Review of the UK/European Symposium on Addictive Disorders 2012 Conference
EURAD attended the UKESAD Conference, which took place from 10th-12th May 2012. In-depth summaries of presentations ranging from the evidence of AA models, to club drugs to advice for alcohol/drug workers.
This week, over 100 worldclass experts in how to recover from addiction shared their knowledge and expertise with attendees at over 40 presentations. The event was organised by the fantastic team at the Addiction Recovery Foundation.
Thursday 10th May 2012
Rt Hon Lord Mancroft
Lord Mancroft opened the conference, in a speech which resonated well with the audience, in which he spoke of the damaging impact of addiction and the impact on their families, which he added, "is wrongly overlooked". He provided context of the UK situation, where quite recently the national drug strategy has changed from being one, which focused mainly on reducing harm, to an approach which places recovery from drug addiction at its' core. He noted that "it is clear that the harm reduction approach is not sufficient as it only contains the problem...what we need to do is help people with drug problems participate more in society". He then called upon the audience, who were made of up people mainly working directly in treatment, rehabilitation or socialisation to see the role that they would play and emphasised the need for treatment to be based upon the individual.
Rokelle Lerner, "Thank you for your willingness to be with their suffering and help show them a new path to recovery"
Rokelle opened the conference with an extremely inspiring talk to all addiction workers or those who work with people who use drugs or alcohol. The core focus of the talk was on how people working in the field of drug use and addiction maintain themselves, their motivation and their vitality.
She spoke about the difficult environment addiction professionals often find themselves working in, in that it oftens gets chaotic and stressful. With a great sense of humour, she alluded to the African proverb that says "Let us take care of the elders for they have come a long way, let us take care of the children, for they have a long way to go. Let us take care of all the people in between, for they are doing all of the work".
So Rokelle asks, are you going to a workplace that matches your spirit? Sometimes you might get so frustrated, you are wandering whether your work is really making a difference but then noting, that there are always going to be challenges to us. She noted that sometimes the body screams, when we don't, with symptoms such as depression, restlessness or fatigue, sometimes setting in without warning.
She notes, "no-one has a job like an addiction counsellor...who are increasingly called upon to assist not only survivors but perpetrators of violent crime, childhood abuse and so on". She continues that some workers develop burnout whilst others may develop compassion fatigue where you absorb the trauma and stress from others. She notes that whilst burnout may come to an end , compassion fatigue may be a little more difficult to deal with but where both exist, one could see the onset of post-traumatic stress disorder symptoms. Indeed, there can be a cost to caring, especially if you are the sort of person that forgets to take care of yourself. She notes however, how important it is to have compassion when you are dealing with emotional healing and that if you cannot show compassion, it may be very difficult for you to have a positive effect on the person you are working with. However, whilst compassion is necessary, it is also important to remember that you are not alone responsible for finding the way out for the other person, it should be more about walking along side someone, not specifically taking the lead.
Protective Traits To Help You Tolerate Stress
Clear values and a sense of purpose
What would be in your triangle? If you drew a pyramid showing how you spent your time over the last 6 months, would the two pyramids look alike?
So what advice does Rokelle give to addiction workers? Well, she says that we need to:
Bring our priorities back in order and bring forth creativity and humour
Try to put your spirit back into your work
Try and take time to stop and pause and see what is really going on
Envisage positive outcomes before going into a difficult session
Stay open to outcome
Ali Crossley and Kathy Gyngell: A discussion on the UK Drug Strategy, Is it recovery or is it rhetoric?
In an interactive session, attendees discussed the implementation of the UK Drugs Strategy, which placed additional emphasis on recovery, as a goal of treatment. Kathy Gyngell spoke of the results of a 2011 survey which showed that out of 200,000 people accessing drug treatment, only 2% had been referred to residential rehabilitation and that only around 4% were discharged free of dependency, which was based on self-reporting. She noted that since 2005, opiate deaths have increased by 5% and that methadone related deaths had increased by 85%, making it the 2nd greatest cuase of drug deaths in England.
So the question is now, are people in England actually able to access support services and referred to services which will enable recovery and abstinence from drugs? One concern raised by the audience was that rather than promoting residential rehabilitation services, mainstream providers were simply adding the word "recovery" to their own job descriptions but changing nothing in terms of how they approached clients. Other delegates noted that small residential rehabilitation units were being excluded from NHS contracts, due to the financial risks put in place throughout the commissioning process. A final concern was the ethical use of recovery champions and the question over whether former drug users, just out of detox are being exploited. Indeed, many in the audience seemed concerned about such cases, where people are being promoted as recovery champions but are very early in their recovery. That of course is not to say that the audience disagreed with the use of champions, in theory, the role model of someone who has been there, worn the t-shirt and out the other side is a very powerful one but it seems necessary that the person has undergone a significant period of time without using drugs and that they have also received the appropriate training and support required to take on such a role.
Recovery Capital and Addiction Theory, Rowdy Yates
Rowdy opened the session by declaring his personal interests, saying that "there is no such thing as an objective speaker or an objective researcher" and spoke of his own history, before academia.
He noted that there was a feeling within mainstream treatment that this was an incurable disease and the best thing you can do is to contain it. So he mentions, AA first talked about recovery in their first few years but then along came the addiction model and then they started talking about being in perpetual recovery. So what is recovery? Is it "change, sustainaing change and empowerment" so that it becomes part of you?
He noted that 90% of people in Scotland in one study said that they wanted to stop using drugs but instead of being provided with the appropriate long-term support, 90% are parked on substitution treatment, so he asks, are people really getting what they want? What about well-meaning harm reduction services who tell people they can't achieve abstinence, is is a misuse of power?
So, how does Rowdy define addiction? Well. he says "addiction is a complex disorder where the roots have little to do with the sumptoms such as substance misuse", instead he says it is a disorder of the whole person.
Interestingly, according to studies of Charles Winnick, the triggers for recovery tend to be about things like developing a relationship with an important person who supports them, not formal treatment itself.
He spoke of the interconnection between addiction and parallel disorders, personality disorders, childhood/sexual abuse, dyslexia etc and explained that when something else is going on, in order to resolve these multiple problems, you need to understand the difference between treatment and support and also which to treat first, for example, is it best to deal with addiction first and then get to the root problem of sexual abuse later?
He also spoke of motivation and how "lack of motivation" is often cited by health workers as a reason for non-compliance, a reason he says is often used to cover up inadquate practice. For this, he points to evidence which suggests that even where external motivation can over time become internalised throughout a gradual process (for example, where someone may attend treatment on the request of a partner but later in the treatment becomes motivated for their own reason to continue).
He queried the small amount of detox time being given to people, adding that the optimal amount of time in a therapeutic community would be around the 9 month point.
He spoke of the dichtomy of retention and treatment outcome, saying it was a mistake to think that low retention = poor treatment outcome or vice versa. Indeed, this is not true in long term methadone maintenance programmes, where the longer you are with it, the less likely you are to come off it. He also pointed towards Australian research which showed that engagement in the treatment process was just as important as time in treatment, noting that people tended to become more actively engaged ias their motivation moved from extrinsic to instrinsic motivation.
He also showed how retention rates could be improved through service re-design (not just based on an individual's motivation). In a study by De Kiern Therapeutic Community, Gent, Belgium in 1997, they saw retention improve from 20% to 60% by establishing a welcome house, increasing interaction with staff, introducing a mentor system with senior residents for new-comers, involving families in various aspects of early treatment and doing taster visits. The welcome house was also used as a safety net for people who dropped out of the main therapeutic community treatment.
He went through the history of addiction recovery groups, from the Washintonians, the Good Templars, the Emmanuel Movement, Blue Cross, to AA and Therapeutic Communities. The consistent elements he noticed were, peer support, focus on an individual's dignity and building up a person's self-esteem and pride. He spoke of how the way we talk about addiction has changed over the years ranging from:
1) Temperance Model (which became then not cool to talk about the evilness of alcohol for example)
2) The addiction Model (where everyone is off the hook, the person can say it's not their fault, everyone else can say "it's not me, let's go get drunk" and the alcohol industry can say "we should think of a way of indicating those people likely to become addicts while increasing our sales"
3) The characterological model, which consider early trauma and personality disorders to be the main factors
4) Psychological approach, where beahviours are learned and can be "unlearned"
5) Bio-social model that see drug and alcohol misuse oas the result of a complex interaction between the drug, social situation and psychological health of the individual (Zinberg), linked to the "Drug, set and setting" approach.
So he says, what you are left with in the modern day, is this bizarre paradox where the disease model is being delivered, even though staff support a more psycho-social model.
So, how to build recovery capital? Well Yates calims it's really just short-hand for impacting upon drug, set and settings. Recovery, he says, is not just about abstinence, it's about how someone sees themselves. The problem with a purely stabilisation approach is that it will always be fragile, you rarely find genuine elimination of substance use, so the person's foot is never entirely "out of the door", so it's easy to go back to the previous way of living.
So, what can we tell from a more recovery focused approach?
Improvements in engagement in employment, where abstinent people are more likely to re-enter the work force
Lowered externalising of problem among children
More settled family life
Rowdy's presentation is available for download here:Rowdy Yates(2 3 5kb)
Friday 11th May 2012
John F. Kelly: The Science behind 12-step treatments and enhancing community responses to drug and alcohol problems
In this session, John Kelly offered the story of the last 20 years in examining the effectiveness of 12-step treatments. Speaking of the past 40 years, Kelly noted the increase in the quality of substance use disorder treatment and also the parallel increase in mutual aid during that same time period.
He noted that not only was mutual aid effective and cost effective, as it is free, but that also people could attend as intensively or for as long as they wanted.
He specifically looked at the evidence behind AA and 12-step treatment models, such as:
The Cochrane Review in 2006 which showed, from trials including over 3000 people, that AA may help patients to accept treatment and keep patients in treatment more than alternative treatments. Three of the studies which were part of the review also showed that compared with other forms of treatment, there were few differences in outcomes
Studies where attendance at self-help groups have been statistically significant in terms of improved health behaviours
Studies which show that attendance at self-help groups have been shown to improve adherence to prescribed medication
Project Match which was a multi-site clinical trial based on alcohol treatment, which showed that 12-step facilitation was just as effective as cognitive behavioural or motivational behavioural therapy
In terms of the latter, he pointed out that mutual help groups may work in a similar way to formal treatment, in terms of helping people not to relapse. He looked at precursors to relapse, such as cue, stress and drug induced precursors and how AA and 12-step models could play a role in these.
So, how exactly does AA work?
Well, in one of Kelly's studies, he found that the vast improvements were in social network changes, where people engaged in 12-step models in an out-patient setting where more likely to gain abstaining friends and stop socialising with heavy drinkers. However, the group in aftercare showed a different picture, they had benefits in terms of social networks but also in terms of spirituality, so what his research suggests is that AA works in different ways for different people. So for the less severe drinkers, social mechanisms seem to play a larger role but with more severe, they see a change in social mechanisms, spirituality and self-efficacy. What he also found in his work, is that in terms of changing social circles, it seemed to be more important to reduce contact with heavy drinkers than to have abstaining friends.
What are the different 12-Step Facilitation Models?
- Stand alone as independent therapy
- Integrated into other existing therapies such as cognitive behavioural therapy (hybrid model)
- Component of a treatment package
- As a modular add-on to other treatments
Formal treatment for substance abuse has increased in quality and quantity over the last 40 years
This has been paralleled by an increase in 12-step organisations and others
There is increasingly rigourous scientific research on organisations such as AA, which show that they can potentiate treatment effects, extend treatment and recovery benefits over the long term
12-Step Models are important in off-setting financial costs associated with alcohol and drug treatment
12-Step Models can enhance community response to alcohol and drug problems
Club Drugs and more: Fat Tony and Antidote
In this presentation, we heard from people working in the clubbing industry in London about what they are currently seeing in club environment. This presentation also looked at what drugs were being more widely used in the gay clubbing environment, as the presenter noticed that these patterns could be likely to carry over to the general population over time.
What was reported during this session was an increase in the use of crystal meth in the gay scene, with more people injecting it. A complaint was made that healthcare services are not aware of this current pattern of use and that harm reduction services have been providing equipment such as filters, with no real knowledge of how people are using the drug. What did seem to come across during the presentation was that drugs were being used in this scene to facilitate sex and to remove barriers such as feeling shame during sex. This is why, the speaker noted, sexual health and drug teams should be working more effectively together.
Of all drugs, mephedrone was highlighted, with the speakers noting an increase in cases such as heart palpitations and noted that there were cases of it now being injected, with oddly violent come-downs and unusually violent reactions being noted in the days coming off it. All through the presentation, the need for healthcare workers to be aware of the signs and symptoms of use were clear.
Fat Tony, noted, that in his experience working in clubs, these young people see clubbing as part of their weekend experience and may not want to stop using drugs and also that they don't see themselves as addicted but at the same point, they are poisioning themselves and that is really sad to see. He said it was sickening because he sees himself in everyone of them, reflecting on his own escalation of drug use (he came clean through a 12-step programme).
Tommy Riddick, spoke of the "Test on Arrest" programme where anyone arrested by police would automatically be tested for Class A drugs and from that, be chanelled into appropriate treatment services. He noted that the face of recreational drug use is changing and that what's happening in the gay scene today is a good indicator for what's coming. Specifically he said "what we've got is a ticking time bomb of recreational use with services not set up to deal with it".
So, how do you make services more accessible to these groups?
Well, Riddick noted the difference of languauge being used by services and service users. He noted the word "slamming" and queried whether health professionals even knew what this term meant.
He also spoke of the danger of classing drugs as "harmless" or "recreational", saying "if someone is on GBL and is in custody but doesn't get the right treatment, they could die but police are seeing these drugs as harmless and don't know what effects they cause". He also asked whether these users, classed as "recreational" are being forgotten in drug policies and treatment centres, because they are maybe not as big a burden on the criminal justice setting?
He noted, "if you look at official figures, there might be only 6 official deaths...that's completely ridiculous...not all deaths are being attributed to these drugs and sometimes they are out of their system so fast, they are not even being picked up at the time of autopsy".
Next we heard from Joe, a young irish guy who had moved to London some time ago and had been using ketamine over the course of a few years. He spoke of how his drug use escalated from using 1g per week to up to 7-8g a day, any of which could be considered a lethal dose, whilst his weight reduced from 12 stone down to nearly 7 stone. At an early point, when he tried to get treatment, he couldn't for over one year as the service he was referred to said it "didn't deal with ketamine". Eventually he was referred to hospital where he underwent an operation on his bladder but his drug use was still not addressed and he was told that ketamine was not addictive. Following the operation, he then needed a kidney transplant. Now he has a kidney function of about 15%. He noted "for a lot of people who need help, they can't find help" because of the way these drugs are being presented as harmless or recreational and that neither the police nor healthservices are really geared up to dealing with them. What we need to deo is ensure that rehabilitation units and detox units are really geared up to deal with new types of drug use and make sure that there are places to go for treatment and that those places are really equiped for it.
Some of the challenges cited for both police and health workers, were the need for testing kits and for drug awareness training programmes. On the positive side, the speakers reflected that positive changes had been made in some clubbing environments in recent years, saying for example, that 10 years ago, in the medical rooms in clubs, people were given advice, told to "cool down" and then going back into the club, whereas now people are apparently more likely to receive better advice and referred to appropriate routes of care.
Top 10 Mistakes Parents In Recovery Make, Phyllis Gardner
It's important to note that this presentation was given by someone who had themselves struggled with addiction but who now works as a parental educator, therefore this presentation was given with more of a "been there, done that, got the t-shirt" manner and not in a critical way of other people.
10) Failing to adopt a positive approach to authority
For example, seeing teachers as an adversary, rather than as a collaborator. Seeing any approach by a teacher for example as a reflection of your parenting style, rather than seeing a teacher as someone who can help your child progress.
9) Chasing Respectability
Over-committing yourself to too many obligations, in order to be seen as "together" or as a "good person". You may over extend your commitments, take on too many responsibilities, do anything to be seen as better, rather than confront issues like your own problems with self-esteem or shame.
8) Failing to share the message with your children
One delegate in the audience said it was a real problem for him to explain to his son what drugs had done to his life, as he had overcome it in the past but the son had not been there to witness it, so the son saw his dad as someone who had taken lots of drugs but was fine and successful but really the message he wanted to give to his son was that drugs nearly destroyed him and that he never wanted that life for his son. The presenter reiterated how important it was to really show and tell your children what it was really like and not just passing over it.
7) Not my child
Failing to know their child, with their own faults and accepting them like that or holding them on too much of a pedestal.
6) Failure to confront errant kids
You might feel like a hypocrit putting boundaries in for your children, where you behaved differently yourself. Regardless of your past, you need to get over feelings like hyprocrisy and put in boundaries for your children where you feel these are appropriate.
5) Overreacting to their mistakes
Put things in perspective before choosing a battle with a teenager.
4) Because I said so
Phyllis explained that sometimes we really do our children a disservice when we fail to teach them how to reason for themselves. If you just tell someone not to do something, ok they might just not do it when you are around but if you explain the reason to them, then on their own, they may be more likely to use logic and reasoning of their own
3) Failure to listen to their problems
2) Lack of consistency
1) Failure to address personal guilt
Phyllis explained that a guilty parent can also be an inconsistent parent, perhaps caving in to children's demands or spoiling them in order to relieve guilt.
The session ended with a practical point, that teachers or counsellors are in the best position to identify the above issues.