8.2 Western-ideology approaches to treatment

Below are some of the treatments available in Nova Scotia.

Withdrawal Management (Detoxification)

All substances have an impact on the body and the brain.  Some substances like alcohol have such a strong impact that they can cause death.  Alcohol withdrawal requires medical intervention when a person wants to slow down or stop.  This service is often referred to as detoxification (detox); however, today we use the term withdrawal management.

Activities

  1. Other words associated with substance use disorders have stigma.  When you hear detoxification or detox, what do you think of?
  2. Compare the terms detoxification and withdrawal management.  Why do you think this has changed?
  3. Is withdrawal management clear?  Do you think language matters in this case?  Why or why not?
  4. Click on this link to an alcohol screening guideline in British Columbia.[1]  Notice the language.
  5. Would you change the term “problem drinking”?  Why or why not?

You may think of a broader health perspective than substance use when you hear the word detoxification; in this context, detoxification or the preferred term, withdrawal management, is a medically assisted/managed program.  Medications and devices can be used to manage withdrawal symptoms, prevent relapse, and treat co-occurring conditions.  Withdrawal management is not in itself “treatment,” but only the first step in the treatment process.

If a person has access to a provincial health card, in-patient withdrawal management may be referred by a health care provider, or it may also be self-referred.  If people have the financial means, they may pay privately or access funds through an insurance provider for private in-patient withdrawal management at a private facility.  Regardless of public or private, all individuals are screened to see if they meet the criteria for in-patient withdrawal management.  It is important to note that screening is not diagnosing, screening is a tool to determine which service an individual may benefit from, based on their substance use.  Screening may highlight some of the areas of intersectionality of substance use.  In-patient withdrawal management is provided by all provincial health care services.  It is important to note that health providers utilize different screening tools to determine suitability for all treatment services, not least of which is in-patient withdrawal management.

Activities

  1. Look up screening tools for substance use.  Do all tools include intersectionality?
  2. Do the tools include the social determinant of health?
  3. Are there areas that are missing?
  4. How would you ensure inclusivity in a screening tool for substance use?

In Nova Scotia, in-patient withdrawal management is provided by the Nova Scotia Health.[2]  This program “provides medical, supervised withdrawal management and support to individuals that require treatment and support to manage their withdrawal symptoms from substances such as alcohol and drugs”.[3]  While enrolled in in-patient withdrawal management individuals have access to a variety of treatment options including counselling, group therapy, referrals (health care and community) as well as food, medicine, and a place to stay between 5-21 days depending on the individual and the health care team.

Food For Thought

  • Are in-patient withdrawal management available for every substance?
  • Where are the in-patient withdrawal management centres in Nova Scotia?
  • Is out of province for in-patient withdrawal management possible?
  • Why do you think someone would leave their province to go to treatment?
  • What are the challenges with accessing in-patient withdrawal management?
  • IS in-patient withdrawal management available to everyone?  If not, who might be excluded?
  • What happens after in-patient withdrawal management?
  • When you think about intersectionality of substance use, does in-patient withdrawal management address all the concerns? Are there barriers people could face in a hospital setting?
  • Does in-patient withdrawal management impact all genders equally?  What concerns might women bring with them to in-patient withdrawal management?
  • Does in-patient withdrawal management support people of all races and cultures?
  • When you think about the social determinants of health, does in-patient withdrawal management address all the concerns?
  • How would you find out if there a wait list for Nova Scotia Health in-patient withdrawal management in Nova Scotia?

In-patient withdrawal management is an important component of treatment, particularly for substances that are life threatening to withdraw from, like alcohol.  Substances like opioids are painful to withdraw from, in which case some individuals may be prescribed opiate replacement therapy, including methadone or buprenorphine, which we will discuss below.

In-patient treatment is also offered by privately owned facilities in Nova Scotia.  Imagine spending days and nights in a beautiful facility with private doctors, registered nurses, and counsellors, all for the cost of approximately $600/day.  Some insurance companies cover the costs of private treatment; however, for those without private health insurance, treatment facilities like these may be out of reach.

Activities

  1. Compare and contrast a program at a private facility with a provincially funded program.
  2. Are privately owned facilities allowed in Canada?
  3. Who licenses these facilities in Nova Scotia?
  4. What does the presence of private clinics indicate about healthcare?

Along with in-patient withdrawal management, people living in Nova Scotia who have a NS health card may have access to out-patient withdrawal management. This program “combines functions of an outpatient (day program) withdrawal management (detox) and structured treatment, providing the support of a team-based approach”.[4] Based on current literature, not all provincial healthcare facilities in Nova Scotia offer this service.  It is currently offered in the Western zone.[5]  Outpatient treatment has been provided in various parts of Nova Scotia; however there have been changes to these types of services, for example this story on Port Hawkesbury residents who wanted to reinstate-daytox-program-at-strait-richmond-hospital  

Food For Thought

  • Why do you think someone might choose out-patient withdrawal management instead of in-patient?  Think about intersectionality and the social determinants of health.
  • What is the difference between the two?

For people who have completed a withdrawal management program, this is often not the end of their journey; it may be just the beginning. In Nova Scotia, options exist for people who are choosing to engage with a health care provider about their substance use. The Nova Scotia Health Authority provides a variety of outpatient treatment programs in various locations, from two-week full day programs to weekly appointments.[6]  For those who are looking for a more intensive program, the Adult Addictions Day Treatment Program[7] may be a fit.  For those looking for a less intensive program, Adult Community Mental Health and Addiction Services[8] may be a fit.  This program “includes a team of mental health and addictions professionals who provide services on an outpatient basis”[9] for adults.  The Nova Scotia Health Authority provides a separate service for youth under the age of 19 that is focused on age-appropriate interventions and treatments.

Food For Thought

  • Any comments on the locations and process for referral? Reflect on the variety of services, both private and public.  Is there anything missing?
  • Are there wait times?
  • Imagine if there was an unlimited budget, what would be a good investment?  Why?

When we talk about using medication to treat substance use disorders, some people suggest it is not different, that in fact we are swapping one substance for another.  This is a myth.  For some individuals, using a different medication or a similar medication may reduce some of the harms of the substance.  The Providence Health Clinic in Vancouver recognized that the continued use of heroin can be fatal if not treated[10] and began working with a small number of individuals who had an opiate use disorder.  They developed SALOME a prescribed heroin project or heroin assisted treatment (HAT). SALOME developed out of the NAOMI project, North America’s first HAT program, an initiative between the US and Canada in the 1990’s.[11]  These projects were breaking new ground as well as challenging ideologies about substance use.  Both NAOMI and SALOME were challenged by previous federal Governments; however, the Providence Health Clinic challenged those decisions and became the only clinic in North America to “provide medical grade heroin and hydromorphone within a supervised clinical setting to chronic substance use patients”[12]

[13]

 

This approach to treating substance use allowed individuals, in partnership with their healthcare provider, to manage their substance use like a chronic illness.  For some, this was a novel approach to treating substance use; for others, it was a clear example of how programs based on a public health approach can change/save lives.

Food For Thought

  • Take a moment and think about how you feel about treating heroin use with medical-grade heroin.
  • What does the evidence say about the safety and effectiveness of medication assisted treatment?
  • What do you want to know more about?
  • What are some of the challenges with programs like these?

Usage of opiates in Canada is being called a public health crisis by both advocates of substance use treatment programs [14] and the Government of Canada.[15] The Government has recognized this crisis has only worsened during the Covid-19 pandemic. Many urban and rural communities across Canada have reported a record number of opioid-related deaths, emergency calls and hospitalizations.[16] In Nova Scotia,[17] 33 individuals died from opiate overdose in 2021. While medications like medical grade heroin and hydromorphone can treat opiate use disorders, there are other medications that have also positively impacted the lives of people who use opiates. Methadone treatment is considered an opioid agonist treatment (OAT) and has been successful in treating people who use opiates. The slow acting methadone reduces withdrawal symptoms, and therefore is considered an opioid agonist.

Listen

Listen to the audio file about Darrell, a physician who was living with an opiate use disorder and how he used methadone in his treatment plan.


Methadone, as we discussed in Chapter 3, is a long-acting opiate, which is substituted for short acting opiates like fentanyl, Percocet, oxycodone, and heroin.[18]  This type of OAT manages the withdrawal symptoms a person experiences as withdrawal from opiates can be physically painful.  It can also be emotionally distressing, particularly if the substance is being used as a coping tool.  Evidence from research around the globe has demonstrated that methadone is an effective treatment; it can help people with an opioid addiction in more ways than one.[19]  Watch the following video about the impact methadone has made on mothers in Prince Edward Island.[20]

 

Methadone, along with buprenorphine and suboxone, other opioid agonists, have changed lives.  Opioid agonist does not work for every person; it may be offered as an option.  The Pharmacy Association of Nova Scotia has a list of pharmacies providing methadone and suboxone.

Activities

  1. Review the following Centre for Addiction and Mental Health pamphlet on opiate agonist treatment.
  2. How long can someone use methadone or bupenorphine?
  3. Are there side effects of these medications?
  4. What are the positive aspects of OAT?  Negative aspects?
  5. Create a poster for OAT.  Include three main facts that you believe would help reduce the stigma of OAT.

Many people who use substances are incarcerated.  According to the 2017 report on drug offences in Canada, over 95,000 people were charged with various drug offenses, many of which were related to cannabis.[21]  One way in which Nova Scotia has decided to tackle the issue of incarceration for substance related criminal activity is the creation of a Court Monitored Drug Treatment Program or Drug Court Program (DCP).   “In 2015, the Mental Health Court Program partnered with the Nova Scotia Health Authority’s Opioid Treatment Program to introduce the Court Monitored Drug Treatment Program”.[22]  The DCP offers “alternative criminal sentences for people charged with crimes directly related to their opioid addiction”.[23]

Drug Courts began in the United States, who were dealing with an unprecedented epidemic of substance use and incarceration as part of the war on drugs.  To deal with the issues facing the criminal justice system, DCP’s were born, which began to recognize the role of intersectionality in substance use and provided “expedited case processing, outpatient treatment, and support services (e.g., job placement and housing)”.[24] Canada adopted its first drug court program in Toronto in 1998.[25]  The programs have evolved, but the focus is still the reduction of the number of individuals incarcerated for substance related crimes and addressing the substance use disorder as the main issue, rather than the crime itself.  DCP’s focus on access to treatment for offenders who meet criteria and provide an alternative to incarceration by offering an opportunity to complete a substance use treatment program[26]. The data on DCP’s is quite promising.  Regardless of the recidivism rates of the individuals who participated in a DCP, “the majority of them had achieved some quality-of-life improvements (e.g., no longer homeless, received several months of addiction treatment and were connected to social supports within the community)”.[27]

Activities

  1. Do DCP’s promote quality of life?  How?
  2. How would you promote a DCP in your community?
  3. Where can you find data on DCP’s in Nova Scotia?  In Canada?
  4. Where are the DCP’s located in Nova Scotia?
  5. Where can you find data on DCP’s in Nova Scotia?  In Canada?

What is a friend? It may be someone you can count on or trust to talk about problems or a bad day. Peer support builds on the concept of friendship, but a peer supporter is different than a friend. “Peer support can be defined as the process of giving and receiving nonprofessional, nonclinical assistance from individuals with similar conditions or circumstances to achieve long-term recovery from psychiatric, alcohol, and/or other drug-related problems”.[28] Peer support is a multi-faceted system within the field of substance use with varying opinions and efficacy. Peer support plays a role at all stages of substance use. It can happen with individuals starting their substance use and can move through all the way to recovery; there is significant value in peer support among individuals who use substances.[29][30][31]

Informal peer support may take place in a situation where someone who uses substances is increasing their use and injecting for the first time. They may be guided by someone who knows how to inject properly and safely, offering clean supplies and ensuring the person tests their substance and does not use too much, putting them at risk of overdose. This is called informal peer support, peer helping or natural helping. Peer helpers try to dissuade people from starting to inject, act as first responders for overdoses, test drug potency, administer first aid, share prescription drugs such as antibiotics, offer temporary housing, counsel on emotional/psychological issues, and support those who are striving to reduce their drug consumption.[32]

Some may suggest sharing prescription medication is not helping; however in the world of harm reduction, knowing what a substance is and where it came from can be preferable to substances that are purchased on the street and may not be as reliable. Peer helpers can also have a role with community agencies and within the larger context of treatment; Dechman further suggests that this type of informal peer support “has not been separated out as a formalized intervention component and rigorously empirically tested, making it difficult to determine its effects”,[33] though anecdotally many individuals who live with a substance use disorder could identify peer helpers and a positive role they have played.

Collage of VANDU protesters carrying banners and signs advocating for drug users..
Collage of VANDU protesters carrying banners and signs. Credit: Vancouver Area Network of Drug Users

In Vancouver, the Vancouver Area Network of Drug Users (VANDU) emerged in 1997, the first drug users union in Canada.  This group secured a permanent site in 1997 and began offering support, education, and advocacy for group members.  They advocated for safe injection supplies and saw the creation of Insite, Canada’s first safe injection site in 2003.  They have provided informal peer support to individuals for over 24 years and continue to do so today.[34]

Formal peer support may be provided through organizations like 12-step programs including Alcoholics Anonymous and Narcotics Anonymous.  While the research on AA and NA has been controversial, “research on the effectiveness of Alcoholics Anonymous (AA) is controversial and is subject to widely divergent interpretations”,[35] for some people AA has played an important role in their reduction or elimination of substance use.  Check out the Nova Scotia Chapters of AA and NA.

In Nova Scotia formal peer support can also be provided by Nova Scotia health through Mental Health Innovations, an evidence-based program offering support for transitioning from an in-patient to an outpatient setting.[36]  This would be appropriate for someone living with a concurrent disorder, mental health, and substance use.   Other formal peer support programs are offered through community-based agencies, for example Mainline Needle Exchange.  Learn more about Mainline here. https://mainlineneedleexchange.ca/[37]

Activities

  1. What is the value in peer support?  Why do community agencies value peer support?
  2. What does the research say about peer support?
  3. Is there evidence the health system values peer support?  Provide two examples.
  4. Are there other applications for peer support?
  5. Find two peer support agencies in Nova Scotia.  Who would you refer?
  6. What training is involved in providing peer support as a service provider?

As noted above, this is not a comprehensive list of treatment options in Nova Scotia; however, this should provide an opportunity to expand knowledge on Western-ideology treatment for substance use disorders.  It is also important to recognize gender as part of treatment models, as it is “now recognized that women have different addiction recovery needs than men, and that recovery processes for women should be gender- or women-sensitive to address their unique needs”.[38]  Please review the principles of effective treatment below and remember that it is the choice of the individual what type of treatment they would like to try.  Whether they are not successful once or fifteen times, clients are encouraged to “never quit quitting”!

Principles of Effective Treatment

The following key principles should form the basis of any effective treatment program:

  • Substance use disorders are complex.
  • No single treatment is right for everyone.
  • People need to have quick access to treatment.
  • Effective treatment addresses all of the individuals needs, not just their substance use.
  • Staying in treatment long enough is critical.
  • Counselling and other behavioural therapies are the most commonly used forms of treatment.
  • Medications can be an important part of treatment, especially when combined with behavioural therapies.
  • Treatment plans must be reviewed often and modified to fit the individuals changing needs.
  • Treatment should address other possible mental health disorders.
  • Treatment should address the social determinants of health.
  • Medically assisted withdrawal is only the first stage of treatment.
  • Substance use during treatment must be monitored continuously, to prevent overdose.
  • Treatment programs should encourage individuals to test for HIV, hepatitis B and C, tuberculosis, and other blood borne illnesses as well as sexually transmitted infections if they engage in risky behaviours.  This way individuals will have a more complete picture of their health.
  • Treatment programs should teach individuals about steps they can take to reduce their risk of these illnesses (harm reduction).[39]

 

Review your learning here.

Image Credits

Collage of VANDU protesters carrying banners and signs from: Vancouver Area Network of Drug Users. (2016). Homepage. https://vandureplace.wordpress.com/


  1. British Columbia Ministry of Health. (2013). Problem drinking part 1: Screening and assessmenthttps://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/problem_drinking.pdf
  2. Nova Scotia Health Authority. (n.d.c). In-patient withdrawal management unit. https://mha.nshealth.ca/en/services/inpatient-withdrawal-management-unit
  3. Ibid, para. 1
  4. Nova Scotia Health Authority. (n.d.d). Outpatient withdrawal management unit, (para. 1). https://mha.nshealth.ca/en/services/outpatient-withdrawal-management
  5. Ibid, para. 4
  6. Nova Scotia Health Authority. (n.d.b). Adult community mental health and addictions services. https://mha.nshealth.ca/en/services/adult-community-mental-health-and-addictions-services
  7. Nova Scotia Health Authority. (n.d.a). Adult addictions day treatment programhttps://mha.nshealth.ca/en/services/adult-addictions-day-treatment-program
  8. Nova Scotia Health Authority. (n.d.b). Adult community mental health and addictions services. https://mha.nshealth.ca/en/services/adult-community-mental-health-and-addictions-services
  9. Nova Scotia Health Authority. (n.d.a). Adult addictions day treatment program, (para. 2). https://mha.nshealth.ca/en/services/adult-addictions-day-treatment-program
  10. McLellan A. T., Lewis D. C., O’Brien C. P., & Kleber H. D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA, 284, 1689–1695. https://pubmed.ncbi.nlm.nih.gov/11015800/
  11. Gartry, C. C., Oviedo-Joekes, E., Laliberté, N., & Schechter, M. H. (2009). NAOMI: The trials and tribulations of implementing a heroin assisted treatment study in North America. Harm Reduction International Journal, 6(2), 1-14. https://doi.org/10.1186/1477-7517-6-2
  12. Providence Health Care. (2021). About SALOME. https://www.providencehealthcare.org/salome/about-us.html
  13. Providence Health Vancouver. (2016). SALOME patient experience video. [Video]. Youtube. https://www.youtube.com/watch?v=8wY0LzYwRYs
  14. Canadian Centre on Substance Use and Addiction. (2017).  Motivational interviewing (the essentials of series). https://www.ccsa.ca/motivational-interviewing-essentials-series
  15. Government of Canada. (2021b). Opioids and the opioid crisis-get the facts. https://www.canada.ca/en/health-canada/services/opioids/get-the-facts.html
  16. Ibid.
  17. Nova Scotia. (2021). Opioid use and overdose strategy. https://novascotia.ca/opioid/
  18. Centre for Addiction and Mental Health. (2021b). Methadone. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/methadone
  19. Ibid.
  20. Prince Edward Island Government. (2017, July 12). Mothers and methadone. [Video]. Youtube. https://www.youtube.com/watch?v=LjT8WvuaFUE&feature=emb_imp_woyt
  21. Boyd, S. (2017). Drug arrests in Canada, addendum. https://drugpolicy.ca/wp-content/uploads/2018/09/Addendum.pdf
  22. The Courts of Nova Scotia. (n.d.). Drug court program (para. 1). https://www.courts.ns.ca/provincial_court/NSPC_MHC_drug_treatment_program.htm
  23. Ibid.
  24. Lurigo, A. J. (2008). The first 20 years of drug treatment courts: A brief description of their history and impact. Probation Journal, 72(1), 13-17. https://www.uscourts.gov/sites/default/files/72_1_2_0.pdf
  25. Government of Canada. (2021a). Drug treatment court program funding program. https://www.justice.gc.ca/eng/fund-fina/gov-gouv/dtc-ttt.html
  26. Ibid.
  27. Ibid, para. 18
  28. Tracy, K., & Wallace, S. P. (2016). Benefits of peer support groups in the treatment of addiction. Substance Abuse and Rehabilitation, 7, 143–154. https://doi.org/10.2147/SAR.S81535
  29. Ibid.
  30. Boisvert, R. A., Martin, L. M., Grosek, M., & Claire, A. J. (2008). Effectiveness of a peer-support community in addiction recovery: participation as intervention. Occupational Therapy International, 15(4), 205-220. https://doi.org/10.1002/oti.257
  31. Kelly, J. F., Fallah-Sohy, N., Cristello, J. & Bergman, B. (2017). Coping with the enduring unpredictability of opioid addiction: An investigation of a novel family-focused peer-support organization. Journal of Substance Abuse Treatment, 77, 193-200. https://doi.org/10.1016/j.jsat.2017.02.010
  32. Dechman, M. K. (2015, May). Peer helpers' struggles to care for "others" who inject drugs. International Journal of Drug Policy, 26(5), 492-500. https://doi.org/10.1016/j.drugpo.2014.12.010
  33. Ibid.
  34. Vancouver Area Network of Drug Users. (2016). Homepage. https://vandureplace.wordpress.com/
  35. Kaskutas, L. A. (2009). Alcoholics anonymous effectiveness: Faith meets science. Journal of Addictive Diseases28(2), 145–157. https://doi.org/10.1080/10550880902772464
  36. Mental Health Innovations (n.d.). Peer support Nova Scotia: Mental health rehumanized. https://www.supportyourpeople.com/peer-support-nova-scotia
  37. Mainline Needle Exchange. (2021). Supporting people. https://mainlineneedleexchange.ca/
  38. Kruk, E., & Sandberg, K. (2013). A home for body and soul: substance using women in recovery. Harm reduction journal10, 39. https://doi.org/10.1186/1477-7517-10-39
  39. Schwab, J. (2021). Drugs, health and behaviour. Pressbooks. https://psu.pb.unizin.org/bbh143/chapter/drugs-and-the-brain-national-institute-on-drug-abuse-nida/

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