 17 years, the safest option is to delay

drinking for as long as possible.

• If 15 to 17 year olds do drink alcohol, they should be supervised, drink

infrequently and at levels usually below and never exceeding

the adult daily limits

Disclaimer

Even if the person’s alcohol use is within these

recommended guidelines, they may still be at risk.

This is because the guidelines may be too high for:

• thin people

• young people

• older people

• people with a history of alcohol dependence

• people who drink regularly to relieve stress or get to

sleep

Disclaimer

• people who are or have been dependent on other drugs

• people who have a poor diet or are malnourished

• people driving or operating machinery

• people using certain medications (e.g. aspirin, sleeping

pills, tranquillisers, antidepressants)

• people with acute or chronic physical or mental health

problems

• people with medical conditions that may be

exacerbated by alcohol

• people recovering from an accident, injury or operation

Addiction related harm and intervention continuum

Adapted from Korn and Shaffer, 1999

Brief Intervention

‘Brief interventions are time limited, self

help and preventative strategies to

promote reductions in substance use in

non-dependent clients and, in the case of

dependent clients, to facilitate their

referral to specialised treatment

programmes’

(Zweben and Fleming, 1999: 253)

Brief Interventions

• Can be 5 mins (giving a pamphlet)

• Or several sessions

• How long do you have?

Ask…its how we ask

• Frank, I’d like to check you’re not drinking too much and driving.

Remind me how many beers you had before you drove me home

last week?

• Gina, we usually ask everyone we see about substance use. But

you’re the sort of person who takes drugs, isn’t that right?

• Joe, I saw you out in town last month. You looked pretty drunk.

What’s going on?

• Ali, it’s standard procedure here to ask the people we see about

their alcohol and other drug use use. Can I ask you a couple of

questions?

AUDIT C/ AUDIT/DAST etc

• There are lots of screening tools-maybe

you use one in your service?

• For more information see

http://www.matuaraki.org.nz/library/ma

tuaraki/screening-assessment-and-

evaluation-aod-smoking-and-gambling

AUDIT

AUDIT C

What we want to know is…

• What people are using?

• How much they are using?

• How often they use?

• How do they use (smoke, swallow, inject)?

• What the effects for them (positive and

negative)?

• What happens if they stop using?

What to do-the FRAMES approach

FRAMES describes a model of BI • Feedback about possible risks • Responsibility for change is theirs • Advice to change is given • Menu of options is suggested • Empathic style is used in conversation • Self efficacy is encouraged

Feedback

After asking the questions, or using a screening tool, results are fed back in an objective way making links to the person’s life. e.g. This has shown that you are drinking above the recommended guidelines. Did you know that drinking at this level significantly increases your risk of alcohol related harms?

Responsibility

The next step is to emphasise that the

responsibility for change lies with

them. e.g. What do you think about this? Do you have

any concerns? Listen carefully to their response as it indicates their readiness to

change:

◦ Precontemplation

◦ Contemplation

◦ Determination (or decision)

Wheel of change (adapted from

Prochaska and Di Clemente, 1982)

• Readiness to change is shown

graphically in this Wheel of Change:

• Are they pre-contemplative? This is

where their response shows they

don’t believe they have a AOD

problem.

• Or are they contemplative? Their

response shows they think that they

may have a AOD problem.

• Or does their response indicate that

they have made a decision that they

have a problem and want to do

something about it?

Stages of change

Pre-contemplative Contemplative Determined –made a decision

Advice

Pre-contemplative Contemplative Determined –made a decision

Advice to change is given

Menu

Pre-contemplative Contemplative Determined –made a decision

Menu of options is provided

Menu of options provided depends

on stage of change and level of use

Serious concerns: offer 30 minute follow-up (if available)

or specialist or Helpline referral

Less serious concerns: offer advice on how to cut down or

reduce harm if necessary

e.g.

1. Record how much you drink

2. Plan for nights out

3. Ensure you have at least 2 rest days per week

Support options

• Withdrawal management-medical, social, home

• 12 step groups in community e.g. AA, NA, Al-Anon

• Community outpatients e.g. CADS

• Day Programmes e.g. CADS

• Residential e.g. Salvation Army Bridge Programme,

• Therapeutic Communities e.g Higher Ground, Odyssey House

• Alcohol Drug Helpline 0800 787 797

• Local options?

Resources

• HPA http://www.hpa.org.nz/research-

resources/latest-resources including Ruby’s Dad

and Standard drink info

• MethHelp www.methhelp.org.nz

• DrugHelp www.drughelp.org.nz

• PotHelp www.pothelp.org.nz

Empathy and supporting Self

efficacy • Empathetic style and Self-efficacy (affirmation of

person’s ability to change)

• the practitioner is empathetic and non-judgmental, and

listens to the person in a reflective way, to try and

understand their feelings

• the practitioner believes the person can change, and

builds them up and affirms them

Record it

After you give brief advice, you need to

record:

• the information gathered

• the advice given

• the menu of options offered

• the action that is to be taken

Motivational Interviewing (MI)

MI is a collaborative conversation style for

strengthening a person’s own motivation

and commitment to change (Miller and Rollnick, 2013: 12)

Conversations about change

• The most common place to get stuck on the

road to change is ambivalence

• Arguments both for and against already reside

within the ambivalent person

• Change talk and sustain talk

• If you are arguing for change and your client is

arguing against it, you’ve got it exactly

backwards (Miller and Rollnick, 2013: 9)

The motivational approach

• Elicits the problem from the person in their

own words

• Allows the person to speak openly and freely

• Facilitates personal exploration of problems

• Arranges things so that the person is convincing

you that there are problems to be addressed!

MI as art and science

The Spirit of MI

1. Partnership-MI is done for and with the person

2. Acceptance Absolute worth

Accurate empathy

Autonomy support

Affirmation

Spirit of MI

3. Compassion-deliberate commitment to

pursuing the best interests of others

4. Evocation-you have what we need and

together we will find it!

Process of MI-The science

• Engaging

• Focusing-on a change goal

• Evoking-their own motivation

• Planning-action

Core Skills

OARS plus offering advise with permission

Open ended questions

Affirming

Reflective Listening

Summarising

Change talk

• When you hear change talk become

interested and curious about it

• When you hear change talk reflect it

• It is normal to hear change talk

embedded in sentences with sustain talk

• A summary using a motivational approach

is a ‘bouquet’ of change talk (Miller and Rollnick, 2013)

Responding to sustain talk and

discord

• Deconstructing ‘resistance’

• Sustain talk is about the target behaviour or

change

• Discord is about your relationship with the

client

• It is natural for ambivalent people to voice

sustain talk and experience discord

• Calling it resistance is pathologising normal

behaviour

More info…

• http://www.motivationalinterview.net

• Miller, W. and Rollnick, S. (2013)

Motivational Interviewing: Helping

People Change (Third Edition) New York:

The Guilford Press

• Order the NZ DVD from

http://www.hma.co.nz/online-

bookshop/catalogue.asp

Shameless self-promotion

Social work with substance users

available on Amazon

Keep in touch or any questions

anna.nelson@matuaraki.org.nz

0274336530

References

Korn, D. and Shaffer H. (1999) Gambling and the Health of the Public:

Adopting a Public Health Perspective. Journal of Gambling Studies

15(4):289-365.

Miller, W. and Rollnick, S. (2013) Motivational Interviewing: Helping

People Change (Third Edition) New York: The Guilford Press

Ministry of Health (2010) Drug Use in New Zealand: 2007/08 New

Zealand Alcohol and Drug Use Survey. Wellington: Ministry of Health

Ministry of Health (2014) Annual Update of Key Results 2013/14: New

Zealand Health Survey. Wellington: Ministry of Health.

References

Nelson, A. (2012) Social work with substance users. London: Sage

Publications

Prochaska, J. and DiClemente, C. (1982) Transtheoretical therapy:

Towards a more integrative model of change. Psychotherapy: Theory,

research and practice. 19:276-288

Royal Society of Arts (RSA) (2007) The report of the RSA Commission

on Illegal Drugs, Communities and Public Policy. London: RSA

Thompson, N. (2003) Language and Communication: A Handbook of

Theory and Practice. Basingstoke: Palgrave MacMillian

References

Zweben, A. and Fleming, M. (1999) Brief interventions for alcohol and

drug problems in J. Tucker, D. Donovan and G. Marlett (eds) Changing

Addictive Behavior: Bridging Clinical and Public Health Strategies.

New York: Guilford Press.