Chapter 29

Substance misuse Jenny Lancaster, John Chacksfield

CHAPTER CONTENTS

Introduction536 Definitions of substance misuse536 History of substance misuse536 Alcohol536 Opiates536 Cocaine537 Cultural context537 Substance Misuse and the Military Dual Diagnosis Substance misuse538 National policies538 What are drugs and other substances?539 Drug action539 Legality540 Measurement540 Why do people use substances?541 Reasons for substance misuse: an occupational perspective541 When does drug use go wrong?541 Problems and dependence542 Treatment of substance misuse544 A model of change544 Stages of change544 Substance misuse treatment in context545 Triggers to treatment entry545 Referral545 Multidisciplinary assessments545 Screening assessments546 Interview techniques546 Structured assessments546 Occupational therapy assessment546

Performance areas546 Performance components546 Performance contexts546 Occupational therapy assessment tools547 Interventions547 Engagement547 Principles of intervention547 Treatment strategies547 Treatment options548 Alcohol misuse548 Drug misuse548 Physical and mental health treatment548 Approaches to intervention548 The Twelve Steps549 Relapse prevention549 Occupational therapy and substance misuse550 Leisure551 Work/productivity552 Work-based substance misuse552 Substance-based productivity552 Self-maintenance553 Evaluation of outcomes553 Summary553

INTRODUCTION Occupational therapists in all fields of practice are likely to meet clients who have problems with substance misuse. This chapter is intended as a starting point for occupational therapists interested in the specialism of substance misuse as well as those who work in other areas of mental health and encounter substance use alongside psychiatric disorder. It discusses the nature and extent of substance misuse in the UK. An occupational perspective is offered on why people take drugs and the types of problems that the individual drug user may experience. The treatment process is outlined and the role of the occupational therapist highlighted. Treatment approaches are described as well as specific occupational therapy intervention strategies available for problem drug and alcohol users. Substance use and misuse are widespread within our society and culture. Ninety percent of the adult UK population drink alcohol and about 10% of the population drink above recommended daily guidelines (Strategy Unit 2004). It is estimated that 3050% of people with severe mental health problems misuse substances (Cabinet Office 2004). The prevalence of illegal drug misuse is harder to assess but it is estimated that 1% of the UK population use heroin or cocaine (NTA 2002). Louis Appleby said in 2000: The problem of substance misuse is now in a central position in mental health services and cannot continue to be the domain of a distant speciality . The authors recommend that education about substance misuse is given priority as part of occupational therapy training as it is now more likely to be the norm than the exception in most clinical presentations. For occupational therapists, substance misuse can affect recovery and needs to be taken into account when planning treatment, whether in terms of direct intervention or as part of wider team goals. DEFINITIONS OF SUBSTANCE MISUSE

The term 'substance use' generally means the consumption of alcohol or psychoactive drugs that have the potential to be addictive. Substance misuse has been defined as drug and/or alcohol taking that causes harm to the individual, his significant other or the wider community (NTA 2002). Substance dependence or dependence syndrome (first proposed by Edwards & Gross, 1976) is a specific diagnostic term describing what is commonly termed addiction (DOH,2011, Gerada & Ashworth, 2008 and Ashworth et al, 2008). Although there are myriad substances that are used and abused due to their psychoactive properties, this chapter will primarily focus on those which cause the most harm: heroin, cocaine and alcohol.

History of substance misuse The use of addictive substances has been intertwined with human occupation for a considerable proportion of mankind's history. Some examples are described below. Alcohol According to Nunn (1996), archaeological evidence exists for the use of alcohol in ancient Egypt from as early as 6000 BC. In Britain in the 17th century, due to the lack of drinking water, beer and gin were commonly drunk by the whole population throughout the day, starting at breakfast (Allen 2001, Tyler 1995). One-third of England's farmland was devoted to growing barley for beer and one in seven buildings was a tavern. In the second half of the century, 2000 coffee houses sprang up in London. This had a sobering effect on the population. Instead of getting drunk in taverns, coffee houses provided a safe place to read, play games and for political debate. Indeed, the first ballot box was used in the Turk's Head Coffee House in London. This change from the use of one depressant substance (alcohol) to a stimulant (caffeine in coffee) has been associated with increased literacy, political change and improved standards of living (Allen 2001). However, with the changes in the occupational lives of workers during the Industrial Revolution, alcohol use dramatically increased in response to days toiling in factories and mines and increasing urbanisation (Tyler 1995). From 1950 to 2004 per capita consumption of alcohol increased from 3.9 litres of pure alcohol per year to 9.4 litres per year. Although this has reduced slightly since 2004, consumption levels have remained above 7 litres per year since 1980 (BMA, 2008). The UK has one of the highest rates of binge drinking in the Europe, particularly amongst young people (Institute of Alcohol Studies, 2010). Binge Drinking has been defined as drinking more than double the recommended daily limits of units of alcohol. In the UK 40% of all drinking episodes for men and 22% for women are defined as binge drinking ((Institute of Alcohol Studies, 2010). There are vast differences in consumption of alcohol between different ethnic and socio-economic groups in the UK. For example, 9% of the white British population do not drink alcohol whereas 90% of those from Pakistani or Bangladeshi origin abstain from alcohol (BMA, 2008). Opiates It is believed that the opium poppy has been used for the last 6000 years (Tyler 1995). Opiates have been widely available in a variety of forms: opium, laudanum, morphine, heroin and methadone. Typically new forms of opiates were developed to 'cure' dependence on the previous form of opiate. Morphine was developed to treat opium addiction, heroin was introduced as a safe, non-addictive miracle drug to cure morphine addiction (Gossop 2000). Currently heroin addiction is typically treated by prescribing methadone or buprenorphine. In the 17th century laudanum, a tincture of alcohol and opium, was used to treat a variety of ailments, including period pains and colic in babies. Controls were not introduced until 1868 due to concerns regarding the numbers of infant deaths through opium overdose (Drugscope, 2007). This control led to a clearer distinction between medical and recreational use (Tyler 1995). Opiate use outside the medical context became seen as deviant. Even so, non-medical use of opiates was not an offence until the 1920s following the intervention of the Rolleston Committee (Tyler 1995) but doctors were still able to prescribe opiates to those who had become dependent. In the 1960s, due to the creation of an illegal market in heroin created by a number of overprescribing private GPs, the 1967 Misuse of Drugs Act led to the creation of the first drug dependency clinics in the NHS. However, in the 1970s and 1980s a massive increase in illegal availability of heroin and high unemployment rates led to a 'working class epidemic' (Tyler 1995). This, combined with a rapid increase in drug-related crime, has led to opiate dependence being viewed as an issue of social deviancy which needs to be controlled. Opiate use has been associated with unemployment and poverty over recent years. It can be viewed as a means of escape from an occupationally deprived life. Since 2008 heroin appears to be reducing, particularly, amongst young people (NTA, 2011) Cocaine Cocaine comes from the coca leaf which has been used as an aid to work among Peruvians Indians for thousands of years (Gossop 2000). Currently, impoverished Peruvian miners chew coca leaves as a substitute for food to help them cope with work (Tyler 1995). Cocaine was first extracted from the leaves in 1855 and became a popular medicine and tonic and in fact, Coca Cola contained cocaine until 1904. It differs from opiates and alcohol in that, although powerfully psychologically addictive, it is not possible to

become physically dependent on cocaine. Cocaine became popular in the UK in the 1970s. It was common among the affluent classes and developed a somewhat glamorous image. However, in the mid-1980s a more powerful, cheaper form of cocaine known as crack was developed. Unlike cocaine, crack use is associated with deprivation, crime and co-existing heroin use (Home Office 2002a). Crack use typically follows a binge pattern where once people start using, they become completely consumed with using more and engage in activities to obtain more crack. Users frequently stay awake for over 24 hours, becoming increasingly more paranoid and aggressive. The binge is followed by a 'crash' in which users experience extreme exhaustion and emotional lability. This pattern of binging and crashing completely disrupts users' daily lives and routines.

CULTURAL CONTEXT Culture mediates views of drugs in terms of how dangerous they are, how legal they should be and how good or bad they are. For example, the Christian, moralist, Temperance movement in 19th-century Britain set out to reduce alcohol consumption (Berridge 2005). At the end of the 19th century, cocaine was highly popular and recommended by doctors such as Sigmund Freud and Sir Clifford Albutt. At the same time, Albutt (cited in Gossop 2000) held a different view of another drug, popular today, as illustrated in a quote from his medical textbook: 'The sufferer is tremulous and loses his self-command, he is subject to fits of agitation and depression. He loses colour and has a haggard appearance. As with other such agents, a renewed dose of the poison gives temporary relief, but at the cost of future misery'. The drug described was coffee. Many cultures use and have used drugs in social ritual or religious ceremony, to enhance skill in war and for pleasure. In some, the cultivation of drug crops, though often illegal, is a major industry that offers considerable employment opportunities and contributes to the national economy (Henman 1985). Drug profits have been known to drive political movements, such as the suggested use of heroin trafficking by the People's Republic of China to fund Communist Party activities (Musto 1993). Alcohol has long been considered to be the dominant drug of European culture, whereas in the Americas plant-based drugs unknown in Europe, such as nicotine and cocaine, were widely used for centuries before alcohol was popularised with the coming of immigrants from Europe (Gossop 2000). Substance misuse from the 18th to the early 20th century was primarily seen as a sin. The drunk and the 'opium sot' were seen as morally degraded. The turn of the 20th century saw this attitude change towards a much more disease-oriented concept that offered a cure. In the 1960s came the idea of dependence as a concept that acknowledged psychological reliance on a drug and, in the 1970s, this was developed into the modern dependence syndrome. More recently, social models of substance misuse have been developed that take into account wider cultural, economic and psychological factors. Over recent years Strategies for Drug Treatment have repeatedly focused on and measured success in terms of reducing the costs to society caused by substance use rather than the personal recovery of people using substances. For example the frequently quoted findings from the Drug Treatment Outcomes Research Study ( Donmall. M et al, 2009) that for every 1 spent on drug treatment saves society 2.50. However an analysis of the final report of this study found that the gains to quality of life for drug users in was too small to normally justify treatment (Drug & Alcohol Findings, 2010)

SUBSTANCE MISUSE AND THE MILITARY Throughout history, substance use has been associated with war and conflict, whether in relation to trafficking and use of profits to fund terrorist activity; to enhance military occupational performance or to assist in coping with combat-related stress. Alcohol is often considered part of army culture and drinking in moderation is advocated as a social lubricant to encourage team bonding. It may help all of these things but the after-effects can be devastating. Research among Vietnam veterans is a clear example of this. Recent research within the British army, post Iraq and Afghanistan, has shown that alcohol presents significant problems for soldiers and veterans across all age groups and is higher than in the general population. Jones and Fear (2011) found that: For regular soldiers deployment to Iraq or Afghanistan was significantly associated with the report of alcohol misuse on return from theatre (ie the area of conflict). Amongst those deployed, alcohol misuse was greatest in those who had undertaken a combat role; that is at greatest

risk of being killed or wounded. A report by Rona et al (2010) explored some aspects of functioning in relation to military alcohol use in the UK Armed Forces. In this study, approximately a tenth of the sample scored highly on a test for alcohol problems and dependence and this was consistently associated with functional impairment, defined by various impacts on their work. The American army employs occupational therapists as part of its Specialist medical Services and they work in substance misuse services as well as mental and physical health care. According to Oakley et al (2008), occupational therapists have made significant contributions within military operations and in disaster relief, including their role in limiting disaster-related mental health problems such as substance misuse.

DUAL DIAGNOSIS Dual diagnosis or co-morbidity refers to the combination of two significant problems or diagnoses that interact to present a range of specific health effects. This section discusses the combination of mental health needs with substance misuse specifically. Recent recommendations by nurse consultants suggest that dual diagnosis is the norm rather than the exception and all health professionals should receive training in both issues as a matter of course. When alcohol and drugs are used by people with mental health diagnoses, they can severely exacerbate symptoms and disrupt treatment. They are associated with disrupted lifestyles, suicide (Duke et al 1994) and violent behaviour (Swanson et al 1990). The issue of substance misuse by people with a mental health problem, has been highlighted as important within UK government policy since the early 2002 with the publication of the Policy Implementation Guide on Dual Diagnosis (DoH 2002). Research has shown that substance users have higher rates of psychiatric disorder than the general population (DoH 2002). Either the disorder may be induced by drug use or drugs can be used to self-medicate the symptoms. Other studies show that drugs and crime are interlinked (Forshaw & Strang 1993). A major American study revealed that violent behaviour is approximately three times more likely in people who both use drugs and have a mental disorder than those who do not suffer either (Swanson et al 1990). Several inquiries have highlighted the combination of substance misuse and mental ill health as a key risk factor, such as the Michael Stone Inquiry and the case of Jonathan Zito. Key studies, such as the Confidential Inquiry into homicide and suicide (Appleby, 2000-2006) and the MacArthur risk study both highlighted the importance of substance misuse in combination with mental disorder as a major risk factor. Valuable guidance documents created by experts and published via the charities RETHINK and Turning Point (Rethink and Turning Point, 2004; Turning Point, 2007) highlight key aspects of treatment for dual diagnosis and recommend various intervention strategies that address the combination of issue concomitantly. There is general agreement (based on the research evidence base) that good practice should be comprehensive (integrated in one service where possible), long term, adopt a staged approach to recovery (according to the model described below) and focused on developing self-management skills and functional goals (Drake et al 2001) A useful treatment model here is the Dual Diagnosis Stages of change model by Osher and Kofoed (1989). This takes into account issues of engagement as part of the change process, which is important for many mental health service users. This model for change includes four phases, namely: Engagement Persuasion Active Treatment Relapse Prevention These phases align closely with the Prochaska and DiClemente Stages of change model (described later in the chapter) and dual diagnosis practitioners often use both in tandem. Occupational therapists working with dual diagnosis emphasise focus on the impact of the combined effects of both diagnoses on human occupation. Use of occupational therapy specific clinical reasoning can be highly effective in treating these cases.

SUBSTANCE MISUSE Currently, in the UK, substances misused are generally categorised as either legal or illegal, are subject to restrictions according to age or cultural acceptability. Substance misuse can lead to social, psychological, physical or legal problems related to intoxication or regular excessive consumption and/or dependence (NTA, 2002). The health and social consequences of drug and alcohol use are comprehensively

summarised in A summary of the health harms of drugs (DoH, 2011) Most of the results of problem use of substances or dependence on them can be observed in the patterns of human occupation exhibited by the user and their impact on the user's quality of life. Some of these effects are described later in the chapter. It is important to remember that the myriad problems that substance misusers experience do not occur in isolation. Frequently people develop substance misuse problems in an attempt to deal with problems in their lives, e.g. the breakdown of a relationship, unemployment or an attempt to relieve the symptoms of mental illness. It has been proposed that it is important to consider the interrelation of three factors in relation to substance misuse (Ghodse 2002, Gossop, 2000): the drug the individual the environment Examining the relationship between the individual and the environment in relation to human occupation is a core component of occupational therapy practice. When working with substance-using clients, occupational therapists consider how the substance use or abstinence from a previously habitually used substance affects occupation, e.g. the woman whose drinking increases due to changes in work environment or the ex-heroin user who, having given up a large network of drug-using friends, feels he doesn't have the confidence to engage in new leisure activities alone.

Substance misuse has been described as a chronically relapsing condition (NTA 2002). Research indicates extremely high relapse rates following an episode of substance misuse treatment, 60% (NIDA, 2009) and that relapse is most likely within a short period following initial treatment (Hunt et al 1971, Milkman et al 1984, Stephens and Cottrell 1972). However, the largest multi-site trial in the UK has proved the long-term effectiveness of drug treatment (Donwell et al, 2009). The costs of drug and alcohol misuse for communities are high. It is estimated that of alcohol misuse in England is between 18-25 billion a year and the cost of illegal drug misuse in England is around 15.4 billion per year (HM Government, 2010). Therefore drug and alcohol misuse has been high on the political agenda many years, with numerous policies and the development of links between the criminal justice system and treatment services e.g. Arrest Referral Schemes. Since the advent of HIV and the development of structured methadone maintenance programmes, treatment for opiate use has traditionally adopted a harm reduction or harm minimisation approach. These approaches include providing needle exchange schemes (to reduce the risk of infection with blood born viruses through sharing injecting equipment, providing education for drug users on safer injecting methods and providing substitute prescribing sometimes of injectable dimorphine (to avoid the risks associated with using contaminated, adulterated street heroin). These approaches have undoubtedly been successful in preventing an epidemic of HIV amongst injecting drug users and substitute prescribing has enabled many drug users to live fully functional productive lives whilst continuing to be prescribed an opiate drug. However, these approaches have caused much controversy and debate over what constitutes successful treatment and recovery. There is a longstanding disagreement and debate in the field of drug treatment between supporters of harm reduction approaches and those that follow 12 Step approaches with is based on total abstinence. When a BBC report in October 2007 reported that only 3% of drug users left treatment free of all drugs (including methadone) despite a huge increase in funding for Drug Treatment, it sparked a debate amongst many figures in the treatment field. This debate is described in Drug Treatment at the Crossroads (Drugscope, 2009). Research into addictive substances and their management has evolved over the last 200 years from being a fragmented and underdeveloped area of science to becoming a frontier subject with its own identity (Edwards 2002). Some of the developments which have led to addiction being taken seriously as a manageable issue, as opposed to a 'sin', have included the landmark research into the relationship between smoking and lung cancer, and the importance given to research in treating the massive heroin problem in the USA among GIs during the Vietnam war.

NATIONAL POLICIES & GUIDANCE

A range of guidelines for treatment have been developed by the National Institute for Clinical Excellence (NICE) and are available on their website at www.nice.org.uk. These include: CG115 CG100 CG52 CG51 Alcohol dependence and harmful alcohol use Alcohol-use disorders: physical complications Drug misuse: opioid detoxification Drug misuse: psychosocial interventions Feb 2011 Jun 2010 Jul 2007 Jul 2007

CG120 Psychosis with coexisting substance misuse

Mar 2011

NICE Public Health guidelines include: PH24 PH1 PH4 Alcohol-use disorders - preventing harmful drinking Jun 2010 Brief interventions and referral for smoking cessation Mar 2006 Interventions to reduce substance misuse among vulnerable young people

Mar 2007

New guidelines are continually in development. The Drug Policy published in 2010 (HM Government, 2010) marks a change in direction with an increased focus on detoxification and abstinence from substitute prescribing as a goal of treatment. This is not without controversy due to large scale studies that highlight the increased risk of drug related deaths after stopping substitute prescribing (Cornish et al, 2010). Having lost tolerance to opiates through the detoxification process, if drug users use drugs again . using similar amounts as they were using before they lost their tolerance there is a high risk of death through accidental overdose.

Contingency Management Nice recommended that Contingency management be introduced to drug treatment services in 2007 in the guideline covering psychosocial interventions for drug misuse. (NICE, 2007). Contingency management is a behavioural approach based on operant conditioning whereby incentives are offered, often the form of vouchers that can be exchanged for goods or service users of the service users choice. The voucher is given contingent on drug tests being conducted negative to illicit drug use. In the contingency management approach the value of vouchers increases with increasing periods of continuous abstinence. There is potential for these vouchers to be used to support occupational and recovery focused goals e.g. used to pay for gardening equipment, art materials or sessions in a sports centre. Since the publication of this guidance Contingency Management (according to evidence based protocol) appears not to have introduced anywhere in the UK. Despite a clear evidence base demonstrating the cost effectiveness of this approach (Lussier et al, 2006), the resource implications as well, as the political the political ones are huge. However, Kings College and the Institute for Psychiatry are currently conducting research (currently unpublished) looking at the implementation of contingency management in the UK known as the CONMAN programme. Changes in NHS Drug and Alcohol Services In 1995 Drug Action Teams (now called Drug and Alcohol Action Teams) were set up as multi-agency partnerships in every borough or county to commission local Drug and Alcohol services. Since the mid 2000s these teams have increasingly retendered the services they commission. This has lead to a significant reduction of services provided by NHS trusts. One survey found that only 16% of service contracts were retained by NHS providers (Wolstenholme, 2009), the majority of service contracts being awarded to Third Sector organisations, with a few awards to partnerships between NHS and Third Sector organisations. Although the early part of the 2000s saw a huge increase in funding in drug services, the retendering that has occurred in the latter half of this decade has been in the context of cuts in funding. This process has led to the loss of many occupational therapy posts in drug and alcohol treatment services.

WHAT ARE DRUGS AND OTHER SUBSTANCES? Drugs and other substances are usually grouped according to psychotropic action or legality. Drug action The action of drugs on the human brain determines whether they are considered an opiate, a stimulant, a depressant, a hallucinogen or a minor tranquilliser. Some drugs, such as cannabis, nicotine and volatile inhalants, do not conform to any of these classifications. It should be noted that drug action and effect can be influenced by: the route of administration, e.g. smoking, drinking or injecting; personality characteristics of the user; cultural expectations; and the immediate setting and expectations. Taking a drug together with another drug, or taking drugs when mentally ill, can also influence drug action and effect. Alcohol and drugs act on specific centres of the brain. For example, opiates (e.g. heroin) act on the opiate receptor in areas of the brain such as the limbic system, specifically the nucleus accumbens and the ventral tegmentum (Stellar & Rice 1987), changing the state of these receptors by using drugs results in pleasurable experiences. Many drugs are thought to act on the dopamine system. Dopamine is a chemical messenger which plays an important role in the brain's reward centre. It is released when we do pleasurable things, from eating good food to having sex. Drugs such as cocaine and heroin cause

a massive surge of dopamine to be released, and this extra dopamine leads to the sensation of pleasure. Over time, repeated drug use can lead to dopamine receptor sites in the brain being reduced or shut down. Therefore, the drug user finds less effect from using a drug, which leads to an increase in the amount used. The other significant effect is that the drug user is likely to experience a decreased ability to feel pleasure or satisfaction in activities of daily life (Whitten, 2009). This can lead to further drug use or thrill-seeking activities. It is important for occupational therapists to be aware of this in their clinical work as clients who have recently stopped using and have reduced dopamine levels may struggle to feel satisfaction from the occupations selected in occupational therapy. Alcohol has a variety of complex actions but is generally a nervous system depressant. The reason alcohol appears to produce euphoria is that it depresses frontal cortex functioning, resulting in loss of inhibition.

Legality Alcohol is legal for use by people over the age of 18. The legality of other drugs is determined in the UK by the Misuse of Drugs Act (HMSO 1979). This classifies drugs as Class A, Class B or Class C. Each class carries particular penalties for use and supply of the drug. Table 29.1 illustrates some of the most common substances in terms of legal classification and psychoactivity. Those working with drug users need to aware of Section 8 of the Misuse Drugs Act which makes it an offence allow drug dealing in any public premise. This Section was used to convict two managers of a charity drop-in centre for the homeless in Cambridge in 2000 (BBC news website, 2000). Despite a strict anti-drug use policy they were convicted due to refusing to pass on confidential information on their service users to the police and being judged to not to have done enough to prevent drug dealing in their centre. Press coverage of the case has been collated and reprinted on the Innocent website. Measurement Alcohol is measured in units of 10 mg. One unit of alcohol can be found in a single measure of spirits, a glass of wine or a half pint of ordinary-strength beer. Drugs are also measured in terms of amount purchased or mode of delivery. Heroin, cocaine and cannabis (resin or leaf forms) are generally measured by weight, although for non-cannabis drugs in powder form, the purity of what is purchased is variable according to what the powder has been mixed (or cut) with. LSD and Ecstasy are sold in units or 'tabs'. WHY DO PEOPLE USE SUBSTANCES? People are known to use substances for many and varied reasons (Edwards 1987, Gossop 2000). Alcohol, for example, is widely used as a social lubricant, to reduce tension, to intoxicate as a way of coping with negative feelings or as a sedative. Drugs such as cannabis are used to remove the symptoms of various physical health problems, to relax, bring pleasure, alter consciousness or as part of initiation into a social group. Heroin use is described as offering a warm, dreamy 'cocoon' and, for many users, it serves as an antidote to emotional pain and the stress of a life lacking in meaning (Tyler 1995). Reasons for substance use: an occupational perspective Substance use is often closely tied to human occupational behaviour. It could be said that the most common reasons for the use of substances lie in their ability to either enhance or disrupt human occupation. Some of the reasons for substance use can be categorised under the headings listed below. These reasons can be applied to almost all substances, including alcohol, nicotine, caffeine and tranquillisers as well as illegal drugs. It is important to note that each individual drug user will have his own very specific reasons and the following list is unlikely to be exhaustive. Enabling occupation By reducing tension By removing inhibition By stimulating mental alertness By imitating others' drug use Avoiding occupation

 Through intoxication Through stimulus seeking via drug use Through escape into drug culture Through denial of responsibility by drug use

As a coping mechanism To cope with anxiety To relieve or avoid facing pain To mask distress To increase confidence and peer acceptance As self-medication for mental health problems To alter perception In order to develop wider understanding of life For desired spiritual attainment As part of religious ritual To assist creativity Because drug-induced perception is considered more pleasant than normality To develop meaning in life Through the ritual and habits of drug-taking behaviour Through the routine of drug obtaining or dealing activities Through the excitement of illegal activities Through interacting and sharing a culture with associates in a drug-using network To enhance occupation By celebrating positive events By enhancing good feelings By removing negative emotional states To cope with occupational imbalance To cope with boredom 'kill time' (occupational deprivation) To cope with the pressure of too many demands on one's time

Applying some of these ideas, using the Human Open System (Kielhofner 2002), a possible model of their interaction can be constructed (Fig. 29.1). WHEN DOES DRUG USE GO WRONG? In general, it is likely that most people can regulate their use of alcohol, caffeine and other drugs without this use leading to damage to themselves, others or their occupational behaviour patterns. However, the use of alcohol and other drugs can and does lead to a considerable range of physical, psychological and social problems.

User surveys reported by the Department of Health (1996) suggest that drug use cannot be tackled in isolation. It is often associated with factors such as unemployment, family break-up and crime. Failure to address the wider life context issues can slow down or reverse progress in treatment of the drug problem itself. Problems and dependence Two issues represented in the academic literature on substances are problems and dependence. These are illustrated in Figure 29.2. The quadrants in Figure 29.2 do not represent distinct categories but each axis lies on a continuum (Drummond 1992). Sector A: those who experience problems related to non-dependent use (e.g. often young people) Sector B: a group who experience both dependence and problems (typical in the clinical setting) Sector C: a group in the population who take a substance but experience neither significant dependence nor problems Sector D: those who are significantly dependent but do not experience problems Research by Drummond (1990) suggested that people who are more dependent on alcohol experience more problems, but that certain problems are more closely related to dependence than others. Also, dependence can lead to abnormal drinking patterns. Where alcohol problems may be subject to sociodemographic effects, dependence is more likely to exist independently of most sociodemographic variables. Dependence and problems can be seen as coexisting and interrelated but not as separate entities (Drummond 1992, Gossop 1994a). Problems Alcohol or drug problems can be said to occur when their use severely disrupts a person's normal lifestyle balance or physical state. Consumption of more than 50 units of alcohol per week for men and over 35 units weekly for women is likely to cause problems (Gossop 1994a). Patterns of drug use can be problematic, such as binge use of a particular drug, or drug use as the only way to cope with difficulties. Physical problems can range from malnutrition to heart problems and lung, liver and gastric disease. Between 50% and 80% of injecting drug users are infected with the hepatitis C virus (British Liver Trust 2007). Psychological problems include anxiety, depression, memory loss, neurological damage, chronic psychotic symptoms and dementia. National figures show that drug and alcohol users die younger than non-users. Dependence Dependence on substances is diagnosed using the dependence syndrome (Edwards et al 1981). This consists of a list of seven problems, three of which at least have to be present in a greater or lesser degree to indicate dependence. 1.

Subjective awareness of compulsion to use a drug or drugs. 2. A desire to stop using the drug in the face of continued use. 3. A stereotyped drug-taking habit; that is, a narrowing of the repertoire of drug-taking behaviour. 4. Experience of withdrawal symptoms (evidence of neuroadaptation/tolerance). 5. Use in order to relieve withdrawal symptoms. 6. Primacy of drug use over other activities in life (salience). 7. Rapid reinstatement of dependence after a period of abstinence. The dependence syndrome is the most widely used method of diagnosing substance dependence and is used within the major diagnostic classification systems, such as ICD10 and DSMIV. It consists of both physical and psychological aspects and aims to emphasise the importance of psychological dependence on a substance as well as physical symptomatology. Edwards (Edwards & Gross 1976, Edwards 1987), who developed the dependence syndrome concept, emphasised the need to take a clinical picture in its social and environmental context and to tailor the picture to the individual. Dependence on alcohol is generally identified either through interview or by using questionnaires such as the Severity of Alcohol Dependence Questionnaire (SADQ) (Stockwell et al 1979) or the Alcohol Use Disorder Identification Test (AUDIT) (Babor et al, 2001). Other concepts of dependence include the addictive personality concept, which suggests that addiction is a form of personality disorder, or that people dependent on a drug are predisposed towards this because of their personality characteristics. The validity of this view has been largely dismissed on the research evidence (Gossop 1994a). Another approach to understanding drug dependence is the conditioning approach, first developed by Wickler (1948) which suggests that drug-related behaviours occur because they become paired with the reinforcing effect of the feelings a drug produces. Other conditioning models exist, as do social models and the basic biomedical approach. A note on the language of recovery Although the recovery model in mental health is historically routed in substance misuse or addiction, from 12-step approaches e.g. Alcoholics Anonymous in particular. Recovery in the field of addiction can be used in a different way to that of mental health and remains a controversial term according to different approaches to treatment. According to 12-step approaches there is an emphasis on defining oneself as in recovery or as a recovering addict once one has become completely abstinent from all drugs and alcohol. Recently the UK Drug Policy Commission created a description of recovery drawing on different approaches to addiction and the model of recovery in mental health: The process of recovery from problematic substance use is characterised by voluntary control over substance use which maximises well-being and participation in the rights, roles and responsibilities of society (UK Drug Policy Commission cited in Drink and Drug and News, 2008) The notion someone with controlled substance use being in recovery is likely to be considered an anathema from a 12 step perspective.

TREATMENT OF SUBSTANCE MISUSE A MODEL OF CHANGE Before considering drug and alcohol treatment in context, it is useful to present a transtheoretical model of change that can be used with clients with any addictive behaviour (or any client working towards behaviour change). The stages of change model is a useful tool for guiding the selection of treatment goals and interventions ( Fig. 29.3). Therapeutic intervention can be targeted to help clients progress through the stages of change. Prochaska & DiClemente (1982, 1986; Prochaska et al 1992) first developed this model with cigarette smokers, who they found reported movement through different stages of change as they attempted to give up. These same stages have since been observed in all other addictive disorders (Gossop 1994b). It reflects the reality that it is normal for an individual to go through all the stages several times before achieving lasting behaviour change. Most of us can relate to attempting behaviour changes ourselves, for example, dieting, starting regular exercise or stopping smoking, where we have not succeeded in maintaining the change at the first attempt. In fact, Prochaska & DiClemente's initial research was with smokers who went round the cycle between three and seven times before finally giving up for good.

Addiction can be viewed as a chronic, relapsing condition in which relapses are viewed as normal events that can be learned from rather than seen as failure. Although represented as a cycle, it is now conceptualised as a spiral acknowledging that each time the person goes through the stages, they are learning from the experience of previous attempts to change. Stages of change The central concept of this model is that behaviour change takes place through the following discrete stages. Precontemplation. These are people who do not recognise that they have a problem, therefore they are outside the 'model of change'. 'Precontemplators' rarely present for treatment. However, when they do, it is in order to assuage the concerns of others. Contemplation. In this stage, the person recognises that his behaviour is problematic and considers doing something about it. This change is characterised by ambivalence. Motivational enhancement therapy or motivational interviewing is a useful, evidence-based approach to use during this stage. Preparation The person prepares to change. Action. Making the change, implementing the plan. Maintenance. Sustain the change, integrating the change into the individual's lifestyle. Due to the nature of this model, it follows that a person may slip back a stage or exit the cycle into precontemplation at any time. By using this model the therapist can establish which stage the client is at and use this to select the most appropriate treatment. For example, a client in the maintenance phase may benefit from learning stress management and developing satisfying occupations in day-to-day life which are important in preventing relapse into drug or alcohol use. This would boost self-confidence and reduce the risk of relapse. However, these strategies would probably be wasted on someone in the precontemplation phase. The use of this framework to guide occupational therapy service delivery is described by Buijsse et al (1999). The model of change is an effective means to assess readiness for treatment. Research indicates that effective treatment matching based on an assessment of treatment readiness is a significant predictor of engagement and retention (Project MATCH 1993, Simpson et al 1997). If the client has an alcohol problem a standardised assessment, the Readiness for Change questionnaire (Heather et al 1991), can be completed. For drug users the stage of change can be ascertained through self-reported drug use, urine analysis and client consultation. In addition to assisting in treatment matching, this model is helpful for both client and therapist in setting realistic and achievable goals; that is, to move to the next stage in the cycle rather than try to stop the behaviour immediately. Also, it is a more optimistic approach in that relapse is viewed as a normal part of the process of achieving long-term behaviour change rather than as failure. Occupational therapy input is ideally placed when the client has reached the maintenance phase. However, the reality is rarely that straightforward. The occupational therapist needs to be able to assess what stage the client is in and respond accordingly. SUBSTANCE MISUSE TREATMENT IN CONTEXT Drug and alcohol treatment services are operated by the NHS, Social Services and prisons, private clinics and the voluntary sector. Treatment settings include hospital and community locations, and treatment can commence in either. Triggers to treatment entry Entry into treatment is usually triggered by a crisis. For example, a family seeks help from their general practitioner as they can no longer tolerate their daughter's growing drug habit; a young person is caught breaking into houses to fund a growing crack cocaine habit; a patient is admitted to hospital because his liver is failing as a consequence of his drinking; a City of London businesswoman is taken to a private clinic by her partner out of concern for the amount of whisky she drinks at work; a vulnerable, homeless person with schizophrenia has been sexually assaulted when incapacitated on tranquillisers; or a sex worker seeks help during her latest attendance at a needle exchange. A crisis is often when an individual moves precontemplation into contemplation according to the model of change described previously. Therefore it can provide a window of opportunity to encourage engagement in treatment.

Treatment services often target these crises as an opportunity to encourage people who to engage in treatment. For example, specialist alcohol nurses assessing people attending A&E or drug users being assessed whilst in police custody after being arrested for drug acquisitive related crime. Referral People with alcohol and drug problems are frequently referred for treatment by their GP, self-refer or are referred after an alcoholrelated physical problem is identified, e.g. in A&E. Others are referred as a result of initiatives within the criminal justice systems (see below). Some referrals will come from employers or employee assistance programmes.

Treatment via the Criminal Justice System Since 2000 there has have been increased links between the criminal justice system and treatment systems. Alcohol Treatment Orders and Drug Rehabilitation Requirements (formerly Drug Treatment and Testing Orders) were introduced as part of the Criminal Justice Act 2003 (HMSO, 2003). These are treatment orders or suspended sentences for those convicted of a drug or alcohol related crime and involve the person agreeing to a programme of drug testing and participation in structured treatment often as an alternative to a custodial sentence. Arrest referral schemes operate whereby those held in police custody are offered a brief assessment by a drug or alcohol worker who aims to facilitate entry into treatment for those identified as having problematic drug or alcohol use. Drug and alcohol misuse within the forensic mental health system has been the subject of several papers (McKeown et al, 1996). Occupational therapy programmes in these settings have been described by Chacksfield & Forshaw (1997) and Chacksfield (2003). MULTIDISCIPLINARY ASSESSMENTS Assessments are initially adisciplinary. The person at the first point of contact may be a nurse, a doctor or a duty drug worker of any profession. The assessment needs to be tailored, needs led and an ongoing progress (NTA 2002). Many guidelines stress the importance of expressing empathy and a non-judgemental manner in the assessment process e.g. NICE clinical guideline 115 (2011), Drug misuse and dependence: guidelines on clinical management (DoH et al, 2007) recognising both the stigma that service users feel as well as ambivalence about change that is common at the beginning of treatment (see A Model of Change described earlier) The goal of the assessment is to discover the primary issues surrounding the client's substance use, his motivation to change his habit and how long and how severe the habit is. During this time the client will be monitored for withdrawal symptoms. He may also be breathalysed or have urine and/or blood tests to monitor the alcohol or drug content and assess liver functioning. A risk assessment will also form a part of the procedure. During the assessment period, a number of assessment techniques may be used, including: screening assessments structured questionnaires interviews observation self-assessment physiological assessments (for example, blood analysis, ECG).

Screening assessments A number of screening assessments can be used. For alcohol NICE recommends the AUDIT, SADQ and APQ tools (NICE, 2011). The widely used CAGE questionnaire (Box 29.1) is a part of the AUDIT and is a useful way to provide fast, rough guides to the extent of drinking problems. According to NICE guidelines NHS staff should be competent to identify harmful drinking and alcohol dependence. They should be able to competent to initially assess the need for an intervention (p 5, NICE, 2011). The authors recommend the CAGE questionnaire (Box 29.1) as a useful brief and effective screening tool for therapists working in any speciality. For drug use there is the Severity of Dependence Scale (Gossop et al 1995), which is designed to be generic for a range of drugs. It is essential to monitor withdrawal (Edwards 1987) and assessments are often used to assist this, such as the Short Opiate Withdrawal Scale (Gossop 1990). The standard outcome measure in drug treatment services is the Treatment Outcomes Profile (TOP) (Marsden et al, 2007). It is requirement placed on all treatment providers by the National Drug Treatment Monitoring System (NDTMS). This outcome measure is also validated for those with alcohol problems.

Box 29.1The CAGE questionnaire 1. Have you ever felt you ought to CUT DOWN on your drinking? 2. Have people ANNOYED you by criticising your drinking? 3. Have you ever felt bad or GUILTY about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (EYE-OPENER) Two or more affirmative replies are said to identify the problem drinker. Research has supported this assertion.

Interview techniques Interviews add to the assessment. These can follow a standard mental health interview approach but should also include questions about the client's substance use such as: number of different drugs used amount used a typical day of use history of use, including first drug use occasion and changes in use over time. NICE recommends that for those with alcohol problems a Motivational Intervention is carried out as part of an assessment using key elements of motivational interviewing i.e. helping people to recognise the problems caused by their drinking, resolving ambivalence, encouraging belief in ability to change and being persuasive and supportive rather than confrontational (NICE, 2011)

Structured Comprehensive assessments Multidisciplinary, structured questionnaires aim to investigate the severity of dependence, the range and complexity of problems, including the effects of drug using behaviour on dependent children, associated with substance use and motivation to engage in treatment or change substance use behaviour. Other issues may include measurement of specific symptoms, such as anxiety, and rehabilitation potential, using occupational therapy assessments. OCCUPATIONAL THERAPY ASSESSMENT Occupational therapy investigates three domains (American Occupational Therapy Association 1994). Performance areas Categories of human daily activity, such as activities of daily living, leisure, self-maintenance and work/productivity. Substance use affects each of these areas in different ways. Occupational therapists are concerned that substance misuse and dependence disrupt the balance of work, self-care and leisure (Busuttil 1989, Lindsay 1983, Chacksfield 1994, Morgan 1994, Nicol 1989, Rotert 1990, Martin et al, 2008). Quantitative research by occupational therapists such as Mann & Talty (1990), Scaffa (1991), Stoffel et al (1992) and Chacksfield & Lindsay (1999) has highlighted poor use of leisure by alcohol-dependent clients as a key problem area. Performance components Fundamental human abilities are required for successful engagement in performance areas including sensorimotor, cognitive,

psychosocial and psychological components. Drug action can create both short- and long-term effects on performance components. Occupational therapy research has suggested that low motivation and low self-esteem are significant in substance misusers (Stoffell et al 1992, Viik et al 1990). Research by Martin et al (2008) in homeless substance users admitted to a halfway house recovery programme, explored performance capacity issues as well as their impact on quality of life, using a variety of ratings, including the Occupational Performance History Interview II (OPHI-II) (Kielhofner et al 1998). Results suggested that intervention by occupational therapists was associated with increased scores on all measures. Issues that led to relapse were related to the environment and positive changes in occupational competence scores on the OPHI-II were associated with recovery at the 6 month stage of follow-up after a dip in scores at 3 months. Which the authors attribute to the impact of the environment. With mastery scores appear to increase again. The research appears to suggest that occupational competence is one of the key factors in recovery from addiction.

Performance contexts Environmental factors and situations that influence the client's engagement in performance areas. These are significant in substanceusing clients due to the way environmental cues can impact and trigger substance use, called 'environmental press' by Kielhofner (2002). This idea has been supported by a growing body of research into cue exposure (Drummond et al 1995). Cue exposure concerns environmental cues or stimuli that trigger addictive behaviour in individuals. A client returning to the same lifestyle on discharge is likely to relapse to substance use and will need work on coping strategies to counteract environmental effects. Occupational therapy assessment tools Occupational therapists will wish to supplement the standard initial interview with open questioning to obtain information about how substance use is impacting on the client's occupational performance areas, components and contexts. The Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS) (Forsyth et al 2005) is a semi-structured interview often used by occupational therapists with this client group. Other appropriate tools include: Occupational Self-Assessment (OSA) Rosenberg Self-Esteem Inventory Self-Efficacy Scale Volitional Questionnaire Coping Responses Inventory (CRI) Interest Checklist Role Checklist Assessment of Motor and Process Skills (AMPS) Internal/External Locus of Control Scale Occupational Performance History Interview (II).

Use of these instruments will be limited by the time available.

INTERVENTIONS Substance dependence is typically a chronically relapsing condition. Therefore interventions often do not follow a linear path. Using the model of change to assess treatment readiness and motivation (described above) combined with an accurate picture of the person's current substance use is important in selecting the most appropriate intervention.

ENGAGEMENT Many people with substance misuse problems struggle to engage with treatment services. Feelings of ambivalence, anxieties about change, fluctuating levels of motivation and a chaotic lifestyle are part of an addiction or dependence. Enhancing engagement and retention is key in achieving positive outcomes of treatment (NTA 2004, DH, 2007, NICE, 2011). The importance of establishing rapport, empathy and motivational enhancement techniques from the initial assessment onwards must not be underestimated (NTA 2004). PRINCIPLES OF INTERVENTION Intervention is a complex process in the field of substance misuse due to the complex needs presented by clients; therefore, a multidisciplinary, multimodal, multiagency approach works best (DoH 1996, Edwards 1987). Some principles of intervention include: tailoring treatment to the individual client fostering a relationship between the client and the treatment institution setting achievable goals for intervention involving the family or carers emphasising empowerment of the client in overcoming substance problems or dependence.

Treatment strategies Strategies tend to aim towards the following goals: 1. detoxification 2. addressing external and internal problems not directly related to substance use 3. reducing external and internal problems that are related to drug use 4. reducing harmful or hazardous behaviour associated with the use of drugs (for example, sharing dirty needles) 5. developing the internal resources (self-esteem, motivation, knowledge) to address the drug problem or dependence 6. establishing a safe, controlled pattern of drug use that is not harmful or dependent 7. establishing abstinence from the problem drug (or drugs) 8. establishing abstinence from all drugs 9. establishing lifestyle that promotes recovery and reduces the risk of relapse These goals are not mutually exclusive and can be carried out in combination. For instance, many physical problems, such as muscle atrophy or memory loss, may continue to require treatment during many of the other stages. Occupational therapists contribute to the intervention programme by enhancing occupational performance via activity-based and other related interventions.

TREATMENT OPTIONS

Alcohol misuse Detoxification or detox followed by abstinence is recommended for people who are physically dependent on alcohol. Detox

involves the prescription of decreasing doses of librium to manage withdrawal symptoms. Those who are at risk of withdrawal fits will be offered inpatient detox, others may be offered a community detox. Those with less severe alcohol problems and binge drinkers may opt for 'controlled drinking'. This means keeping alcohol consumption within safe levels by adhering to a set of personal rules, e.g. not drinking alone, not having more than two drinks a day, not drinking on consecutive days. After becoming abstinent or successfully controlling alcohol, NICE (2011) recommends that people are offered: Cognitive behavioural therapy (frequently provided in the form of a relapse prevention approach which will be discussed later). Behavioural therapies e.g. cue exposure: repeatedly exposing a person to learnt cues to drink alcohol until they habituate to the cues and the cravings to drink are extinguished. Social network and environment-based therapies. These approaches involve an individual being supported to build a network of family and friends that are supportive of a change in drinking. Recreational, social and vocational activities can be encouraged as part of this approach. This approach fits with the research of McIntosh & McKeganey (2000) who found that developing a non substance using network and developing a role or a positive identity were key factors in preventing relapse.

Behavioural couples therapy: a manual based method combining cognitive behavioural therapy with methods that address relationship problems caused by the alcohol use.

Drug misuse A hierarchy of goals has been developed for drug treatment (DoH 1996, NTA 2002). These are: reduction of health, social and other problems directly related to drug misuse reduction of harmful or risky behaviours associated with the misuse of drugs (e.g. sharing injecting equipment) reduction of health, social or other problems not directly attributable to drug misuse attainment of controlled, non-dependent, or non-problematic, drug use abstinence from main problem drugs abstinence from all drugs.

This hierarchy of drug treatment goals endorses the principle of harm minimisation, which refers to the reduction of the various forms of drug-related harm (including social, medical, legal and financial problems) until the drug misuser is ready and able to come off drugs (DoH et al 1999). Harm reduction interventions include safer injecting advice and needle exchange schemes. As described earlier in recent years treatment services have been criticised for focusing on harm minimisation techniques and failing to do enough to help people achieve abstinence. Substitute prescribing Many opiate-dependent users require prescription of a substitute drug, methadone or buprenorphine. This aims to stop the user experiencing unpleasant withdrawal symptoms but does not provide a 'high'. The rationale behind substitute prescribing is that the drug user no longer has to inject street heroin, with its associated health risks, or be involved in illegal activities in order to fund a habit. Long-term prescription of methadone, or methadone maintenance, aims to allow users to stabilise their drug use and therefore their lives and, combined with psychological and social support, enables users to make positive lifestyle changes. It requires close monitoring due to the risk of overdose or harm related to illicit drug or alcohol use. Physical and mental health treatment Many clients also have physical, social, legal and psychological problems which need to be addressed as part of a comprehensive treatment plan (see section on dual diagnosis). APPROACHES TO INTERVENTION There are numerous models of substance misuse treatment and it is beyond the scope of this chapter to cover all of them. However, those approaches that occupational therapists are most likely to come across and those of most relevance to occupational therapists are described below.

Mutual Aid Self Help Approaches. These approaches are recommended in national guidelines (NICE, 2007 &2011). The most well known by far are the 12 Step approaches of Alcoholics Anonymous (AA) and its associate Narcotics Anonymous (NA). The 12-step approach is a self-help movement that offers an extensive international support network for substance users and their families. Meetings of these organisations occur at various times during the day and are supplemented with Step Meetings, for those serious about abstinence, and individual support from a sponsor. The sponsor is a person who has been successful in his abstinence for a significant length of time and who has worked his way through the Twelve Steps (Box 29.2). Criticism has been made of the requirement that those who attend have to adhere to the idea that dependence is a disease and that people attending have to constantly remind themselves that they are alcoholic, even when they have been abstinent for many years. Additionally, criticism is directed at the idea that a higher power is responsible for an AA or NA member's abstinence, suggesting that this removes the responsibility for sobriety from the individual. However recent research has found that it supportive social network that 12-step approaches provide rather than the belief system that is key to good outcomes (Litt et al, 2009). This research recommends that treatment providers de-emphasise the philosophy of 12 step approaches but encourage attendance as a means of gaining social support that promotes abstinence. Recent research into what makes this approach effective may be of particular interest to occupational therapists. Studies have found that changing from someone in need of help to someone who provides help to others and taking an active role in meetings e.g. by making coffee was associated with positive outcomes as opposed to just attending (Pagano et al, 2004, Weiss et al, 2005). In this way developing a productive and valued role was key positive outcomes. The 12 Step approach is widespread and is highly popular in the USA within private and public healthcare programmes. Box 29.2The Twelve Steps of Alcoholics Anonymous 1. We admitted we were powerless over alcohol that our lives had become unmanageable. 2. Came to believe that a Power greater than ourselves could restore us to sanity. 3. Made a decision to turn over our will and our lives to the care of God as we understood Him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 6. We were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings. 8. Made a list of all the persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take a personal inventory, and when we were wrong promptly admitted it. 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry it out. 12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics, and to practise these principles in all our affairs. A growing, secular alternative to 12 Step approaches is SMART recovery http://www.smartrecovery.org/ A programme is offered online and with a network of meetings and volunteers based on Motivational Enhancement Therapy, Cognitive Behaviour Therapy and Rational Emotive Behaviour Therapy.

Relapse prevention Based on the model of change, relapse prevention (RP) (Marlatt & Gordon 2005) has become one of the most widely used intervention approaches in the field of addiction based on cognitive behavioural therapy. Marlatt (Marlatt & Gordon 2005) suggested that RP is a self-management programme that is designed to enhance the maintenance phase of the model of change. NICE recommend that this approach is only routinely offered to those with co-existing anxiety and depression (NICE, 2007). However, as described earlier (under dual diagnosis) it is likely that most service users are likely to present with these addition problems. Relapse prevention can be defined as 'a wide range of strategies to prevent relapse in the field of addictive behaviours' with an emphasis on 'self management and the techniques and strategies aimed at enhancing maintenance of habit change'. It is a self-control programme that combines behavioural skills training, cognitive interventions and lifestyle change procedures' (Wanigaratne et al

1990, p1). There is a growing body of evidence supporting the effectiveness of RP interventions (Carroll 1996, Irvin et al 1999). The RP approach uses cognitive behavioural strategies to help clients who are trying to stop or reduce drug or alcohol use to learn how to anticipate and cope with situations and problems that might lead to a relapse (Wanigaratne et al 1990). The model focuses on the notions of high-risk situations and coping strategies available to the individual. Research has shown that people who are aware of potential relapse situations and use specific strategies can effectively reduce their risk of relapse (Kirby et al 1995, Litman 1980). Boredom and negative mood states are most likely to precipitate a relapse. Second comes social pressure and being offered, or talking about, drugs. Other risk factors beyond these include alcohol use, interpersonal conflict and environmental cues. Environmental cues or triggers to relapse are important factors in prognosis, therefore these are given high significance in relapse prevention. Initial stages of relapse prevention focus on enabling the client to develop good awareness of internal and external triggers to craving. Methods used include diary keeping, where clients regularly chart substance use and the antecedent and consequent feelings, activity and location of use. Clients are encouraged to identify possible relapse triggers unique to themselves and work on these with the therapist. The therapist, either in a group setting or individually, can help the client to analyse these situations. The client will also be taught how to analyse situations for himself. Structured problem-solving techniques are used as well as role-play or rehearsal of relapse situations. Specific cognitive behavioural techniques (Marlett & Gordon 2005, Wanigaratne et al 1990) used to assist the client in preventing relapse include: Seemingly Irrelevant Decisions (SIDs): this works on how to identify and prevent covert planning that may lead to relapse, such as happening to go into the local pub to buy cigarettes and eventually obtaining alcohol Problems of Immediate Gratification (PIGs): methods for dealing with craving by seeing this as caused by high risk situations and external cues. Described as metacognition, by Marlatt (2010) he describes a method for managing urges. Urge Surfing, which is based on mindfulness is cited as an excellent method for managing this by facilitating detachment (I notice I am feeling the urge to drink versus acting immediately to drink) and understanding that the urge will actually arise and then subside. Not responding to it at its peak starves it through active coping. Coping strategies, such as relaxation methods, distraction, biofeedback or other approaches, may assist this technique. In addition to specific coping techniques, RP stresses the importance of 'global lifestyle change'. It aims enable clients to: arrive at a balanced lifestyle learn effective time management (to fill up the vacuum left by giving up the substance use) discover and take up positive activities identify and change unhealthy habit patterns.

Therefore it can be seen that relapse prevention is an approach that fits well with occupational therapy, in particular because it focuses on lifestyle and real situations that cause relapse. Here, occupational performance areas, components and contexts are critical to treatment success. Developing psychological performance components, such as self-esteem and volition, for example, can help an individual cope with environmental triggers to relapse, also called environmental press (Kielhofner & Forsyth 1997).

OCCUPATIONAL THERAPY AND SUBSTANCE MISUSE The earliest papers describing occupational therapy with alcoholics highlight areas for concern that are close to those identified by modern occupational therapists after research and the experience of time. For example, a Canadian occupational therapist, Hossack, writing in 1952, highlighted reduction in former interests and activities as well as social connections, difficulty concentrating, tension and family problems. She suggested that the alcoholic 'must look to a more fully rounded life with a balance of activity'. Doniger, in 1953, suggested unpredictability, elusiveness, relationships, leisure and motivation as areas for concern. The issues raised by these two pioneers of occupational therapy in the field of addiction remain key throughout much of the subsequent occupational therapy literature. Occupational therapy can have a significant impact in preparing a client for change and in changing from substance misuse to a more controlled or abstinent life. Substance dependence has an inherent occupational nature as illustrated by these diagnostic criteria for substance dependence: A great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects. Important social, occupational or recreational activities are given up or reduced because of substance abuse. (American Psychiatric

Association 1994, p181) For many clients with substance misuse problems, prior to treatment their lives have completely centred around their drug/alcohol use. After becoming abstinent or engaged in treatment, clients may experience a vacuum in their day-to-day lives which leaves them deskilled, vulnerable and bored. Occupational therapy can help clients to develop skills and coping strategies, as well as a more satisfying, balanced lifestyle. The research of McIntosh & McKeganey (2000) found that it wasnt enough for ex users to keep busy but finding activities that were purposeful, meaningful and rewarding. Some of the general issues occupational therapy can address are divided under the three occupational performance area headings of work, self-care and leisure. Intervention is usually via individual work and group work. It can involve both task-oriented and personcentred activities aimed at developing performance components in a range of contexts, for example learning to cope with anxieties without alcohol or saying 'no' if offered drugs. Group contexts and community locations can provide the chance for try-outs of performance components. Individual work can focus on enhancing very specific components through counselling and/or role-play. LEISURE Leisure is one of the key problem areas for substance misuse clients. This is principally because leisure activities and contexts are where alcohol and drugs are most commonly used. Negative mood states, such as boredom, and social pressure are the two most common factors in relapse. Many people who have become dependent on substances will know few or no other leisure activities apart from those that involve substance use. The importance of leisure as an effective component of relapse prevention has been highlighted in a wide range of research literature (Bennett et al 1998, Burling et al 1992, Cheung et al 2003, Hodgson & Lloyd 2002, Mcauliffe 1990), including occupational therapy literature (Hodgson & Lloyd 2001). Leisure activities are particularly useful in reducing the frequency of negative thoughts and alcohol craving (Bennett et al 1998) as well as building self-confidence (Cheung et al 2003), therefore reducing the risk of relapse. The use of physical activities in particular for a variety of therapeutic goals is described in the research literature (Burling et al 1992, Donaghy & Mutrie 1999) and provides a small but promising evidence base. Ussher et al (2000) describe the development of a physical activity programme as part of an occupational therapy programme within a community alcohol service. The goals of occupational therapy will focus on learning how to use leisure time and how to counteract negative mood states. During treatment, new or forgotten leisure activities can be tried out. Sport and fitness-related activities will raise self-esteem and confidence and counteract negative affect. Discovering or rediscovering leisure can help develop motivation to change and move clients round the process of change, in conjunction with other therapies. Group work can be used to explore leisure-seeking and leisure replacement techniques and self-motivation. As part of a relapse prevention programme, rehearsal and role-play around leisure-based relapse situations can be useful. This can be linked to cue exposure therapy programmes, in which role-play is carried out in the environment where substances may have been used or obtained. Leisure intervention may form an important part of family therapy, where family-oriented leisure has been involved with or affected by substance use. In the authors' clinical experience, activities that help a substance user to engage in adaptive interactions with family members are often highly successful. This is especially so where the client enjoys and can remember the activity and where it stimulates both client and relative. Examples include practising magic tricks (as described in the case vignette in Box 29.3), cooking group meals, learning day trip locations, swimming, playing racket sports, bowling and visiting theatres, cinema or art galleries. Activities that individuals can take up as a hobby and talk about with the family are effective. The impact of substance misuse on family is often highly significant. Box 29.3Case vignette (based on a case in a London alcohol unit) Brian was a 32-year-old man diagnosed with alcohol dependence, who had a history of verbal and sometimes physical violence towards his two young children. He valued his role as a father but felt he did not know what to talk to his children about. Occupational therapy involved attendance at six weekly group sessions on magic tricks (involving card and coin tricks). After the third week his children visited him and he showed them one of the coin tricks he had learned. They were delighted and spent an hour talking to him about it and trying to learn what he could do. He took stage magic up as a hobby and obtained the admiration of family and friends for his abilities. He remained sober for over a year.

WORK/PRODUCTIVITY Work and productivity in substance misuse cover three distinct areas of discussion: drug use during everyday, legal employment drug use or dealing following similar patterns to paid work and providing similar rewards and meaning to life helping service users gain employment.

Work-based substance use Where substances are used during a job, this can be very subtle and often either linked to peer pressure or for coping with work pressure. Substance use can be considered a part of work when the entertainment of business clients is part of the working day. Substances are often hidden at work and used covertly. Initial experiences of high achievement reinforce this pattern of substance use but errors of judgement usually ensue and crises occur. Jobs are often affected negatively or lost altogether once substance misuse patterns become established. Other non-paid work, such as housekeeping and voluntary work, will exhibit similar features to the above. Occupational therapy goals focus on helping a client cope with work without using the drug. In addition, intervention aims to develop resistance to relapse triggers in work settings. Work may involve liaison with an employer to develop graded re-entry into work and to identify coping strategies and support strategies for both employer and employee. People who, owing to their substance use, have lost work or have been unable to hold down a job may need to start with low-pressure, voluntary work until they have developed the confidence, tolerance and skills to enter full-time employment. Substance-based productivity Where maintaining a drug habit becomes work, an individual's effort can be directed to obtaining a regular supply of the substance, selling the substance or engaging in regular criminal activity in order to fund the drug habit. These three types of behaviour can follow patterns and display characteristics that are very similar to legal employment. A certain amount of a product will have to be obtained during the day. Where dealing is involved, this product will have to be sold to obtain money to either buy more or maintain a regular supply of drugs. In order to achieve this, and avoid arrest by the authorities or violence from peers, a considerable repertoire of specialised dealing, trading and bargaining habits can be developed. Alcoholics often describe a daily routine of waking, drinking, obtaining money, going to purchase alcohol and drinking it. When withdrawal occurs, more alcohol is purchased. This pattern can be as regular as the routines in a 9-to-5 office job. Occupational therapy can focus on identifying habit-maintaining skills and transferring these to non-drug related activities, such as voluntary work, training or employment. Clients can be encouraged to enrol in training to develop business skills or apprenticeshiptype work where a gradual skill transfer can occur. This type of intervention should ideally occur in conjunction with appropriate support. Alcoholics Anonymous and Narcotics Anonymous offer opportunities for members to engage in voluntary work to help run the organisation. This can work well, as support from peers with experience of abstinence is available. Vocational Interventions There is an increasing focus in treatment services on helping service users gain employment. This is part of a wider policy initiative aimed at reducing the number of people receiving benefits but also acknowledging the positive link between employment and recovery from substance dependence (NTA, 2006, McIntosh & McKeganey, 2000, Scottish Executive, 2001). Occupational therapists have a key role in enabling services work towards meaningful employment. There is significant evidence from the U.S. and some from the UK to support the fact that employment, training and education for substance misusing clients enhances clinical outcomes by reducing rates of relapse, restricting time of use, and reducing criminality and parole violation (Alverson, Alverson & Drake 2001; Fisher & Anglin 1987 ; Hubbard et al 1989; Jenner 1998; Kang et al 2006; Platt 1995; Platt et al 1998; Room 1998 and Valliant 1998). The above research found the need for pre-vocational skills development (personal development: confidence building, inter-personal skills, time keeping, budgeting skills) was necessary and essential in order to improve employment outcomes. A research review by the Effective Interventions Unit (Scottish Executive, 2001) also highlighted the importance of soft skill or prevocational skill development. Occupational therapists are skilled in developing prevocational skills as part of a rehabilitation programme. People with addiction problems have often lost confidence and skills through years of substance misuse (Chandler et al, 2004, Gutman at al, 2004 & Morganstern at al 2003). Occupational therapy can enable clients to rebuild confidence and skills through engagement in activities that are carefully selected to provide the right balance of challenge and skill. For example through community and occupation based group work projects. A large scale study undertaken by Kang et al (2006) highlighted that there is poor compliance with vocational services for methadone treatment patients without their being pre-vocational work integrated into a specialist work rehabilitation programme. Occupational therapists are specialists in pre-vocational work using creativity and building on activities of daily living which encourages structure in a clients life and ensures a meaningful day. Research indicates that delivering a vocational programme in conjunction with treatment improves outcomes (Drake et al, 2003). Education, employment or training goals should therefore be included in all treatment plans. Occupational therapists, alongside employment specialists where they are present, can act as vocational leads within the MDT, assessing vocational and pre-vocational skills and developing individualised plans.

The most widely used outcome measurement tool; the Treatment Outcomes Profile(TOP) (Marsden et al, 2007), measures employment and education/training as an indicator of treatment success. There is strong evidence that interventions to engage service users in employment, training and education is most effective when integrated into clinical treatment teams (Drake et al, 2003). Enabling service users to develop and work towards vocational goals is central to the role of the occupational therapist, addressing prevocational and vocational skills as a primary focus of intervention. SELF-MAINTENANCE Self-maintenance activities tend to decrease the more substances are used. The compulsion to use a drug eventually supersedes any awareness of nutrition, health, cleanliness, safety or responsibility for finances and daily life becomes chaotic. Drug users, once abstinent or stabilised in treatment, often feel particularly de-skilled to cope with day-to-day household activities such as budgeting or basic time management. Dental problems and loss of teeth is a common consequence of drug use (Edwards 2010) the effect that this has on self-image can pose a barrier to achieving occupational and social goals. Remedial dental work can be a helpful early goal included in a treatment plan to help them construct a non- addict identity and remove perceived barriers to social interaction caused by the appearance of teeth or loss of teeth ( Robinson, 2005)

EVALUATION OF OUTCOMES Outcome measurement is possible through a wide range of occupational therapy-specific and other questionnaires or assessment tools. Some of these are described in the assessment section (above). Most of those described are used as before and after measures of blocks of intervention. Others can be used on a sessional basis, such as the General Health Questionnaire (Goldberg 1986). In addition all drug services in England are required to routinely use the Treatment Outcomes Profile (TOP) (Marsden et al, 2007).. This is an outcome measure developed by the NTA that measures: Drug and alcohol use Physical and psychological health Social functioning Offending and criminal involvement.

SUMMARY This chapter has focused on the range of issues presented by people who misuse substances and the intervention strategies open to them. It is clear that there is considerable scope for occupational therapists to contribute to substance misuse treatment. Substance misuse occurs at the very centre of human occupation, in work, leisure and self-care, and it gradually takes over as the most central driver of occupational behaviour, changing and damaging performance components as it progresses. Occupational therapy methods work well with the key clinical approaches already developed in the field of addiction. Furthermore, occupational therapists can learn and enhance practice through their work with the subtle and complex issues that clients in this field present. Further research is recommended in this area, as is further education, especially as substance use exists within all areas of mental health practice and is more likely to increase than decrease in everyday practice.

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Useful Contacts College of Occupational Therapists, Specialist Section Mental Health Website: www.cot.org.uk/ Drugscope Tel: 0207 928 1211 Website: www.drugscope.org.uk Provides information on drugs and drug misuse. Alcohol Concern Tel: 0207 928 7377 Website: www.alcoholconcern.org.uk Alcohol Concern is a national alcohol misuse agency. Drinkline 0800 917 8282 Alcoholics Anonymous (AA) Tel: 0207 352 3001 Website: www.alcoholics-anonymous.org.uk Narcotics Anonymous (NA) Tel: 0207 730 0009 Helpline: 0207 251 4007 Website: www.ukna.org/ National Consortium of Consultant Nurses in Dual Diagnosis & Substance Use - Website: www.dualdiagnosis.co.uk/ National Drugs Helpline 0800 776600 Website: www.talktofrank.com

Figure 29.1Drug use and the Human Open System: an example (all names are fictitious).

Figure 29.2Diagram to show how problems and dependence coexist (after Edwards et al 1977).

Figure 29.3A model of change (adapted by Jenny Lancaster from Prochaska & DiClemente 1982, 1986).Table 29.1 Drugs and substances according to psychoactive quality and legality

Drug name

Method of consumption

Legal class/status

Stimulants

Nicotine

Smoking in cigarette, cigar, pipe Legal if aged 16+

Cocaine

Heated and inhaled or smoked

Illegal: Class A

Crack cocaine

Smoked or injected

Illegal: Class A

Amphetamines

Tablets or injected

Illegal: Class A

Depressants

Alcohol

Oral ingestion via carrier substance

Legal if aged 18+

Benzodiazepines

Tablet form, oral or injection

Legal if prescribed

Opiates

Heroin

Injected or smoked by heating and inhalation (chasing the dragon)

Illegal: Class A

Drug name

Method of consumption

Legal class/status

Hallucinogenics

Lysergic acid diethylamide Manufactured as tabs, small Illegal: Class A (LSD or acid) squares of paper which are Psilocybin ('magic placed mushrooms) on the tongue Infusion (tea) or Illegal: Class A if prepared smoked after drying Tablet form MDMA ('ecstasy') for use, e.g. by drying Illegal: Class A Cannabis Smoked, inhaled Illegal: Class B

Other