Leader’s GuideDrug Addiction and BasicCounselling SkillsTreatnet Training Volume B, Module 1: Updated 13 February 20081
Volume B: Elements of Psychosocial TreatmentModule 1:Drug Addiction and BasicCounselling SkillsModule 2:Motivating Clients for Treatment andAddressing ResistanceModule 3:Cognitive Behavioural andRelapse PreventionStrategiesWorkshop 1Workshop 1Workshop 1Workshop 2Workshop 2Workshop 2Workshop 3Workshop 3Workshop 3Workshop 4
Module 1: Training goalsIncrease knowledge of the biology ofdrug addiction, principles of treatment,and basic counselling strategies2. Increase skills in basic counsellingstrategies for drug addiction treatment3. Increase application of basiccounselling skills for drug addictiontreatment activities1.3
Module 1: WorkshopsWorkshop 1: Biology of Drug AddictionWorkshop 2: Principles of Drug AddictionTreatmentWorkshop 3: Basic Counselling Skills forDrug Addiction TreatmentWorkshop 4: Special Considerations whenInvolving Families in DrugAddiction Treatment4
Icebreaker: If I were the President15 Min.If you were the President (King, PrimeMinister, etc.) of your country, what 3things would you change related todrug policies, treatment, and / orprevention?5
Workshop 1: Biology of Drug Addiction6
Pre-assessment10 Min.Please respond to the pre-assessmentquestions in your workbook.(Your responses are strictly confidential.)7
Training objectivesAt the end of this workshop you will be able to:l Understand the reasons people start drugusel Identify 3 main defining properties of drugaddictionl Identify 3 important concepts in drugaddictionl Understand characteristics and effects ofmajor classes of psychoactive substancesl Understand why many people dependent ondrugs frequently require treatment8
Introduction toPsychoactive Drugs9
What are psychoactive drugs? (1)“ Any chemical substance which, when takeninto the body, alters its function physicallyand/or psychologically.”(World Health Organization, 1989)“ any substance people consider to be a drug,with the understanding that this will changefrom culture to culture and from time to time.”(Krivanek, 1982)10
What are psychoactive drugs? (2)¾ Psychoactive drugs interact with thecentral nervous system (CNS) affecting:¾ mental processes and behaviour¾ perceptions of reality¾ level of alertness, response time, andperception of the world11
Why do people initiate drug use? (1)Much, if not most, drug use ismotivated (at least initially) by thepursuit of pleasure.12
Why do people initiate drug use? (2)Key Motivators & Conditioning FactorsForget (stress / pain amelioration)¾ Functional (purposeful)¾ Fun (pleasure)¾ Psychiatric disorders¾ Social / educational disadvantagesAlso, initiation starts through:¾ Experimental use¾ Peer pressure¾13
Why do people initiate drug use? (3)After repeated drug use, “deciding” to usedrugs is no longer voluntary becauseDRUGS CHANGE THE BRAIN!14
What isDrug Addiction?15
What is drug addiction?Drug addiction is a complex illnesscharacterised by compulsive, and attimes, uncontrollable drug craving,seeking, and use that persist even in theface of extremely negativeconsequences.16
Characteristics of drug addiction¾¾¾Compulsive behaviourBehaviour is reinforcing (rewarding orpleasurable)Loss of control in limiting intake17
Important terminology1.Psychological craving2.Tolerance3.Withdrawal symptoms18
Psychological cravingPsychological craving is a strong desire orurge to use drugs. Cravings are mostapparent during drug withdrawal.19
ToleranceTolerance is a state in which a personno longer responds to a drug as theydid before, and a higher dose isrequired to achieve the same effect.20
Withdrawal¾¾¾¾¾¾¾¾The following symptoms may occur when druguse is reduced or discontinued:Tremors, chillsCrampsEmotional problemsCognitive and attention deficitsHallucinationsConvulsionsDeath21
DrugCategories22
Classifying psychoactive cinogensLSD, DMTBenzodiazepines icotineKetamineBarbituratesKhatCannabis (lowdoses)CaffeineCannabis (highdoses)Magic mushroomsMDMAMDMA23
Alcohol24
Alcohol: Basic facts (1)Description: Alcohol or ethylalcohol(ethanol) is present in varying amounts inbeer, wine, and liquorsRoute of administration: OralAcute Effects: Sedation, euphoria, lowerheart rate and respiration, slowed reactiontime, impaired coordination, coma, death25
Alcohol: Basic facts (2)Withdrawal Symptoms:¾ Tremors, chills¾ Cramps¾ Hallucinations¾ Convulsions¾ Delirium tremens¾ Death26
Long-term effects of alcohol use¾Decrease in blood cells leading toanemia, slow-healing wounds and otherdiseases¾ Braindamage, loss of memory,blackouts, poor vision, slurred speech,and decreased motor control¾ Increased risk of high blood pressure,hardening of arteries, and heart disease¾ Liver cirrhosis, jaundice, and diabetes¾ Immune system dysfunction¾ Stomach ulcers, hemorrhaging, andgastritis¾ Thiamine (and other) deficiencies¾ Testicular and ovarian atrophy¾ Harm to a fetus during pregnancy27
Tobacco28
Tobacco: Basic facts (1)Description: Tobacco products contain nicotineplus more than 4,000 chemicals and a dozengases (mainly carbon monoxide)Route of administration:Smoking, chewingAcute Effects: Pleasure; relaxation; increasedconcentration; release of glucose; increasedblood pressure, respiration, and heart rate29
Tobacco: Basic facts (2)Withdrawal Symptoms:¾ Cognitive / attention deficits¾ Sleep disturbance¾ Increased appetite¾ Hostility¾ Irritability¾ Low energy¾ Headaches30
Long-term effects of tobacco use¾ Aneurysm¾ Cataracts¾ Cancer (lung and other types)¾ Chronic bronchitis¾ Emphysema¾ Asthma symptoms¾ Obstructive pulmonary diseases¾ Heart disease (stroke, heart attack)¾ Vascular disease¾ Harm to a fetus during pregnancy,weight at birth¾ Deathlow31
CannabinoidsMarijuanaHashish32
Cannabis: Basic facts (1)Description: The active ingredient in cannabis isdelta-9-tetrahydrocannabinol (THC)¾Marijuana: tops and leaves of the plantCannabis sativa¾Hashish: more concentrated resinous form ofthe plantRoute of administration:¾Smoked as a cigarette or in a pipe¾Oral, brewed as a tea or mixed with food33
Activity 1Think of all the names for marijuana in yourcommunity and how this drug is consumed.Share your thoughts with the rest of the group.34
Cannabis: Basic facts (2)Acute Effects:¾Relaxation¾¾Increased appetite¾¾Dry mouth¾Altered time sense¾Mood changes¾Bloodshot eyes¾Impaired memoryReduced nauseaIncreased bloodpressure¾ Reduced cognitivecapacity¾ Paranoid ideation35
Cannabis: Basic facts (3)Withdrawal Symptoms:¾ Insomnia¾ Restlessness¾ Lossof appetite¾ Irritability¾ Sweating¾ Tremors¾ Nausea¾ Diarrhea36
Long-term effects of cannabis use¾Increase in activation of stressresponse system¾ Amotivational syndrome¾ Changes in neurotransmitter levels¾ Psychosis in vulnerable individuals¾ Increased risk for cancer, especiallylung, head, and neck¾ Respiratory illnesses (cough,phlegm) and lung infections¾ Immune system dysfunction¾ Harm to a fetus during pregnancy37
StimulantsMETHAMPHETAMINECRACKCOCAINE38
Types of stimulants (1)Amphetamine Type Stimulants(ATS)¾ Methamphetamine¾Speed, crystal, ice,yaba, shabu¾ Amphetamine¾ Pharmaceuticalproducts used forADD and ADHDMethamphetamine half-life: 8-10 hours39
Types of stimulants (2)Cocaine¾Powder cocaine(Hydrochloride salt)¾Smokeable cocaine(crack, rock, freebase)Cocaine half-life: 1-2 hours40
Activity 2What stimulants are used in your community andhow are they consumed?Share your thoughts with the rest of the group.41
Stimulants: Basic facts (1)Description:Stimulants include: (1) a group of synthetic drugs(ATS) and (2) plant-derived compounds (cocaine)that increase alertness and arousal by stimulatingthe central nervous systemRoute of administration:Smoked, injected, snorted, or administered by mouthor rectum42
Stimulants: Basic facts (2)Acute effects: Euphoria, rush, or flashWakefulness, insomniaIncreased physical activityDecreased appetiteIncreased respirationHyperthermiaIrritabilityTremors, convulsionsAnxietyParanoiaAggressiveness43
Stimulants: Basic facts (3)Withdrawal symptoms: Dysphoric mood (sadness, anhedonia)FatigueInsomnia or hypersomniaPsychomotor agitation or retardationCravingIncreased appetiteVivid, unpleasant dreams44
Long-term effects of stimulants¾¾¾¾¾¾¾¾¾¾¾¾¾Strokes, seizures, headachesDepression, anxiety, irritability, angerMemory loss, confusion, attention problemsInsomnia, hypersomnia, fatigueParanoia, hallucinations, panic reactionsSuicidal ideationNosebleeds, chronic runny nose, hoarseness,sinus infectionDry mouth, burned lips, worn teethChest pain, cough, respiratory failureDisturbances in heart rhythm and heart attackLoss of libidoWeight loss, anorexia, malnourishment,Skin problems45
Methamphetamine use leads to severe tooth decay“Meth Mouth”(New York Times, June 11, 2005)49
Opioids50
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Opioids: Basic facts (1)Description:Opium-derived or synthetic compounds thatrelieve pain, produce morphine-like addiction,or relieve symptoms during withdrawal frommorphine addiction.Route of administration:Intravenous, smoked, intranasal, oral, andintrarectal52
Opioids: Basic facts (2)Acute effects: EuphoriaPain reliefSuppresses cough reflexHistamine releaseWarm flushing of the skinDry mouthDrowsiness and lethargySense of well-beingDepression of the central nervous system(mental functioning clouded)53
Opioids: Basic facts (3)Withdrawal symptoms: Intensity of withdrawal varies with level andchronicity of useCessation of opioids causes a rebound infunctions depressed by chronic useFirst signs occur shortly before next scheduleddoseFor short-acting opioids (e.g., heroin), peak ofwithdrawal occurs 36 to 72 hours after last doseAcute symptoms subside over 3 to 7 daysOngoing symptoms may linger for weeks ormonths54
Long-term effects of opioids¾ Fatal overdose¾ Collapsed veins¾ Infectious diseases¾ Higher risk of HIV/AIDS and hepatitis¾ Infection of the heart lining and valves¾ Pulmonary complications & pneumonia¾ Respiratory problems¾ Abscesses¾ Liver disease¾ Lowbirth weight and developmental delay¾ Spontaneous abortion¾ Cellulitis55
Other drugs¾Inhalants¾ Petroleum products, glue, paint, paint removers¾ Aerosols, sprays, gases, amyl nitrite¾Club drugs (MDMA-ecstasy, GHB)¾Hallucinogens (LSD, mushrooms, PCP, ketamine)¾Hypnotics (quaaludes, mandrax)¾Benzodiazepines (diazepam / valium)¾Barbiturates¾Steroids¾Khat (Catha edulis)56
Activity 3Working individually or in small groups, think ofthe drugs that are consumed in your area and theway they are consumed both by youth and adults:Share your thoughts with the rest of the group.57
Introduction toAddiction and the Brain58
Addiction Brain DiseaseAddiction is a brain disease that ischronic and relapsing in nature.59
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How a neuron works61
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The reward systemNatural rewards FoodWaterSexNurturing63
How the reward system works64
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Activating the system with drugs66
The brain after drug use (1)Control Methamphetamine(Source: McCann et al. (1998). Journal of Neuroscience, 18, 8417-8422.)67
Partial Recovery ofBrain Dopamine Transporters inMethamphetamine (METH) AbuserAfter Protracted Abstinence30ml/gmNormal ControlMETH Abuser(1 month detox)METH Abuser(24 months detox)
The brain after drug use (2)DA Days Abstinent69
Drugs change the brainAfter repeated drug use, “deciding” to usedrugs is no longer voluntary becauseDRUGS CHANGE THE BRAIN!70
?Questions?Comments?71
Thank you for your time!End of Workshop 172
Workshop 2:Principles of Drug Addiction Treatment73
Training objectivesAt the end of this workshop you will be able to:1. Identify 3 basic components ofcomprehensive treatment for substanceabuse2. Identify 2 individual factors that help peoplestay in treatment3. Identify 3 factors within a programme thathelp people stay in treatment4. Understand and identify 5 basic principles ofeffective treatment74
ComprehensiveTreatment75
Addiction treatment goalsThe goals of addiction treatment are to helpthe individual:¾ Stopor reduce the use of drugs¾ Reducethe harm related to drug use¾ Achieveproductive functioning in their family,at work, and in society76
Why is comprehensive addiction treatmentneeded?¾ Addicted individuals usually sufferfrom mental health, occupational,health, or social problems that maketheir addictive disorder difficult totreat¾ For most people, treatment is a longterm process that involves multipleinterventions and attempts atabstinence77
Components of comprehensive drug abusetreatment
Activity 1: Your organisation20 Min.Using the previous graphic, think about all theservices that your organisation provides.¾ What services do your clients most oftenneed?¾ What services could your organization addto meet your clients’ needs?79
Treatment durationIndividuals progress through drugaddiction treatment at various speeds, sothere is no predetermined length oftreatment.In general, longer treatment durationresults in better outcomes.80
Treatment compliance (1)Client factors that affect treatmentcompliance are¾ Readinessto change drug-usingbehaviour¾ Degreeof support from family and friends¾ Pressureto stay in treatment from thecriminal justice system, child protectionservices, an employer, or family members81
Treatment compliance (2)Factors within the program that affecttreatment compliance are¾A positive therapeutic relationship between thecounsellor and client¾A clear treatment plan, which allows the client toknow what to expect during treatment¾Medical, psychiatric, and social services¾Medication available when appropriate¾Transition to continuing care or “aftercare”82
Drug addiction treatmentDrug addiction treatment is offered inspecialized facilities and mental healthclinics by a variety of professionals such as:Medical doctors¾ Psychiatrists¾ Psychologists¾ Social workers¾ Nurses¾ Case managers¾ Certified drug abuse counsellors¾ Other substance abuse professionals¾83
Activity 2: Group activity15 Min.Identify factors within your program (orothers’ programs) that may do the following:1.2.Help clients to comply with their treatment planInterfere with clients’ compliance with theirtreatment plan84
Principles of Addiction Treatment85
Principles of effective treatment (1)1. NO single treatment is APPROPRIATE FOR ALL2. Treatment needs to be READILY AVAILABLE3. Effective treatment attends to MULTIPLE NEEDS,not just to drug use problems4. The treatment plan must be ASSESSEDCONTINUALLY and MODIFIED AS NECESSARY toinsure that it meets the client’s changing needs5. Remaining in treatment for an ADEQUATE PERIODOF TIME is critical for treatment effectiveness.Continued86
Principles of effective treatment (2)6.Counselling (individual and/or group) and otherbehavioural therapies are CRITICAL7.Medications are IMPORTANT elements oftreatment for many clients, especially whencombined with behavioural therapy8.People with coexisting mental disorders shouldbe treated in AN INTEGRATED way9.Detoxification is only the FIRST STAGE ofaddiction treatment and by itself does little tochange long-term drug use.Continued87
Principles of effective treatment (3)10. Treatment does NOT need to be voluntary to beeffective11. Possible drug use during treatment must beMONITORED continuously12. Treatment programs should provide assessmentfor HIV/AIDS and other infectious diseases aswell as counselling to help clients changebehaviours that place themselves or others atrisk of infection13. Recovering from drug addiction can be a LONGTERM PROCESS and frequently requiresmultiple episodes of treatment88
Categories ofTreatment89
Categories of treatmentResearch treatment components include:¾Detoxification¾Pharmacological treatment¾Residential treatment¾Outpatient Treatment90
Medical detoxification¾Detoxification is a process whereindividuals are treated for withdrawalsymptoms upon discontinuation ofaddictive drugs¾Detoxification treatment is conductedunder the care of a physician in aninpatient or outpatient setting91
Pharmacological treatment¾Medications to reduce the severity and risk ofwithdrawal symptoms¾Medication to reduce relapse to illicit drug use¾Agonist maintenance treatment for opiates(methadone, buprenorphine)¾Antagonist treatment for opiates (naloxone,naltrexone)92
Residential treatmentResidential treatment programs providecare 24 hours / day in non-hospitalsettings.Models of care include:¾ Therapeuticcommunity (TC)¾ Residential,or “rehab,” program93
Residential treatment models¾ Therapeutic community (TC):¾ Highly structured treatment (6-12 months)¾ Focus on re-socialization¾ Developing personal accountability¾ Residential (“rehab”) program¾ Typically 30 days long¾ Aftercare includes counselling and / or peersupport94
Outpatient treatmentRecommended elements of outpatient treatmentinclude the following: Weekly sessions for around 90-120 days Family involvement Positive reinforcement approaches Cognitive-behavioural materials 12-step meetings or support groupparticipation Urinalysis and breath alcohol testing Medication as appropriate95
Ethical andLegal Issues96
Ethical guidelinesEthical Values:Be good!Do good!And above all: Do no harm!97
Ethical and legal issuesEthical guidelines are¾ A set of professionalstandards¾ A set of principles toguide professionalbehaviour¾ Often a matter of opinionand cultural context¾ Not always a legalconcernLegal guidelines are¾ Determined by laws¾ Implemented if ethics areconsistently violated¾ Often enforced by civil orcriminal penalties98
Professional and ethical issuesTreatment professionals should have acopy of the following:¾Relevant ethical guidelines or code of conductfor your region¾Laws or regulations affecting their clinicalprofessions99
Professional boundariesMaintain a professional relationship with aclient at all times¾ Avoiddual relationships with clients¾ Avoidsexual relationships with clients¾ Avoidpersonal relationships with clients100
Confidentiality (1)¾The client’s rights and the limits ofconfidentiality should be explained at thebeginning of treatment¾The relationship with any client should beprivate and confidential¾Client information should not be communicatedoutside of the treatment team¾Information should only be released with theclient’s or guardian’s permission101
Confidentiality (2)Confidentiality must be maintained at alltimes, except when to do so could result inharm to the client or others.102
Activity 3: Case study15 Min.Discuss in small groups the following cases:A) A young man tells his clinician that he intends tokill his former girlfriend just as soon as shereturns from an out-of-town trip.B) A client’s employer comes to you asking forinformation on your client’s test results.How should the clinician act in cases A and B?103
Additional principles of counselling¾An addiction treatment professional should¾Respect the client¾Be a role model¾Control the therapeutic relationship¾Emphasise the client’s personal responsibility forrecovery¾Provide direction and encourage self-direction¾Be conscious of his or her own issues104
?Questions?Comments?105
Thank you for your time!End of Workshop 2106
Workshop 3:Basic Counselling Skills forDrug Addiction Treatment107
Training objectives (1)At the end of this workshop you will be able to:lIdentify a minimum of 4 counselling strategiesuseful in drug abuse treatmentlConduct a minimum of 3 counselling strategieslStructure a regular counselling sessionlUnderstand the importance o
Workshop 3: Basic Counselling Skills for Drug Addiction Treatment Workshop 4: Special Considerations when Involving Families in Drug Addiction Treatment. 5 Icebreaker: If I were the President If you were the President (King, Prime Minister, etc.) of your country, what 3 things would you change related to drug policies, treatment, and / or prevention? 15 Min. 6 Workshop 1: Biology of Drug .
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