Addictions therapy focused on current best practices.
What is an addiction?
An addiction is considered a medical condition where an individual has become physically and/or psychologically reliant on a specific substance use and/or behaviour.
What type of things do people get addicted to?
Addiction is often classified in two categories:
1. Substance use addictions: this can include alcohol, opioids (Percocet, heroin, fentanyl, etc), cocaine/crack cocaine, crystal meth, cannabis, and tobacco
2. Behavioural/Process addictions: this can include gambling, sexual behaviours (including pornography), and video games
How do I know if my use has become problematic?
There are four questions we often ask individuals who use substances to explore if their use has become problematic:
1. Are you able to control your substance use (amount and frequency of use)?
2. Do you continue to use despite its consequences?
3. Do you spend a lot of time using and recovering from your use?
4. Do you have powerful urges or cravings to use?
Additionally, if you believe that your substance use is having a negative impact on your mental/physical health, employment, relationships, and/or finances, it may be beneficial for you to seek support.
Who becomes addicted?
Any human can become addiction to a substance and/or behaviour. Addiction does not discriminate!
What causes addiction?
There are many factors involved that could contribute or predispose an individual to developing an addiction. These involve:
- Biology/Genetics: There is some research indicating that individuals may inherit a vulnerability to developing an addiction. Additionally, when an individual uses a substance, it immediately activates the “reward centre” in the brain, creating a euphoric sensation. Individuals often want to repeat “feel good” state and continue to use.
- Environment: Individuals who are exposed to substances regularly in their homes, at school, work, or with their peers, may be more influenced to use as well.
- Mental health concerns: Many individuals who struggle with mental health concerns such as anxiety, depression, or trauma use substances to help manage their symptoms. It is estimated that at least 60% of individuals living with addiction also have a mental health disorder.
- Physical pain: Individuals may also develop a dependency on substances to attempt to manage their physical pain, this is most commonly seen with opioid use.
The continuum of use
The continuum of use is a way to understand an individual’s severity of use, which is often helpful when exploring the type of treatment that may be most appropriate.
- Experimentation: An individual is curious about a substance or behaviour and may use.
- Occasional use: An individual uses substance infrequently and often in specific situations such as social events.
- Regular use: An individual begins using more frequently, such as a few days per week, or even daily, however it may not have led to any consequences at this time.
- Misuse: This is when an individual use begins to have negative consequences and they are often increasing their use despite this.
- Addiction: Physical and/or psychological dependency are now present and there are often significant negative consequences.
How is Addiction treated?
There are several support options available for someone looking to make changes to their addiction.
Withdrawal management: Programs to assist with withdrawal symptoms from substances. This is offered both in a residential facility and community-based programming.
Community treatment programs: A combination of group and individual therapy which requires several weeks of commitment often for 4-6 hours, 5 days per week.
Residential treatment programs: A higher intensity treatment option where an individual resides in a facility for 18 days to 1 year (depending on the program). There is a combination of group and individual therapy.
Individual therapy: Some agencies offer counselling covered by OHIP. Another option is private psychotherapy.
Self-help resources: Programs often run by individuals in addiction recovery, such as 12-Step Meetings and SMART Recovery groups
Addiction medicine: Medications used to reduce or manage cravings (see below for more information)
Abstinence .vs. Harm Reduction:
Our addiction specialists know that everyone will have their own unique goal for their addiction recovery. When choosing the type of treatment approach, we will start by identifying the persons goals and stage of change. It is important to identify if the individual wishes to start with a goal of harm reduction or abstinence. Harm reduction approaches aim to meet the individual where they are at and support making smaller, often more realistic goals, such as reducing their use daily or changing the method of use to a safer option (such as moving from drinking hard liquor to beer to start).
Harm reduction can be considered ‘controversial’ especially for families and loved ones who naturally want to see their loved one recovered and abstinent as soon as possible. Motivation and readiness for change in people living with addictions tends to fluctuate and even though it might be obvious to everyone around them (and even themselves), insight doesn’t always translate into the ability to make and sustain changes in their use. When working from a harm reduction approach the therapist will attempt to work with the client on minimizing the harm from their use. This is controversial because sometimes it can appear to others that the therapist is ‘condoning’ the person’s using. This is a very common misconception.
The harm reduction approach is grounded in an acceptance of the reality of addiction which is characterized by a loss of control of use. If we accept that the person does not have control or the ability to ‘just stop’ (because if they did then they would have already), we begin to understand why harm reduction can be considered a client centred approach and a good starting place if the person is still on the fence about abstinence.
The overarching goal of this approach is to maintain the therapeutic rapport by respecting the person’s readiness and to explore ways to reduce the likelihood of harm from their ongoing use. If we start trying to help people prepare and plan for abstinence when they are still ambivalent towards sobriety, it can be invalidating, ineffective, and reduce the likelihood that the client will continue with therapy.
What are the stages of change and why they matter?
The Stages of Change is a model used to understand the different stages of readiness an individual may experience on the journey towards change. This model considers a person’s awareness of their behaviour and their motivation to make changes in real time.
The value of this model cannot be understated as it informs the selection and efficacy of the therapeutic intervention. In other words, if we don’t consider where someone is at in ‘the stages of change’, we may not be able to help them as effectively.
For example, if someone is in denial of their use being problematic and we suggest they stop using completely and attend residential treatment, it may result in them not returning to therapy and therefore being without any support at all. Instead, if we openly explore the pros and cons of their substance use and even why others may perceive their use as problematic (even if they don’t view it as such), there will be a better chance of the client feeling understood and remaining connected with services.
● Link to questionnaire “What is your stage of change?”
● List the stages
Addiction Medicine has become an increasing aspect of substance use recovery. At this time there is only evidence to support the use of addictions medicine for individuals who are struggling with alcohol and/or opioid use can speak to their family physicians or attend specialty addiction medicine clinics to explore medication to support their recovery.
For alcohol use, medication prescribed can support reduction in physical urges and cravings. For some people it may also reduce the euphoric effect of alcohol while drinking, leading to a reduction in use at that moment. Common medications include naltrexone, acamprosate, gabapentin, and topiramate. None of these medications induce nausea or vomiting when alcohol use is consumed. This ‘aversion’ based medication was seen historically in the use of “Antabuse”, which is no longer commonly prescribed.
Opioid Use Disorder:
For opioid use, medication prescribed is often referred to as “Opiate Use Replacement Therapy” or ORT. ORT is intended to support an individual who is experiencing intense withdrawal symptoms and cravings that is preventing them from being able to sustain their recovery goals. The medication helps by eliminating the withdrawal symptoms as well as reducing the physiological and psychological cravings. The medication provides an “antagonist effect” which means it sticks in the receptors and provides the relief that is sought after without the ‘high’ of the drug. This can be helpful to client’s as it allows them to manage the symptoms that keep them stuck in the cycle of addiction and rebuild their life in a way that would be difficult if not impossible if they continued to get high.
There are two main medications prescribed: methadone (which is in a liquid form) and suboxone (which is in a pill form). Recently, a version of suboxone, known as Sublocade, has been prescribed that is an injection provided once per month, however this is often very expensive and not commonly covered by insurance.
If you are interested in exploring addiction medicine as a supplement to your recovery plan, you can find an Addiction Medicine Specialist at various Rapid Access Addiction Medicine (RAAM) Clinics in Ontario at https://www.metaphi.ca/