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-VhU hU content.xmlExploring Substance Use in CanadaExploring Substance Use in CanadaA Curriculum for Social Service WorkersJulie CrouseNSCCNova ScotiaExploring Substance Use in Canada by Julie Crouse is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.ContentsAbout the BookInstructor Resources - Request AccessIntroduction Chapter 1: Language and substance use 1.1 Overview1.2 Substance use and the determinants of health1.3 Changing the language of “addiction”1.4 Race, stigma and substance use1.5 Gender, stigma and substance use1.6 The language of compassion1.7 Self-careAdditional Resources Chapter 2: Why People Use Substances 2.1 Overview2.2 Why do people use substances2.3 Why do people continue to use substances2.4 Concurrent disorders2.5 The stages of change2.6 Self CareAdditional Resources Chapter 3: What are psychoactive substances? 3.1 Overview3.2 Opioids (an overview)3.3 Examples of opioids3.4 Stimulants (an overview)3.5 Examples of stimulants3.6 Depressants (an overview)3.7 Examples of Depressants3.8 Hallucinogens (an overview)3.9 Examples of Hallucinogens3.10 Psychotherapeutic Agents (an overview)3.11 Examples of Psychotherapeutic Agents3.12 Steroids3.13 Self careAdditional Resources Chapter 4: Substances and their impacts on the brain and body 4.1 Overview4.2 Routes of administration4.3 The brain4.4 The Brain and Nervous System4.5 The Impact of Substances on the Brain4.6 Self care Chapter 5: Process Addiction 5.1 Overview5.2 Gambling5.3 Compulsive eating, sexual behaviours, & internet use5.4 Self careAdditional Resources Chapter 6: Theories 6.1 Overview6.2 Moral theory6.3 Biological theory6.4 Psychological theories6.5 Social theories6.6 Substance Use Disorders as Biopsychosocial Phenomemon6.7 Trauma6.8 Self careAdditional Resources Chapter 7: Substance Use Laws in Canada 7.1 Overview7.2 Substance Use Laws in Canada7.3 The “War on Drugs”7.4 Advocating for change7.5 Self careAdditional Resources Chapter 8-Treatment Approaches 8.1 Overview8.2 Western Ideology Approaches to Treatment8.3 Indigenous Approaches8.4 Trauma Informed Practices8.5 Self careAdditional Resources Chapter 9: Harm Reduction 9.1 Overview9.2 What is harm reduction9.3 Harm Reduction Services in Canada9.4 A gender approach to harm reduction9.5 Self careAdditional Resources Chapter 10: Health Promotion, Prevention, Early Intervention & Recovery 10.1 Overview10.2 Health promotion10.3 Prevention and early intervention10.4 Recovery10.5 Self careAdditional ResourcesVersion HistoryLong Description1About the BookCover Image: Bald eagle and rainbow by marneejill via Flickr CC BY-SAWelcome to Exploring Substance Use in Canada: A Guide for Social Service WorkersLand acknowledgementI would like to acknowledge that I live in Mi’kma’ki –the unceded territory and ancestral homeland of the Mi’kmaq Nation. Our relationship is based on a series of Peace and Friendship treaties between the Mi’kmaq Nation and the Crown, dating back to 1725. In Nova Scotia, we recognize that we are all treaty people. Please take a moment and think about the space you are sharing, take time to learn more and reflect on opportunities challenge the status quo.I would like to acknowledge the individuals who use substances in Canada, many of whom share their experiences and stories through research captured in this text. As we begin our exploration into substance use in Canada, it is important to recognize and honor those who are living with a substance use disorder and those who have contributed to research. Please review the following powerful manifesto: Nothing About Us Without Us-A ManifestoI would like to acknowlege the The Council of Atlantic Academic Libraries (CAAL) for the funding through the AtlanticOER Development Grants to complete the Instructor Resources and H5P content for this text book and Amber Davidson for her hard work in completing the Instructor Resources. I would also like to thank Dr. Carole Roy and Dr. Leona English as well as Lynn MacGregor at the NSCC Copyright Office and my family and friends for their support in the creation of this work.This is an introductory text on substance use in Canada for Social Service workers. This text will be updated yearly with new evidence-based information, training, and resources. It is a living document, and learners and instructors are encouraged to share evidence-based resources with the author. It is an “open” textbook.Substance use disorders (SUD), often known as addictions, are an essential area of study for the Social Service Professional. Why? Chances are you will find yourself working with individuals who use substances. You may also find yourself working with people who live with a process addiction or behavioural addiction, for example, gambling. Take a moment to develop a learning goal for yourself, for this course. What is important to you?Food For ThoughtWhat is one goal for your learning about substances?What is one goal for your learning about substance use disorder?What is one goal for your learning about process/behavioural addiction like gambling?Track your learning goal and modify as needed.Julie Crouse, Faculty at NSCC June 8, 2022 Access to Instructor ResourcesSend an email to copyright@nscc.ca to request access.2Instructor Resources - Request AccessHere you will find PowerPoints for each chapter. I would like to thank the Council of Atlantic Academic Libraries for the funding to complete the Instructor Resources through the AtlanticOER Development Grants.Chapter 1- Language and Substance UseChapter 2 Why people use substancesChapter 3 What are Psychoactive SubstancesChapter 4 Substances and Their Impact on the Brain and BodyChapter 5 Process AddictionChapter 6 TheoriesChapter 7 Substance Use Laws in CanadaChapter 8 Treatment approachesChapter 9 Harm ReductionChapter 10 Health Promotion, Prevention, Early Intervention and Recovery 3IntroductionIntroductionIn Canada, as well as other countries like the United States, “attitudes towards individuals with addiction are heavily moralized”2 with a focus on the responsibility of an individual to heal themselves. This concept of substance use as a moral failing has resulted in laws and policies that harm rather than support people who live with a substance use disorder.4 Kulesza et al.6 suggest substance use may be better understood by examining the intersection between multiple social identities (racial/ethnic minority, women) and structural inequalities. College educators can help students understand the impact policies, laws and regulations have on individuals and families through curriculum designed with an intersectional lens to look at gender, race and substance use.The subject of substance use is complicated. There are various agencies that address substance use, from the Government of Canada, Correctional facilities, Public Health, Canadian Centre on Substance Abuse, The Centre for Addiction and Mental Health, National Native Alcohol and Drug Abuse Program, and various health authorities, private agencies, and businesses as well as non-governmental organizations across the country. Each of these agencies has a mandate to address substance use in some way, from individual treatment through to incarceration; and while these agencies have some power in how substance use is treated, each of these agencies focus on substance use differently, some recognizing systemic injustices and others focusing on morality. There is a tremendous amount of information on substance use and various perspectives that agencies promote as well as the overall western approach to understanding and treating substance use disorders. As I have taught about substance use, I have had to ask myself, do I understand the intersections between substance use, gender, and race? How can I help build a more comprehensive curriculum, and how can I help students build on their experiences and knowledge in this curriculum? Students may learn about challenging laws and health policies and advocating for change to support marginalized groups, which require deep compassion for those who struggle with substance use. They may build on their understanding of systemic power and acknowledging cultural values to challenge the systems that put people at risk of substance use and substance use disorders. This process can begin by understanding the micro and macro forces that shape substance use in Canada. As Brookfield notes, “even if we realize that our problems are reflections of structural contradictions that we can do little about individually, knowing that we are not their cause is crucial to our well-being”.2 Many of the issues related to substance use are systemic, for example, poverty and violence4 and though they may not be resolved by your students, their understanding can help them improve their practice as future social services workers.Addressing stigma is also necessary in order to challenge inequities.234 Stigmas are negative attitudes and beliefs which often lead to “labeling, stereotyping, separation, status loss, and discrimination”,6 and are prevalent in the field of substance use. Some authors even suggest that stigma is an underlying factor in substance use, that “stigma figures in the social construction of substance use”.8 Citizens are affected by substance use, directly and indirectly, individually, and societally; and by understanding this, stigmas associated with substance use may decrease; “both scientists and mental health advocates have long suggested that an increase in the lay public’s understanding [of substance use] … may reduce discrimination and prejudice”.10 Greater understanding of stigma may help reduce systemic inequities related to race and gender.PurposeThe purpose of this project is to help students critically explore substance use in Canada. Using a critical epistemology, “a disclosure of the crossing/tension between being and power”2 and a feminist pedagogy, which “focuses on the thoughts and experiences of individual students and tries to create an open learning community where mutual dialogue and empathy is valued”,4 this text will address the role of gender, race, and stigma within substance use. It allows for compassion, critical reflection, and greater understanding of systemic forces, in hopes of improving services for those living with a substance use disorder. It is a compendium for college students; it will help students further their understanding of substance use by tackling the historical context, feminist and critical race theories, and western and non-western points of view in order to support the further development of critical thinking skills. Brookfield suggests that “to think critically is mostly defined as the process of unearthing, and then researching, the assumptions one is operating under, primarily by taking different perspectives on familiar, taken-for-granted beliefs and behaviors”.6 This OER will help students explore their assumptions about substance use.Theoretical Framework of the ProjectIn order to make changes to systems of power, students should have an awareness of how those systems exert power. Brookfield suggests that by using critical theory, we are able “to identify, and then to challenge and change, the process by which a grossly iniquitous society uses dominant ideology to convince people this is a normal state of affairs”.2 Approaching this project from a place of critical theory, identifying how systems perpetuate substance use becomes important: “Critical perspectives generally assume that people unconsciously accept things the way they are, and in so doing, reinforce the status quo”.4 Developing greater awareness of how the systems function will enable students to work with people who struggle with substance use.Embracing a feminist and critical race perspective will help further unpack substance use for the students. For example, women have unique needs and feminist theory acknowledges these unique needs.234 Feminist theory has been at the forefront of new directions in political, social, and cultural theories. Using the intersectionality of substance use with feminist and critical race theory provides a multi-faceted, culturally and gender responsive perspective, as “recent theoretical work emphasizes the importance of adapting an intersectionality framework to achieve better public health-related outcomes”.6Using feminist theory can be critical as it “offers the potential to challenge hidden assumptions and beliefs and thereby effect change in ways that can improve the lives of those who have often been invisible, powerless, or disenfranchised”.8As a white faculty, it is important to acknowledge my privilege and approach this project from a place of ‘nothing about us without us’. Material used includes the voices of the groups impacted by substance use. I have reviewed materials for diverse and unique perspectives to ensure course material is culturally responsive, appropriate, and will not cause harm. Deeper understanding of various perspectives may impact on the understanding of stigma, substance use, and approaches that are effective for working on substance use in the community.Gaps in KnowledgeThe theories of substance use from a western perspective are evolving. While a moral theory is still prevalent in much of the population, guides laws like Canada’s Controlled Drug and Safety Act,2 and is perpetuated by the media, there has been a shift in the medicalization of substance use disorders. The recent decriminalization of certain substances and certain amounts in British Columbia4 is the beginning of an understanding that substance use is not a moral failing. As our understanding of substance use continues to evolve, a broader perspective which includes gender, language, culture, trauma, and systemic factors may help us understand and perhaps address some of the societal inequities that put individuals and communities at risk of substance use. However, there is no panacea, nor any magic bullet and Wright suggests that “if substance use is ‘always already’ part of the metaphysics of western culture, it can be hard to be analytical about specific effects at specific times”.6 This is one piece of a complicated puzzle.Non-Western ViewsResidential schools, relocation, and forced assimilation have had a devastating impact on Indigenous communities across Canada. Citizens are responsible to learn, to grieve, to develop empathy, and to make change. Gouthro suggests that we must develop deeper understanding of “inclusion, diversity, and discrimination, to build on and radically challenge existing theoretical frameworks”.2 How has substance use impacted Indigenous, Black, and People of Colour communities?This text tries to embody Two-eye seeing2 by using examples of Indigenous peoples through the National Film Board (NFB), Truth and Reconciliation Commission (TRC), and other Indigenous resources. Elder Albert Marshall, Mi’kmaq Indigenous Leader from the Eskasoni First Nation, suggests that “learning to see from one eye with the strengths of Mi’kmaq ways of knowing, and from the other eye with the strengths of Western ways and learning to use both these eyes together for the benefit of everyone” (personal communication, February 9, 2021). Being responsive to Indigenous ways of knowing must include a holistic view by not only sharing stories, but treatment resources like sweat lodges, traditional teachings, and an emphasis on the mind, body, emotion, and spirit connection using the medicine wheel. I will also honor the ways of knowing of People of Color by including a history of the war on drugs, and prohibition, to recognize the racialization of substance use and the power of racism in substance use.Learning ActivitiesAccording to Merriam and Tisdell, “the online or virtual world is a whole culture in and of itself”.2 Having an Open Educational Resource allows for students to interact through technology and reduces barriers to access (the resource is free of costs). The curriculum has been created with text, quizzes, activities, and questions for reflection, activities designed to improve engagement and critical reflection. Colucci suggests that using activities “can also be helpful to discuss sensitive topics”4; the topics we will be discussing can be difficult for many of the students. The activities are designed to make them think and question, they may bring up painful experiences. The curriculum tries to reflect trauma sensitivity. Students come to the classroom with knowledge that has been shaped by numerous factors, “who we are shapes both how we experience things and what we know, then our histories, our experiences, and our positionalities in society will shape how we meet contemplative practices”.6 Embedding a trauma sensitive approach that respects student’s past, oppressions that they may face/have faced, and traumatic experiences they may have had is critical in properly implementing mindfulness, which is implemented at the end of each chapter. Using David Treleaven’s8 work on trauma-sensitive mindfulness will help students recognize symptoms like withdrawal, anger, tears, disorientation, and encourage them to get support. Students will be encouraged to be aware of what activates them and how they normally self-regulate. Students will also be encouraged to engage in self-compassion, so they do not continue to carry trauma-related shame if they are activated.10 Each section has a self-care module that students are encouraged to participate in.EthicsAs I reflect on this work, I have begun to address my privilege, as well as my experience working in mental health and substance use. This OER is an opportunity to contribute to a deeper understanding of how we engage with individuals who use substances, who find themselves living with a substance use disorder, and allow for compassion and mindful engagement. I hope this text will contribute to a deeper understanding of how we understand and engage with individuals, communities and societies experiencing substance use and will lead to a more compassionate approach addressing substance use in Canada.Buchman, D., & Reiner, P. (2009). Stigma and addiction: Being and becoming. The American Journal of Bioethics-Neuroscience, 9(9), 18-19. https://doi.org/10.1080/15265160903090066Syed, A., Sadler, M. D., Borman, M. A., Burak, K. W., & Congly, S. E. (2020). Assessment of Canadian policies regarding liver transplant candidacy of people who use alcohol, tobacco, cannabis, and opiates. Canadian Liver Journal, 3(4), 372-380. https://doi.org/10.3138/canlivj.2020-0005Kulesza, M., Matsuda, M., Ramirez, J. R., Werntz, A. J., Teachman, B. A., & Lindgren, K. P. (2016). Towards greater understanding of stigma: Intersectionality with race/ethnicity and gender. Drug and Alcohol Dependence, 169, 85-91. https://doi.org/10.1016/j.drugalcdep.2016.10.020Brookfield, S. D. (2014). The power of critical theory for adult teaching and learning, (p. 5).(2nd ed.). Open University Press.Matto, H. C., & Cleaveland, C. L. (2016). A social-spatial lens to examine poverty, violence, and addiction. Journal of Social Work Practice in the Addictions, 16(1), 7-23. https://doi.org/10.1080/1533256X.2016.1165113Kulesza, M., Matsuda, M., Ramirez, J. R., Werntz, A. J., Teachman, B. A., & Lindgren, K. P. (2016). Towards greater understanding of stigma: Intersectionality with race/ethnicity and gender. Drug and Alcohol Dependence, 169, 85-91. https://doi.org/10.1016/j.drugalcdep.2016.10.020Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. https://doi.org/10.1146/annurev.soc.27.1.363Matthews, S., Dwyer, R., & Snoek, A. (2017). Stigma and self-stigma in addiction. Bioethical Inquiry, 14, 275–286. https://doi-org.libproxy.stfx.ca/10.1007/s11673-017-9784-yLink, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. https://doi.org/10.1146/annurev.soc.27.1.363Matthews, S., Dwyer, R., & Snoek, A. (2017). Stigma and self-stigma in addiction. Bioethical Inquiry, 14, 275–286. https://doi-org.libproxy.stfx.ca/10.1007/s11673-017-9784-yBuchman, D., & Reiner, P. (2009). Stigma and addiction: Being and becoming. The American Journal of Bioethics-Neuroscience, 9(9), 18-19. https://doi.org/10.1080/15265160903090066Jan, N. A. (2019). The metacolonial state: Pakistan, critical ontology, and the biopolitical horizons of political Islam. John Wiley & Sons, para. 1). https://doi.org/10.1002/9781118979419.ch1Chung, Y. A. (2016). A feminist pedagogy through online education. Asian Journal of Women’s Studies, 22(4),372-391. https://doi-org.libproxy.stfx.ca/10.1080/12259276.2016.1242939Brookfield, S. D. (2014). The power of critical theory for adult teaching and learning, (p. vi). (2nd ed.). Open University Press.Ibid, p. vMerriam, S. B., & Tisdell, E. J. (2016). Qualitative research: A guide to design and implementation (4th ed.)(p. 61). Jossey Bass.The British Columbia Centre of Excellence for Women’s Health. (2010). Trauma-informed approaches in addictions treatment: Gendering the national framework. https://bccewh.bc.ca/wp-content/uploads/2014/02/2010_GenderingNatFrameworkTraumaInformed.pdfHomes, C. (2021). Bridging the gap in women’s substance use services: A trauma-informed, gender-responsive, and anti-oppressive approach. City University of Seattle. http://repository.cityu.edu/bitstream/handle/20.500.11803/1465/ChristineHolmesCapstone .pdf?sequence=2&isAllowed=yKulesza, M., Matsuda, M., Ramirez, J. R., Werntz, A. J., Teachman, B. A., & Lindgren, K. P. (2016). Towards greater understanding of stigma: Intersectionality with race/ethnicity and gender. Drug and Alcohol Dependence, 169, 85-91. https://doi.org/10.1016/j.drugalcdep.2016.10.020Kulesza, M., Matsuda, M., Ramirez, J. R., Werntz, A. J., Teachman, B. A., & Lindgren, K. P. (2016). Towards greater understanding of stigma: Intersectionality with race/ethnicity and gender. Drug and Alcohol Dependence, 169, 85-91. https://doi.org/10.1016/j.drugalcdep.2016.10.020 Lambert, J. L. (1997, November 8). Feminist assessment: What does feminist theory contribute to the assessment conversation? ASHE Annual Meeting Paper (p. 4). American Association for Higher Education. https://files.eric.ed.gov/fulltext/ED415819.pdfGovernment of Canada (2021a). Controlled drugs and substances act. https://laws-lois.justice.gc.ca/eng/acts/c-38.8/CBC. (2022). Canada took a step toward decriminalizing hard drugs. Here’s what it can learn from other countries. https://www.cbc.ca/news/health/safe-supply-around-the-world-1.6479317Wright, C. (2015). Consuming habits: Today’s subject of addiction. Subjectivity, 8(2), 93-101. http://dx.doi.org.libproxy.stfx.ca/10.1057/sub.2015.6 Gouthro, P. A. (2019). Taking time to learn: The importance of theory for adult education. Adult Education Quarterly, 69(1), 60-76. https://doi.org/10.1177/0741713618815656Cape Breton University. (2013). Two-eyed seeing model developed in Cape Breton drives new national grant for Aboriginal health research. http://www.integrativescience.ca/uploads/files/2013-CBU-Two-Eyed-Seeing-Model-Developed-in-Cape-Breton-Drives-New-National-Grant.pdfMerriam, S. B., & Tisdell, E. J. (2016). Qualitative research: A guide to design and implementation (4th ed.) (p. 158). Jossey Bass.Colucci, E. (2007). Focus groups can be fun; The use of activity-oriented questions in focus group discussions. Qualitative Health Research, 17(10), 1422-1433. https://doi-org.libproxy.stfx.ca/10.1177/1049732307308129 Berila, B. (2014). Contemplating the effects of oppressions: Integrating mindfulness into diversity classrooms. The Journal of Contemplative Inquiry, 1, 55-68. https://doi.org/10.4324/9781315721033Treleaven, D. (2021). The truth about mindfulness and trauma. https://davidtreleaven.com/the-truth-about-mindfulness-and-trauma/Ibid.IChapter 1: Language and substance useLearning ObjectivesBy the end of this chapter you should be able to:Recognize the role of the social determinants of health on individualsDefine intersectionalityDescribe stigmaRecognize appropriate and inappropriate language regarding substance useExplain how language contributes to stigmaExplain how stigma can impact a person’s healthIllustrate the role of compassion for others and self11.1 OverviewAs we start our journey into substance use and process addiction/behavioural disorders we will start with an exploration of the power of language. Can we change how we treat substance use by changing the language? Let us explore the possibilities.Perhaps this is your first exploration of the complex world of substances, substance use, and substance use disorders; maybe you have direct experience with this topic, through family, friends, or community. You may even have struggled with substances yourself. If so, I appreciate your engagement with this topic, all are welcome here! This text will help guide your educational journey from why people use substances, substance use disorders, Canada’s policies on substances, theories of substance use, as well as supporting individuals who use substances and finally recovery and prevention. I hope this resource will be a helpful guide as we delve into a topic that is complex and challenging. I encourage you to take care of yourself as you work through each chapter, including reaching out to your support system as needed. Are you ready? Let’s get started! Take a minute to think about what you know about addictions and complete the quiz below.An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.nscc.ca/substanceuse/?p=21#h5p-1 How did you do? If you answered all 9 questions correctly, congratulations, you have busted some myths about substance use and have a solid footing on which to build your knowledge! If not, do not worry, we will tackle these questions and more throughout this text. On that note, let’s begin our journey.21.2 Substance use and the determinants of healthWhat makes you who you are? When you think about who you are, everything matters; for example, your physiology (body and brain), the environment around you, your biological makeup, your life experience, your gender, your abilities, your ethnicity, and your psychological well-being (mental health). These are just some of the factors that have gone into your development and where you find yourself at this moment in time. These are part of Canada’s Determinants of Health.The determinants of health2 are a broad range of factors that impact every person’s health, includingIncome and social statusEmployment and working conditionsEducation and literacyChildhood experiencesPhysical environmentsSocial supports and coping skillsHealthy behavioursAccess to health servicesBiology and genetic endowmentGenderCultureRace / RacismThese factors, along with other social factors like systemic racism and sexism impact your health. For example, “studies have shown that people exposed to racism have poorer health outcomes (particularly for mental health), alongside both reduced access to health care and poorer patient experiences”2 The social determinants of health therefore tell us our health is affected by more than just exercise and healthy eating. When we use the social determinants of health to explore our health we are looking at the big picture. Sometimes we are not always aware of the various systems which play a role in our life. To help us understand ourselves a little more, let us start with reflecting on our own experiences.ActivitiesReview the Government of Canada’s determinants of health website.Create a picture of yourself. Using the social determinants of health, identify our experiences with one example in each category.What is one intervention that could have impacted your health in a positive way?What is one intervention that could have impacted your health in a negative way?When you think about the social determinants of health, what areas do you think might put you at risk of a substance use disorder? Why?After participating in this activity, you may have a deeper understanding of yourself. More exploration of the social determinants of health can help you gain a deeper understanding of substance use When people study substance use and the people who live with a substance use disorder, the social determinants of health can be used to look broadly at the many factors and systems that intersect in a person’s life. To understand and develop empathy for people living with a substance use disorder, we must examine not only the determinants of health, but how the intersection between those determinants of health impact an individual. For example, if a person has multiple social identities (for example a racial/ethnic minority and a woman) and there are structural inequalities linked to these identities (racism, sexism), these intersections may compound the negative impacts on their health2, which may lead to substance use. In other words, there may not be one single factor that relates to a person’s substance use or substance use disorder.The video Intersectionality and health explained2may help you understand intersectionality further.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=23#oembed-1 Research suggests we must acknowledge intersectionality, systems, and theories to work effectively in the field of substance use and substance use disorders. As you further your understanding substance use, take time to reflect on each section, participate in the food-for-thought and activity sections, and reflect on your growing understanding.Food For ThoughtHow did you become aware of substance use?What do you think the difference is between substance use and substance use disorders?Take a moment and reflect honestly on how you feel about substance use and substance use disorders.Where do your beliefs about substance use come from? Friends, media, family?Now that we have established the complexity of substance use, the next section will examine the language we use and the role it plays in the lives of people with substance use disorders, their family, friends, and health care workers.Government of Canada. (2020). Social determinants of health and health inequities. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.htmlStanley, J., Harris, R., Cormack, D., Waa, A., & Edwards, R. (2019). The impact of racism on the future health of adults: Protocol for a prospective cohort study. BMC Public Health, 19(346), p.1. https://doi.org/10.1186/s12889-019-6664-xKulesza, M., Matsuda, M., Ramirez, J. J., Werntz, A. J., Teachman, B. A., & Lindgren, K. P. (2016). Towards greater understanding of addiction stigma: Intersectionality with race/ethnicity and gender. Drug and Alcohol Dependence, 169, 85-91. https://doi.org/10.1016/j.drugalcdep.2016.10.020Sociological Studies Sheffield. (2020, Oct. 8). Intersectionality and health explained. [Video]. https://www.youtube.com/watch?v=rwqnC1fy_zc31.3 Changing the language of “addiction”Addiction as a diagnosable and treatable illness is recent, though the phenomenon of people misusing substances is not. For example, in the first four iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM) used in psychiatry, addiction as a disorder was not included; neither for substances nor behaviour. The DSM is “the standard classification of mental disorders used for clinical, research, policy, and reimbursement purposes in the United States and elsewhere”4 and is a text you will use in your program and in your work. As our understanding of substance use and behaviour has changed, our ability to diagnose and support has also changed; the most recent version, DSM-V, now includes substance-related and addictive disorders. There are some behavioural disorders like gambling which continue to use the term addiction. By changing the language, perhaps we can reduce the stigmatization of the term.What is stigma? You may have heard the term stigma to describe poverty, disability, mental illness, and culture. Stigmas are negative attitudes or beliefs about a topic,2 and are prevalent in the field of substance use; some even suggest stigma is an underlying factor in substance use and behaviours as Matthews et. al. suggest, “stigma figures in the social construction of addiction”4 If we can address the stigma of the language, we may begin to tackle the stigma of substance use disorders; “stigma not only impedes access to treatment and care delivery, but it also contributes to the disorder on the individual level”.6 If we change the language of addiction, will it reduce stigma and improve health outcomes for people living with addiction? Only time will tell, though “both scientists and mental health advocates have long suggested that an increase in the lay public’s understanding of stigma…may reduce discrimination and prejudice”.8 Substance use is highly stigmatized.The next step in our learning journey, as we develop greater understanding of substance use and stigma, is to examine the language we use. For many people, substance use disorders are seen simply as “addiction“. Take a moment and reflect on the word addiction.Food For ThoughtWhen you think of the word addiction, what do you think of?When you reflect on the word addict, what springs to mind?Let us start with this short primer called Illuminate.2One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=28#oembed-1 What is your responsibility as a Social Service worker for helping to reduce the stigma of substance use disorders (SUD)? Reflect on the video, it is focusing on taking substance use out of the shadows. One way we can do this is to explore the word addiction itself, to understand its meaning and its history. The term has evolved and only came to use in the 17th century relating to substance use, with the medical conception of addiction beginning around the 19th century.2 The word addiction has it roots in Latin and was used in the Early Roman Republic as “being bound to”.4 In the case of the Roman Republic, it was bound to a creditor, to someone you owed something. In today’s world should we view a substance use disorder as still being bound to? Does this impact our ability to support individuals with substance use disorders? If we examine the concept of having no will when it comes to substance use, this may contribute to the stigma associated with substance use disorders.Food For ThoughtThink for a moment about the idea of “being bound to”; what does this make you think of?Can you relate this concept of bondage to substances or behaviours?What is the “power” of addiction?How do you think this concept contributes to stigma?Do you think changing the language will reduce stigma? Why or why not?For many, addiction suggests an inability to manage consumption of licit and illicit substances or an inability to manage an activity like gambling. For others, the word addiction relates to an activity they love to do; addiction has been used to describe activities people are passionate about. This confusion between the terms adds to the stigma; the “contemporary usage of addiction is contradictory and confusing; the term is highly stigmatizing but popularly used to describe almost any strong desire, passion or pursuit”.6 Let us think for a moment how you use the word addiction? Is this a word you have used before? Has it related to substance use? Perhaps you have used this word to describe your relationship with a particular snack food, “I am addicted to chocolate,” or maybe a technology “I am addicted to this new app.”A close up of a variety of milk chocolate.Chocolate Credit: M.Verkerk CC BYA woman looking at her phone.Woman on Phone. Credit: antonynjoro via Pixabay Addiction, consequently, is a term we not only use to describe substance use disorders, but we use it to describe our relationship with the world around us and we use it interchangeably in both positive and negative ways. If you look up addiction on the internet, you will find the term addiction being used by companies marketing products, celebrity blogs, individual podcasts, and more. The stigma of the word addiction, however, seems to relate only to substances and behaviours that society deems inappropriate, dangerous, or unhealthy. Addiction as a term and a concept is so polarizing that in fact “there was an attempt to avoid it entirely by writing it out of the diagnostic manuals and substituting other terms like abuse and dependence”4 Addiction as a concept relating to substances has been difficult to define and is slowly being replaced by phrases such as substance use, misuse, or substance use disorder. Even the term substance abuse has been highlighted as a negative term due to the negative connotation associated with punishment6 Addiction, therefore, as a concept relating to substances and activities is often associated with negative behaviours. This association has led to the stigmatization of the term addiction. Stigmatizing Words Fact Sheet by the Canadian Centre on Substance Abuse. Long Description.Stigma impacts the way we treat people, it impacts the way people who use substances see themselves and access support. Please watch the following video Stop Stigma2by people with substance use disorders who talk about how stigma has impacted their lives.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=28#oembed-2 How do we reduce the stigma associated with the words we use when it comes to substance use disorders?Food For ThoughtWhy do you think the word addiction still has stigma?Do you prefer substance use disorder rather than addiction? Is there another term you think is less stigmatizing?Can you think of a different term than process addiction to address an addiction to food, shopping, sex, gambling, or technology?What are terms you can use to describe your love for something that do not include addiction?As noted above, stigma impacts individuals who use substances. According to Volkow, people with addiction are consistently blamed for their disease2. This stigma can prevent individuals from accessing support due to self-stigmatization (lack of self-worth, low self-esteem) as well as previous poor experiences with healthcare or other services. As Social Service workers, we can seek to stop stigma by helping individuals, family, friends, and communities use language that reduces stigma. Let’s listen to Dr. Kenneth Tupper discuss ways we can address stigma and discrimination in substance use disorders in the video Stigma and Discrimination in the Language of Addiction.4One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=28#oembed-3 Some researchers have suggested we can reduce stigma of many illnesses, including substance use disorders, by using person-first language. For example, rather than saying an “addicted person,” or an “addict,” we say “a person with a substance use disorder.” Person-first language has also been championed by people living with mental illnesses and other disabilities. This puts a person before a diagnosis, making the person the focus, rather than the illness. When reflecting on the social determinants of health and intersectionality we are looking beyond one factor to the whole individual and multiple connections between these factors, their life, and their experiences. When we choose person first language, we choose to see all the parts of the individual. Rather than focusing on the substance use, we see a whole person and work with the unique aspects that make a person who they are. This allows both a Social Service worker and the agency supporting the individual to provide a more comprehensive service.ActivitiesWrite down all the words you have heard or used to describe substance use. Place them on a continuum of positive to negative.What do you notice?How do you think these words impact individuals living with a substance use disorder?How do you think the language you use might impact your professional relationship with clients as a Social Service worker?What is one way you might challenge your beliefs about substance use disorders?Create a poster or handout focusing on stigma and substance use.Develop a social media post that addresses stigma and substance use.We are all affected by addiction whether directly or indirectly, and to improve health outcomes of all Canadians the stigma associated with both the term and the activity must be addressed. Greater understanding of the terms we use interchangeably for “addiction,” unpacking the stigma associated with the term, and choosing language that highlights the individual rather than the behaviour, we can change how we see and work with people living with a substance use disorder. This can lead to a change in how others view and treat people with substance use disorders in Canada.Take a minute to try the word search. Can you define all the words?An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.nscc.ca/substanceuse/?p=28#h5p-2 Image CreditsChocolate by M Verkerk, J.J.G.Claessens via Wikimedia Commons shared under a CC BY licenseWoman on Phone by antonynjoro via Pixabay shared under a Pixaby licenceCanadian Centre on Substance Use and Addiction. (2018). Stigmatizing language fact sheet[infographic]. https://www.ccsa.ca/sites/default/files/2019-05/CCSA-NAAW-Stigmatizing-Language-Fact-Sheet-2018-en.pdfAmerican Psychiatric Association. (2021). Diagnostic and statistical manual of mental disorders (DSM–5). https://www.psychiatry.org/psychiatrists/practice/dsm?_ga=2.179182436.1550973016.1636716595-1556092926.1621254941Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. https://doi.org/10.1146/annurev.soc.27.1.363Matthews, S., Dwyer, R., & Snoek, A. (2017). Stigma and self-stigma in addiction. Bioethical Inquiry, 14, p. 275. https://doi-org.libproxy.stfx.ca/10.1007/s11673-017-9784-yVolkow, N. D. (2020). Stigma and the toll of addiction. The New England Journal of Medicine, 382(14), 1289-1290. http://dx.doi.org.libproxy.stfx.ca/10.1056/NEJMp1917360Buchman D., & Reiner, P. (2009, September). Stigma and addiction: Being and becoming. The American Journal of Bioethics-Neuroscience, 9(9), 18-19. https://doi.org/10.1080/15265160903090066Canadian Centre on Substance Use and Addiction. (2019). Illuminate. [Video]. YouTube. https://www.youtube.com/watch?v=23KMfX5R8lMLevine, H. G. (1978). The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal of Studies on Alcohol, 15, 493-506. https://doi.org/10.15288/jsa.1978.39.143Ibid.Rosenthal, R. J., & Faris, S. B. (2019). The etymology and early history of ‘addiction’. Addiction Research & Theory, 27(5), 437-449. https://doi.org/10.1080/16066359.2018.1543412Levine, H. G. (1978). The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal of Studies on Alcohol, 15, p. 439. https://doi.org/10.15288/jsa.1978.39.143Canadian Centre on Substance Use and Addiction. (2017). Changing the language of addiction [fact sheet]. https://www.ccsa.ca/changing-language-addiction-fact-sheetNorthern Health B. C. (2017, March 29). Stop stigma. Save lives: Experiences of stigma. [Video]. YouTube. https://www.youtube.com/watch?v=NtxaFXThrzAVolkow, N. D. (2020). Stigma and the toll of addiction. New England Journal of Medicine, 382(14), 1289-1290CCSA. (2017, December 7). Stigma and Discrimination in the Language of Addiction, Dr. Kenneth Tupper. YouTube. https://youtu.be/FowNgyoAhpc41.4 Race, stigma and substance useAccording to Statistics Canada,2 approximately 23% of Canadians identify as a “minority.” This includes People of Color, Indigenous people (Aboriginal, Metis, Innu, Innuit), and immigrants from countries all over the world. If you remember in section 1.1, we discussed race/racism as one of the social determinants of health. When a person experiences racism, research shows that racist incidents are similar to traumatic experiences; and there are both physical and mental health ramifications.4 People of Color have experienced racism for centuries. The impacts of slavery, which existed in Canada,6 and colonization of People of Color has been and is both overt, subtle, and systemic.8 Indigenous people have also been impacted by racism and stigma through colonization. This racism extends through the language we use when it comes to substance use.In this section we explore how language contributes to racism, which in turn can lead to substance use. We will explore how stigma subsequently plays a large role in creating barriers for treatment and support of substance use disorders. Let us watch this video to explore how the language of substance use has impacted Indigenous communities.2One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=32#oembed-3 Food For ThoughtWhere does language come from?Reflect on specific language/terms you use.Are there terms you would change? Why?How do you think you can decolonize language?Numerous studies have documented relationships between self-reports of discriminatory experiences and reports of distress, which can lead to substance use.2 While further research must be done to determine the causal relationship, the relationship exists. This means that if a person experiences racism they may use substances as a form of coping. Rather than using substances to cope, we can help promote healthier choices through access to healthcare that addresses the social determinants of health, including racism. One example of an agency ensuring the intersectionality of health is addressed is the North End Community Health Centre in Halifax, NS.4One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=32#oembed-1 Flow chart on how colonialism leads to addiction.Flow chart on how colonialism leads to addiction. Credit: First Nations Health Authority. Long Description.One step we can take as Social Service workers is to actively talk about racism and how it exists in our lives. Addressing the language we use is an important part of addressing racism, reducing stigma, and supporting the health of minorities in Canada. For example, the intersectionality of black people’s lives in Canada includes “age, gender, sexual orientation, ability, religion, immigration status, country of origin, socioeconomic status, and racialized identity”2 For Indigenous Canadians intersectionality also exists between colonialism, residential schools, and trauma. “While the experiences of First Nations, Métis and Inuit in Canada are unique, they have all endured and pushed back against hundreds of years of colonization, persecution and on-going structural violence that was intended to push them to the margins of society” 4The knowledge of these overlapping factors and identities are critical when providing service as this can reduce barriers and stigma. Service provision can be more comprehensive, for example, and programming must be culturally and trauma sensitive when working with people who have a racialized identity. Due to their identity, we can assume that they have experienced racism. Racism can lead to further stigma, which in turn creates barriers to treatment and support. This racism has led to perceptions of substance use among Indigenous communities.READINGThe article below is an example of how racism and stigma have impacted Mi’kmaq people in Nova Scotia when it comes to accessing health care.Stigma, systemic racism preventing people from seeking health care in Cape Breton by Ardelle Reynolds, October 7, 2021 in the online edition of The Chronicle Herald.Food For ThoughtReflect on racism and stigma in healthcareWhat are three ways racism and stigma are creating a barrier for service in this article?What do you think you need to be aware of when providing services?When you read stories like this and others, it may cause you to feel emotional. This emotional reaction may result in feeling uncomfortable or unsafe. It is important to understand where these feelings begin. As you explore your thoughts, feelings, and emotions, this is an opportunity to also explore your understanding of racism in Canada. This could lead to further education about slavery in Canada, or of residential schools. Perhaps you may wish to learn more about traditional or cultural ways of knowing; exploring the concept of two-eyed seeing, developed by Elder Marshall, Mi’kmaq Indigenous Leader from the Eskasoni First Nation who suggests making change as “one conversation at a time” (personal communication, February 9, 2021). You may reflect on your identity and begin to examine privilege, “an invisible package of unearned assets”.2READINGPeggy McIntosh’s White Privilege Checklist.As Social Service workers, it is your responsibility to understand systemic issues that create barriers to service so you may work with empathy, compassion, and knowledge. This will contribute to reducing racism and stigma.Flow chart on how community leads to connection.Flow chart on how community leads to connection. Credit: First Nations Health Authority. Long Description. Promoting the importance of traditional knowledge and traditional treatment is another step in the reduction of stigma. It is through the resilience of Indigenous communities that “Indigenous peoples, languages, cultures, and traditions have not only survived, but they have also been revived, reclaimed, and revitalized”.2 Watch the video4 below and reflect on the importance of Indigenous culture, practices, and treatment in healthcare.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=32#oembed-2 We know “substance use disorders are one of the most stigmatized mental health issues”.2 From the language we use, to the communities we engage with, we must be aware how language plays a role in racism and stigma for people who use substances and have substance use disorders. While we must be prepared to have difficult conversations and be prepared to talk about intersectionality, race, racism, and stigma in our work, it will require further training; seek out training that can support your understanding of language, racism, and stigma.Image CreditsFlow charts on Colonialism and Community from: First Nations Health Authority. (2015). Decolonizing substance use, (pp. 10, 15). https://uphns-hub.ca/wp-content/uploads/2021/05/PowerPoint-Decolonize-Substance-Use-Indigenous-Harm-Reduction.pdfGovernment of Canada (2016). Census profile. https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/details/page.cfm?Lang=E&Geo1=PR&Code1=01&Geo2=PR&Code2=01&SearchText=Canada&SearchType=Begins&SearchPR=01&B1=Visible%20minority&TABID=1&type=1Lee, B., Kellett, P., Seghal, K., & Van den Berg, C. (2018). Breaking the silence of racism injuries: A community-driven study. International Journal of Migration, Health, and Social Care, 14(1), 1-14. http://dx.doi.org/10.1108/IJMHSC-01-2016-0003Cooper, A. (2006). The hanging of Angélique: The untold story of slavery in Canada and the burning of Old Montréal. University of Georgia Press.Government of Canada (2020). Social determinants and inequities in health for Black Canadians: A snapshot. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health/social-determinants-inequities-black-canadians-snapshot.htmlTEDx Talks. (2020, April, 8). TEDx San Francisco University-Len Pierre-Decolonizing Substance Use & Addiction. [Video]. Youtube. https://www.youtube.com/watch?v=j95ayhyadNEGibbons, F. X., Etcheverry, P. E., Stock, M. L., Gerrard, M., Weng, C. Y., Kiviniemi, M., & O’Hara, R. E. (2010). Exploring the link between racial discrimination and substance use: what mediates? What buffers? Journal of Personality and Social Psychology, 99(5), 785–801. https://doi.org/10.1037/a0019880North End Community Health Centre. (2021). 50 Years of NECHC. [Video]. Youtube. https://www.youtube.com/watch?time_continue=20&v=yN1GQ7_dkXo&feature=emb_logoGovernment of Canada (2020). Social determinants and inequities in health for Black Canadians: A snapshot, (para. 6). https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health/social-determinants-inequities-black-canadians-snapshot.htmlInteragency Coalition on AIDS & Development. (2019). Indigenous harm reduction, reducing the harms of colonialism, policy brief, (p. 4) https://www.canada.ca/en/public-health/services/health-promotion/population- health/what-determines-health/social-determinants-inequities-black-canadians-snapshot.htmlMcIntosh, P. (1989). White privilege: Unpacking the invisible backpack. Peace and Freedom Magazine. https://psychology.umbc.edu/files/2016/10/White-Privilege_McIntosh-1989.pdfInteragency Coalition on AIDS & Development. (2019). Indigenous harm reduction, reducing the harms of colonialism, policy brief, (p. 4) https://www.canada.ca/en/public-health/services/health-promotion/population- health/what-determines-health/social-determinants-inequities-black-canadians-snapshot.htmlRoyal College of Physicians and Surgeons of Canada. (2015, March 25). Bridging the gap between traditional and western medicine: The remarkable work of Dr. Karen Hill. [Video]. YouTube. https://youtu.be/nVQU1EmoWoUWinters, E., & Harris, N. (2019). The impact of Indigenous identity and treatment seeking intention on the stigmatization of substance use. International Journal of Mental Health & Addiction, 18, 1403–1415. https://doi.org/10.1007/s11469-019-00162-651.5 Gender, stigma and substance useWhen I first started in the divorce, um, when we first separated, I was straight. I was tryin’ to do right. I had the kids in church. And it got so hard, and somebody was always goin’ “well if you did this if you did that,” and I started feelin’ beneath. Uh, when I had the car wreck, I knew one way I could support my kids—I started sellin’ drugs.2Gender, as we discussed is one of the social determinants of health. Have you thought about how gender plays a role in substance use disorders? Researchers suggest there are “environmental, sociocultural and developmental influences”2 when it comes to sex, gender and substance use. This means how a person is born regarding their biological sex (male or female), as well as how they identify (gender), plays a role in their substance use and in their development of substance use disorders. Please watch the following video4 to explore sex, gender and substance use.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=35#oembed-1 Race and gender, as intersections of identity, also play a role in substance use and the development of a substance use disorder. Research suggests substance use disorders do differ by both biological sex and by gender.2 Subsequently, there has been an increase in woman-focused research, as the majority of current treatment supports and services are still misinformed by research with a “male-as-norm” bias.4 Review the Table on Sex Differences in Substance Use. This is important to be aware of, as we are exploring the social determinants of health and beginning to tackle racism, sexism, and the stigma associated with substance use.An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.nscc.ca/substanceuse/?p=35#h5p-3 Food For ThoughtWhy do you think we should be aware of sex and gender when discussing substance use?What do you think are some issues specific to sex and gender for those who use substances?Women as a gendered group face greater stigmatization than men for using drugs since they go against the character traits of perceived female identity. The stigma of drug use is also greater for mothers since they are expected to be the caregivers, raise children, and be more family oriented than fathers.2What this suggests is society that societal expectations of women result in moral judgments and women are judged for using substances. As Social Service workers, it is important to be aware of these stigmas and judgments. When we think about women who use substances and those who have a substance use disorder, we must examine our assumptions. We reflect so we can provide non-judgmental services and ensure the research we are using addresses “unexamined assumptions about how women “should” behave” and how these “have influenced research agendas”.2 These assumptions consequently impact availability of evidence-based services and programs for treatment and prevention. We also must be aware that in general, “women report more problems related to health and mental health, as well as more past trauma and abuse (physical and sexual), and experience more sexual problems. Women are more likely to begin using drugs after a specific traumatic event, and to suffer from post-traumatic stress disorder”.4 How can we ensure that a program for women who live with a substance use disorder is the best it can be?Several years ago, the United Nations developed a list of the issues that are specific to women who have substance use disorders. Of note is the association between substance use disorders and all forms of interpersonal violence (physical, sexual, and emotional) in women’s lives.2 To engage with people who identify as women, Social Service workers must be aware of the following issues:Shame and stigmaPhysical and sexual abuseRelationship issuesFear of losing childrenFear of losing a partnerNeeding a partner’s permission to obtain treatmentThese issues are not solely issues for a Canadian audience, they are worldwide. Based on these issues, the United Nations developed a list of concerns practitioners should address when supporting women with substance use disorders. These include:Lack of sex and gender-specific services for womenNot understanding women’s issuesLong waiting listsLack of childcare servicesLack of financial resourcesLack of clean/sober housingPoorly coordinated services.2ActivitiesReview the UN lists above.Brainstorm any missing concerns you think would be important to include.Imagine you are providing a program for women with substance use disorders. What would you need to do to ensure your program meets UNODC recommendations?To support women’s health, Social Service workers must also address the stigma of women using substances. Rather than provide supportive and well-rounded (“wrap-around”) services, some services may come from a place of moral judgment, which puts women who use substances in a greater position for marginalization and reduced health outcomes. “Women living with a history of substance use and addiction encounter many barriers when trying to access forums that are directly related to their life issues”.2 Women have reported “feeling unsupported and judged”4 which negatively impacts their mental health and may prevent them from further accessing health care. Being aware of the societal issues related to women and substance use is one area Social Service workers can make a real difference, through providing not only a judgment-free service, but a service that provides supportive services based on the UNODC recommendations. Gender based services that also support a harm reduction approach and address women’s needs are an important part of a social service workers toolbox.ActivitiesResearch harm reduction.Why is harm reduction important in providing services to women?Harm reduction is simply that, reducing the harms that are associated with substance use (see Chapter 9). Harm reduction in women’s programming should be comprehensive, addressing the issues identified above. For example, when working with women who are pregnant and using substances, some people may want to judge.WATCHPlease watch the following clip and answer the questions in the activity below. NFB Video: Bevel Up-Becky and LizActivitiesBrainstorm a list of society’s attitudes towards pregnant women using substances.How do you think moms who use substances might be judged by a healthcare provider?How do you think moms who use substances might be judged by a workplace or by community services?What risks can this lead to?How can you support a mom who is using substances or has a substance use disorder?Women are becoming increasingly at risk for substance use disorders; for example, the Canadian Centre on Substance Abuse has suggested women’s use of alcohol has been on the rise since 2004.2 In 2020, “30.5% of women of reproductive age reported consuming alcohol weekly in the past year and 18.3% reported engaging in heavy alcohol consumption”. 4Table 1 – Percentage of females and males who report past-year drinking, by sex, aged 15+, Canada NPHS* 1994-95, 1998-99, CAS*** 20041994-951998-992004Female71.574.076.8Male79.882.282.08NPHS = National Population Health Survey ** CAS = Canadian Addiction Survey Food For ThoughtWhy do you think women are increasing their substance use?Why do we need to know about women’s drinking habits?Why do you think women are increasingly at risk of substance use disorders?There are many issues to be aware of when it comes to gender and substance use. Whether providing support for women who have a substance use disorder or treatment for women’s substance use disorders, Social Service workers must acknowledge the realities of women’s lives, the stigma they face: “women with histories of addiction and incarceration face stigma regarding their roles in society, particularly with regard to their roles as mothers and women”2 and the high prevalence of violence and other types of abuse.4 Services must be comprehensive, from prevention through to treatment and recovery for women and girls, and should be based on a holistic and woman-centered approach that acknowledges their psychosocial needs.6Lee, N., & Boeri, M. (2017). Managing stigma: Women drug users and recovery services. Fusio: the Bentley Undergraduate Research Journal, 1(2), 65–94. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6103317/Becker, J. B., McClellan, M. L., & Reed, B. G. (2017). Sex differences, gender, and addiction. Journal of Neuroscience Research, 95(1-2), 136–147. https://doi.org/10.1002/jnr.23963National Institute on Drug Abuse. (2019). Sex, gender and addiction. [Video]. Youtube. https://www.youtube.com/watch?v=nP–FR198CcBecker, J. B., McClellan, M. L., & Reed, B. G. (2016). Sociocultural context for sex differences in addiction. Addiction Biology, 21(5), 1052-1059. https://doi.org/10.1111/adb.12383Kruk, E., & Sandberg, K. (2013). A home for body and soul: substance using women in recovery. Harm reduction journal, 10, 39. https://doi.org/10.1186/1477-7517-10-39Lee, N., & Boeri, M. (2017). Managing stigma: Women drug users and recovery services. Fusio: the Bentley Undergraduate Research Journal, 1(2), 65–94. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6103317/Becker, J. B., McClellan, M. L., & Reed, B. G. (2017). Sex differences, gender, and addiction. Journal of Neuroscience Research, 95(1-2), 136–147. https://doi.org/10.1002/jnr.23963Kruk, E., & Sandberg, K. (2013). A home for body and soul: substance using women in recovery. Harm reduction journal, 10, 39. https://doi.org/10.1186/1477-7517-10-39United Nations Office on Drugs and Crime (2018). Women and drugs; drug use, drug supply and their consequences. https://www.unodc.org/wdr2018/prelaunch/WDR18_Booklet_5_WOMEN.pdfIbid.Paivinen, H., & Bade, S. (2008). Voice: Challenging the stigma of addiction -a nursing perspective. International Journal of Drug Policy, 19(3), 214-219 https://doi.org/10.1016/j.drugpo.2008.02.011Eggertson, L. (2013). Stigma, a major barrier to treatment for pregnant women with addictions: Canadian Medical Association Journal, 185(18), 1562. https://doi.org/10.1503/cmaj.109-4653Canadian Centre on Substance Use and Addiction. (2004). Girls, women and substance use. https://www.ccsa.ca/sites/default/files/2019-05/ccsa-011142-2005.pdfVarin, M., Palladino, E., Hill MacEachern, K., Belzak, L. & Baker, M. M. (2021). At a glance: Prevalance of alcohol use among women of reproductive age in Canada. Health Promotion and Chronic Disease Prevention in Canada Journal, 41(9), 267-272. https://doi.org/10.24095/hpcdp.41.9.04Gunn, A. J., & Canada, K. E. (2015). Intra-group stigma: Examining peer relationships among women in recovery for addictions. Drugs, 22(3), 281–292. https://doi.org/10.3109/09687637.2015.1021241Covington, S. (2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, 40(Sup5), 377-385. https://doi.org/10.1111/adb.12383Covington, S. (2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, 40(Sup5), 377-385. https://doi.org/10.1111/adb.1238361.6 The language of compassionThe social determinants of health related to substance use are a complicated topic, and so is providing effective support. Social Service workers must be aware of these factors and “must be carefully chosen because of the sensitivity of the subject, and the associated pain and trauma experienced by the participants”.2 When we work with people who have substance use disorders we may feel tempted to “fix” the person. Your role as a Social Service worker is not to diagnose or treat but to provide support and appropriate referrals. One way to provide support is to use compassion.Food For ThoughtWhat do you think compassion is?Why do you think compassion is important when discussing substance use?Why do you think compassion is important when working with clients?How can you demonstrate compassion?To further understand being compassionate in your practice, please review this short video on how to be compassionate and supportive when working with people who use substances.2One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=37#oembed-1 An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.nscc.ca/substanceuse/?p=37#h5p-4 Being compassionate is important, it is also important to understand our boundaries. Investing much time supporting an individual can be taxing and can result in compassion fatigue. “Compassion fatigue is a recent concept that refers to the emotional and physical exhaustion that affects helping professionals and caregivers over time”.2 Ensuring self care, including compassion for oneself, is one way to improve success in this field. At the end of each chapter there is a section called self-care. Each self-care section provides resources and activities that can improve mental health.Food For ThoughtWhat are two ways you can prevent compassion fatigue?What was one learning from Chapter 1?What do you want to know more about?For further information on the topics in Chapter 1, please review the Additional Resources section.Lee, B., Kellett, P., Seghal, K., & Van den Berg, C. (2018). Breaking the silence of racism injuries: A community-driven study. International Journal of Migration, Health, and Social Care, 14(1), 1-14. https://doi.org/10.1108/IJMHSC-01-2016-0003Canadian Centre on Substance Use & Addiction. (2021). My journey begins with compassion. [Video]. Youtube. https://www.youtube.com/watch?v=RD0EOwWK8gIJarrad, R., Hammad, S., Shawashi, T., & Mahmoud, N. (2018). Compassion fatigue and substance use among nurses. Annals of General Psychiatry, 17(13), https://doi.org/10.1186 /s12991-018-0183-571.7 Self-careEach chapter has a self care section because taking care of oneself is an important part of being an effective Social Service worker. In this self-care section we will be exploring strategies for coping while working in the field of substance use and living in the world of the Covid pandemic.READPlease take a moment to review the Health-Care Providers Infographic3 by the Canadian Centre on Substance Use & Addiction.Try one of the strategies suggested.Report back on your experience.Canadian Centre on Substance Use & Addiction. (2020). Managing stress anxiety and stress during Covid-19. https://www.ccsa.ca/sites/default/files/2020-04/CCSA-COVID-19-Stress-Anxiety-and-Substance-Use-Health-Care-Providers-Infographic-2020-en.pdf8Additional ResourcesVideosThe Urgency of Intersectionality TedTalk by Kimberlé Crenshaw via YouTube.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=42#oembed-1 SL Project Final by Nova Scotia health via Vimeo.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=42#oembed-2 Under the Rug by The Marguerite Centre via YouTube.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=42#oembed-3 Mi’kmaq Honour Song-Mi’kmaq Sign LanguageOne or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=42#oembed-4 Additional ResourcesChanging the Language of Addiction A 2017 fact sheet created by the Canadian Centre on Substance Use and Addiction.Language Matters A combating stigma pamphlet created by the Canadian Commission on Mental Health.Stigmatizing Language Fact Sheet A 2018 fact sheet created by the Canadian Centre on Substance Use and Addiction.Systemic Racism in Canada’s Healthcare System A research paper written by B. Gunn, University of Manitoba.Anti-Racism Resources Created by the Public Service Alliance of Canada, hosted on the Public Service Alliance of Canada website, Anti-racism Resources page.White Privilege: Unpacking the invisible knapsack by Peggy McIntosh White Privilege: Unpacking the Invisible Knapsack first appeared in Peace and Freedom Magazine, July/August, 1989, pp. 10-12, a publication of the Women’s International League for Peace and Freedom, Philadelphia, PA. IIChapter 2: Why People Use SubstancesLearning ObjectivesBy the end of this chapter you should be able to:Define substance useDefine substance use disorderDiscuss aspects of substance useDiscuss aspects of substance use disordersExplore the role of substance use as culture/traditionDescribe the continuum associated with substance useDefine physical and psychological dependency92.1 OverviewThis section of our text will be an exploration of why people use substances. We will look at substance use within cultures, within age groups and the motivating factors behind substance use. We will begin to explore why people to continue to use substances and how substance use can develop into a substance use disorder.What is substance use? Substance use is the use of a psychoactive substance (substances that impact the brain) by an individual, community, culture, or society. Why do we use substances? We use substances for many reasons. Psychoactive substances have been a part of human history for thousands of years, “as a species, humans have a fascination with any psychoactive agent that alters our basic perception of our environment”.2Historically, psychoactive substances have been used in religious ceremonies, for medicinal purposes, or by the general population in a socially approved way (drinking coffee). 2 According to Csiernik4, archaeological evidence dating back to 10,000+ years shows evidence of the use of psychoactive substances used for both cultural purposes and recreational purposed. Betel seeds have been found in archeological sites on the continent of Asia6 and alcohol was used in ancient Egypt and Rome.8 Wine was introduced to European countries through the Roman expansion. “During the expansion of the Roman Empire, rural areas of west central Europe became Romanized. As a part of this process, indigenous inhabitants adopted some customs from urban Roman culture, including wine drinking with meals”.10 Tobacco was first introduced to Europeans shortly after Columbus’ landfall in the Americas in 149212 and other substances we will explore also have rich histories with many uses and traditions. As noted, there are several reasons from historical, cultural, and medicinal as to why people use substances.ActivitiesBrainstorm a comprehensive list of why people use substances.Once your list is complete, arrange the reasons in a continuum from positive to negative based on your beliefs.Reflect on the positive and negative. Who decides what is positive and negative?What is “normal use”?Research a culture/group that uses substances.Csiernik, R. (2015). Substance use and abuse: Everything matters (2nd ed). Canadian Scholars Press.Crocq, M. A. (2007). Historical and cultural aspects of man’s relationship with addictive drugs. Dialogues in Clinical Neuroscience, 9(4), 355–361. https://doi.org/10.31887/DCNS.2007.9.4/macrocqCsiernik, R. (2015). Substance use and abuse: Everything matters (2nd ed). Canadian Scholars Press.Vetulani J. (2001). Drug addiction, part I: Psychoactive substances in the past and present. Polish Journal of Pharmacology, 53, 201–214. https://pubmed.ncbi.nlm.nih.gov/11785921/Counsell, D. (2009). Egyptian mummies and modern science. Cambridge University Press. https://doi.org/10.1017/CBO9780511499654.014Engs, R. (1991, April 27). Romanization and drinking norms: A model to explain differences in western society. Paper presented: Society of American Archaeology Annual Meeting.Sadik, T. (2014, March 28). Traditional use of tobacco among Indigenous Peoples of North America: A literature review. https://cottfn.com/wp-content/uploads/2015/11/TUT-Literature-Review.pdf102.2 Why do people use substances“I grew up around a family of smokers who gave cigarette smoking a classy edge. I would always be mimicking the adults by pretending to smoke. This is the introduction to me normalizing cigarettes and participating in the social norms of tobacco use”.2There are many reasons why people use psychoactive substances, from medicinal to religion to enjoyment. You may be wondering why; however, some people can use substances and have healthy relationships with substances yet do not develop a disorder while others do.2 Watch the following video of Tyler Sullivan-King4 who shares their story of using substances and developing a substance use disorder.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=49#oembed-1 Tyler’s prescription for an opiate from an injury was a powerful experience with a powerful substance. Tyler also mentioned their environment as “not ideal”. This combination of factors developed into a substance use disorder.What is a substance use disorder (SUD)? A substance use disorder according to the American Psychiatric Association2 is a “pattern of symptoms resulting from the use of a substance that you continue to take, despite experiencing problems as a result”.4 As with other diseases and disorders, the likelihood of developing a substance use disorder differs from person to person, and no single factor determines whether a person will develop a substance use disorder.6 In general, the more risk factors a person has, the greater the chance that taking substances may lead to substance use and a SUD. “Risk factors are those that make drug use more likely”. 12 Protective factors, on the other hand, “are those associated with reduced potential for drug use”.16Key Risk and Protective Factors for Drug Use 2 Catagories/DomainsRisk FactorsProtective FactorsCommunityCommunity disorganizationLaws and norms favorable to drug usePerceived availability of drugsCommunity cohesionCommunity norms not supportive of drug useSchoolAcademic failureLittle commitment to schoolParticipation in school activitiesSchool bondingFamilyParental attitudes favorable to drug usePoor family managementFamily history of antisocial behaviorFamily sanctions against usePositive parent relationshipsPeer/IndividualEarly initiation of antisocial behaviorAttitudes favorable to drug usePeer drug usePositive peer relationshipsNetwork of non-drug using peersAccording to this research, “for individuals who begin using illicit substances at an early age, several risk factors may increase the likelihood of continued and problematic use in later ages”.2Please watch this video from the Canadian Centre on Substance Use and Addiction2 exploring the power of protective factors in lifetime wellness.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=49#oembed-2 ActivitiesReview the risk and protective factors.Reflect on the social determinants of health. How many of these risks or protective factors can you identify relate to the social determinants of health?Reflect on Tyler: can you identify any risk factors that may have impacted his development of a substance use disorder?Why do you think those with all the risk factors may not develop a substance use disorder?On the other hand, why might someone who has all the protective factors develop a substance use disorder?In Canada, there is a social acceptance within many cultures around the use of substances, including weddings, graduations, funerals, celebrations.ActivitiesReflect on the social acceptance of substances. Name the activities that accept substances.Reflect on how companies promote the use of alcohol through the media.What is the narrative you have heard about using alcohol throughout the lifespan?Watch the CBC Documentary- Girls Night Out: A Personal Look at Binge Drinking in Young Women (cbc.ca)What does this suggest about substance use and age? What does this suggest about substance use and gender?Substance abuse and dependency is stigmatized, yet alcohol use is often culturally accepted. Why is that?Choose a “normal” day and make note of how many advertisements you see for substances. Categorize them into medication, alcohol, and cannabis. What are the numbers? What does this suggest?There are many reasons why societies, cultures and people use substances. As Social Service workers you may have the opportunity to explore an individual’s journey, using your individual helping skills. You may have the opportunity to engage with a community, focusing on a specific group of people. For example, you may be working with a school, developing a survey on substance use among the youth. What types of interventions might you explore based on what you know about why people use substances? Be prepared, as you have learned, to explore every story, from a lens of “nothing about us, without us”. The individual and the community must be the leader in their stories.Chapter CreditAdapted from Unit 6.1, and 6.2 in Drugs, Health & Behavior by Jacqueline Schwab, licensed under a CC BY-NC-SA license.Updated with Canadian Content.Lee, B., Yanicki, S., & Solowoniuk, J. (2011). Value of a health behavior change reflection assignment for health promotion learning. Education for Health, 24(2), 509. http://www.educationforhealth.net/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/City of Hamilton. (2019, Novmber 18 ). #SeeThePerson - Tyler. YouTube. https://www.youtube.com/watch?v=J2OcFc-_bacAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.Ibid, p. 175Schwab, J. (2021). Drugs, health and behaviour. Pressbooks. https://psu.pb.unizin.org/bbh143/chapter/drugs-and-the-brain-national-institute-on-drug-abuse-nida/Public Safety Canada. (2018). School-based drug abuse prevention: Promising and successful programs. https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/sclbsd-drgbs/index-en.aspxPublic Safety Canada. (2018). School-based drug abuse prevention: Promising and successful programs. https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/sclbsd-drgbs/index-en.aspxPublic Safety Canada. (2018). School-based drug abuse prevention: Promising and successful programs. https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/sclbsd-drgbs/index-en.aspxIbid, para. 1Canadian Centre on Substance Use and Addiction. (2021). Community connections supporting lifetime wellbeing. [Video]. Youtube. https://www.youtube.com/watch?v=1Hj06BlVrnI112.3 Why do people continue to use substancesWhy do people continue to use substances, as part of a substance use disorder? You may think of substance use as a habit, as something that gets reinforced through daily repetitions and habits.Food For ThoughtReflect on a “normal day”. What do you do from the moment you wake until the moment you go to sleep? Are any of these activities’ habits?Identify the habits you have?Do you think these are healthy or unhealthy habits? Why do you believe this to be so?How does this habit make you feel? Why?Have you ever tried to change a habit? Were you successful? How?Reflect on a negative habit you currently have. Where does this habit come from? What does this habit solve for you? Have you ever thought about changing it? What would it take to change it?A substance use disorder is an unhealthy habit and every time a person uses a substance (repetition) it causes a reaction in both the body (physical) and the mind (psychological). The substance use is pleasurable, and the repetition can work like an enforcer, drilling those habits deeper and deeper. In time, through the repetition of use and the reinforcement of the habit, this can make the substance use a very difficult habit to break. The habit may become both physical and psychological.ActivitiesBrainstorm all the ways you think a person can become physically dependent on a drug and review with your class.Brainstorm all the ways you think a person can become psychologically dependent on a drug and review with your class.Compare and contrast your ideas from your brainstorm.What is physical dependence?What is physical dependence? Physical dependence is “a physiological state of cellular adaptation occurring when the body becomes so accustomed to a drug that it can only function normally when the drug is present”. 2 This means without the substance in the body, the body simply does not function “normally”. When someone experiences these symptoms, it is called withdrawal. This can include shaking or trembling, nausea, cramping, muscle spasms and more. People who have a substance use disorder may experience withdrawal, “the development of physical disturbances or physical illness when drug use is suddenly discontinued in the opposite direction to the original effects of the drug”. 4 This is the body’s physical response to the absence of the drug. Withdrawal can range from discomfort to death, depending on the physical dependence (how long a person was using a substance, how often) and the type of substance a person is using. All these factors will impact their withdrawal, for example, withdrawal from opioids is different than withdrawal from alcohol. When working with people in withdrawal, it is important to remember it is painful, for both physical and psychological reasons.With physical dependence also comes tolerance. Tolerance is the “body’s adaption to the presence of the drug requiring increased amounts to produce the same outcome as originally experienced.2 This means that over time it takes more of the substance or drug to produce the same feeling. This has been known as “chasing the dragon”.ActivitiesBrainstorm a comprehensive list of factors that impact tolerance.Why do you believe some people develop a tolerance to substances quicker than others? Discuss with your classmates.What is psychological dependence?What is psychological dependence? Individuals who have a substance use disorder may also develop a psychological dependence. When you reviewed the activity exploring your habits, perhaps you determined a habit you engage in makes you feel happy. A psychological dependence is the “mind need” for a substance, “a drug becomes so important to a person’s thoughts or activities that the person believes that he or she cannot manage without the substance”. 2 There is also the belief that persons with substance use disorderssuffer in the extreme with their feelings, either being overwhelmed with painful affects or seeming not to feel their emotions at all. Substances of abuse help such individuals to relieve painful affects or to experience or control emotions when they are absent or confusing.2In this case, a person simply wants to numb their emotional pain and knows that by using and continuing to use a substance their pain can be numbed. Psychological dependence is just as intense as physical dependence, if not more so. If you believe you need a particular substance to manage your daily life, the withdrawal from that substance can be difficult.ActivitiesWhat have you heard about withdrawal?What types of substances do you think create physical withdrawal?What types of substances create psychological withdrawal?Do you think physical or psychological is more intense? Why?Both physical and psychological withdrawal may be reasons why a person continues to use substances, and /or experiences a substance use disorder. According to the American Psychiatric Association2 to diagnose a substance use disorder a person must have dependence and have experienced withdrawal. This would include substances like alcohol, heroin, cocaine, and even cannabis, which was a recent addition to the DSM-V. Withdrawal, both physical and psychological can be quite painful, particularly for people who are using opiates. Let’s watch the John Lenec discuss his experiences with opioid use and withdrawal.4 Note the language used by the Canadian Press. How might you change this language to reduce stigma?One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=51#oembed-1 What did you notice? What were the physical symptoms of withdrawal John discussed? What were the psychological symptoms of withdrawal John mentioned? The symptoms of withdrawal may prevent some people from reducing or stopping their substance use. The table below indicates a number of substances. Please review the types of dependence for the most commonly used substances.Psychoactive Substances Dependence Chart2DrugDangers and Side EffectsPsychological DependencePhysical DependencePotential for DisorderCaffeineMay create dependenceLowLowLowNicotineHas negative health effects if smoked or chewedHighHighHighCocaineDecreased appetite, headacheLowLowModerateAmphetaminesWithdrawal accompanied by severe “crash” (depression) as effects wear off, particularly if smoked or injectedModerateLowModerate to HighAlcoholImpaired judgment, loss of coordination, dizziness, nausea, and eventually a loss of consciousnessModerateModerateModerateBarbiturates and benzodiazepinesSluggishness, slowed speech, drowsiness, in severe cases, coma or deathModerateModerateModerateToxic inhalantsBrain damage and deathHighHighHighOpiumSide effects include nausea, vomiting, tolerance, and addiction.ModerateModerateModerateMorphineRestlessness, irritability, headache and body aches, tremors, nausea, vomiting, and severe abdominal painHighModerateModerateHeroinAll side effects of morphineHighModerateHighMarijuanaMild intoxication; enhanced perceptionLowLowLowLSD, mescaline, PCP, and peyoteHallucinations; enhanced perceptionLowLowLowIt is important to note cannabis is not indicated above; however, in the DSM-V it is included as a substance with psychological dependence as people can experience withdrawal. Were you surprised by any of the states of dependence for any of the substances? The dependence on a substance is one factor that can keep people in a cycle of use. Uncomfortable withdrawal may make it difficult to go to school, work, or take care of a family. In some cases, it is extreme, as mentioned in the video.Are you a regular coffee drinker? Have you ever tried to give up coffee? Did you experience any symptoms? Do you smoke tobacco? Have you tried quitting? What was that like? When we think about substance use and withdrawal, we may immediately go to substances we see in the media, like heroin and cocaine. It is important to note, based on the chart above, every substance is different, and psychological and physical dependence will be experienced differently depending on the substance and the person who uses it.Activities Based on what you learned about physical and psychological dependence, as well as all the reasons people use substances, brainstorm:Reasons why individuals start using substancesReasons why individuals continue/maintain useReasons why individuals escalate/increase frequency or amount of substance useReasons why individuals stop using substancesReasons why individuals start using substances againGroup reasons in two charts, positive and negative.Identify 1 resource that could provide support for each reason.All substances have some risk, as they impact our body and brain in different ways. In Chapter 3 we will examine the various substances, their origins and their impact on the body and mind.Chapter CreditAdapted from Unit 5.2 in Drugs, Health & Behavior by Jacqueline Schwab, licensed under a CC BY-NC-SA license.Updated with Canadian Content.Csiernik, R. (2015). Substance use and abuse: Everything matters (2nd ed.), (pp 19). Canadian Scholars Press.Ibid, p. 31Ibid, p. 29Ibid, p. 20Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5) 231-244. https://pubmed.ncbi.nlm.nih.gov/9385000/American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596Canadian Press. (2016, December 21). You think you’re dying’: Ex-Heroin user on withdrawal. [Video]. YouTube. https://youtu.be/Zks_fdt-aHYSchwab, J. (2021). Drugs, health & behaviour. Pressbooks. https://psu.pb.unizin.org/bbh143/chapter/altering-consciousness-with-psychoactive-drugs/122.4 Concurrent disordersWe all have mental health, like we all have physical health. Our mental health is shaped by many factors, including “our social, economic, and physical environments”. 2 It can depend on what we are experiencing at any moment, our ability to cope and our ability to be resilient. Reflect on the reasons why people use substances. As we have explored, not all substance use will develop into a substance use disorder. There are many reasons why people use substances, one reason you may not have explored is mental health. Mental health is one of the social determinants of health, and good or poor mental health does play a role in a person’s substance use.There are many individual factors that make people vulnerable or resilient to a substance use disorder.2 When we look at these characteristics, they may include positive self-image, self-control, or social competence as well as chronic illness, poverty, and homelessness.4 You may start to see a connection between mental health and substance use. There is a direct relationship (sometimes called a correlation) between mental health disorders and substance use disorders.A sad woman sitting on a kitchen floor and holding a half full wine glass.Sad woman drinking wine. Credit: Zachary KadolphTwo smiling men clinking their cups of beer together by a bonfire.Two happy men drinking beer. Credit: Dylan SauerweinThis is different than someone using a substance because of how they are feeling. Emotions like happiness and sadness may be a reason why someone uses a substance, for example having a drink at a social event. The difference between mental health and a mental health disorder, for example, depression, is that the mental health disorder is a diagnosable illness, like a substance use disorder. Healthcare practitioners use the DSM-V to diagnose mental health disorders, like substance use disorders. Some of the people you will meet will be living with mental health disorders AND substance use disorders; this may be called a concurrent disorder, or a dual diagnosis. People who have a concurrent disorder may experience a “combination of problems, such as: anxiety disorder and an alcohol problem, schizophrenia and cannabis dependence, borderline personality disorder and heroin dependence, and bipolar disorder and problem gambling”. 2Which comes first, mental health or substance use? There are researchers on both sides of this argument. According to the Canadian Mental Health Association, “people who experience problems with alcohol or drug use are more likely to be diagnosed with a mental illness and people who experience a mental illness are more likely than others to also experience a substance use problem”. 2 What we do know empirically, which means through research and observation, is mental health disorders and substance use disorders are related, regardless of which came first.Food For ThoughtReflect on a mental health disorder and substance use disorder. Why do you think they are related?Why do you think people who have mental health disorders use substances?What role do you think early diagnosis of a mental health disorder plays in the development of a substance use disorder? Why?Please watch this video by Royal Talks, which helps explain the concurrent disorders and the importance of support for improved health outcomes.2One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=55#oembed-1 The risks of developing a substance use disorder if you have been diagnosed with a mental health disorder are high. According to the Mental Health Commission of Canada, “people living with mental illness are twice as likely as other Canadians to experience problematic substance use”. 2 When we dig further into mental health disorders and look at specific disorders, Buckley et al.4 suggest at least 50% of people who have been diagnosed with schizophrenia have a co-occurring substance use disorder.Mental illness can impact anyone at any time; however, “70% of mental health problems have their onset during childhood or adolescence”2 making substance use among youth especially problematic. If a young person is using substances to reduce the impacts of a mental health disorder, it is critical the mental health disorder be diagnosed early, so the appropriate treatments can be implemented, and the outcomes can improve. Early intervention programs that diagnose mental health disorders, along with programs to improve mental health, reduce risks for developing a substance abuse disorder. Promoting mental health, preventing mental health disorders, and preventing substance use are part of Health Canada’s focus on helping to “prevent, treat or reduce the harms associated with opioids, stimulants, alcohol, prescription drugs, and other potentially harmful substances”.4One way we can support individuals with concurrent disorders is to ensure they have access to appropriate resources, and the resources are working in collaboration.Food For ThoughtReflect on collaboration.What does collaboration mean to you?What is one strategy you could use to ensure collaboration with a community agency or healthcare provider?As Social Service workers it is important to be aware of any diagnosis your client may have. This will help you direct clients to appropriate services for their health.ActivitiesImagine you are working with a client who lives with depression and has an alcohol disorder.Brainstorm a list of resources that would be appropriate to address their concurrent disorder.Why did you choose these resources?What resources could you direct family members to if requested?Why is it important to be aware of family supports?Try this quiz to check your learning on Chapter 2 thus far.An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.nscc.ca/substanceuse/?p=55#h5p-5 Image CreditsSad woman drinking wine by Zachary Kadolph shared under a Unsplash license.Two happy men drinking beer by Dylan Sauerwein hared under a Unsplash license.World Health Organization. (2014). Social determinants of mental health, (p. 8). https://apps.who.int/iris/bitstream/handle/10665/112828/9789241506809_eng.pdfSubstance and Mental Health Services Association. (n.d.). Risk and protective factors. https://www.samhsa.gov/sites/default/files/20190718-samhsa-risk-protective-factors.pdfMawani, F. N., & Gilmour, H. (2010). Validation of self-rated mental health. Statistics Canada. https://www150.statcan.gc.ca/n1/en/pub/82-003-x/2010003/article/11288-eng.pdf?st=SgFoG2ghCentre for Addiction and Mental Health. (2021). Concurrent disorders, (para. 1). https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/concurrent-disordersCanadian Mental Health Association. (2018, December 4). Concurrent mental illness and substance use problems, (para. 2). https://cmha.ca/brochure/concurrent-mental-illness-and-substance-use-problems/Royal Talks. (2019). Connections between substance use & mental health and identifying ways of getting help. [Video]. Youtube. https://www.youtube.com/watch?v=lWhmc0tAuqcMental Health Commission of Canada (2021). Mental health and substance use, (para. 1). https://mentalhealthcommission.ca/what-we-do/mental-health-and-substance-use/Buckley, P. F., Miller, B. J., Lehrer, D. S., & Castle, D. J. (2009). Psychiatric comorbidities and schizophrenia, Schizophrenia Bulletin, 35(2), 383–402. https://doi.org/10.1093/schbul/sbn135Canadian Scholars Press.Government of Canada. (2006). The human face of mental health and mental illness in Canada. Public Health Agency of Canada. https://www.phac-aspc.gc.ca/publicat/human-humain06/pdf/human_face_e.pdfGovernment of Canada. (2021). Substance use and addictions program. https://www.canada.ca/en/health-canada/services/substance-use/canadian-drugs-substances-strategy/funding/substance-use-addictions-program.html#wb-auto-4132.5 The stages of changeNow that you have a deeper understanding of why people use substances, we can explore the various stages in which they may use substances or choose to change their substance use. In 1984, Prochaska and Diclemente developed a model to explore change among people who smoked tobacco and who wanted to quit.2 They determined change happens in different stages and at each stage has different internal motivators and different tasks. Prochaska and DiClemente’s Transtheoretical Model of Change or the Stages of Change is used when working with people who live with a substance use disorder.4 This model can also be used for other health interventions including diabetes management, high blood pressure, and high cholesterol. “Change interventions are especially useful in addressing lifestyle modification for disease prevention, long-term disease management and addictions”.6People living with a substance use disorder may not be ready to acknowledge their habits, particularly when it comes to their substance use. Understanding where a person may place themselves on this model is helpful for you as a Social Service worker and for them. This will help you and them develop strategies to move through the stages, if reduction in use, change in substance, harm reduction, or recovery is something they would like to achieve. This is important to note, this is their choice, not yours and whatever changes they make, if any, are their decision.How do you use this model? The graphic below indicates the stages of change; note the arrows. There is no beginning or end; this is because people can start making changes at any time. People may also skip through stages. When using this model, it is important to be nonjudgmental and supportive at each stage.Circle diagram of the states of change: precontemplation (not ready for change), contemplation (getting ready), decision (ready), action, maintenance, relapse. There are two arrows on either side of the circle indicating a cycle.Diagram of the states of change. Credit: Lunn et. al.Now that you have viewed the stages of change, let’s explore each stage individually.Pre-contemplation: Remember when you reflected on your habits? Had you thought about what you were doing every day? If not, that’s ok! This is the stage that we called pre-contemplation, it is the stage where you are doing what you do, without considering making any changes. You may feel comfortable or confident in the choices you are making. You may also see your choices as helpful. In the context of substance use, we know people use substances for many reasons. Imagine someone who has experienced trauma and is using substances to cope. In pre-contemplation they may see their substance use as the only way to cope, in which case they are not prepared to make a change. They may have also tried changing many times and have simply given up.ActivitiesHow could you determine if a client is in pre-contemplation?What are three questions you could ask a client who you believe is in pre-contemplation?What should you be aware of in this stage?Contemplation: In this stage, people have acknowledged there is a habit or a behaviour that is not a healthy behaviour, but they are not yet prepared to make a change. The thought of making a change may cause a person to begin to feel pain. This could be fear of the loss of the behaviour, it could be fear of withdrawal. At this stage you may see individuals develop barriers to change, for example using terms like “I know, but…”. The person may also see the benefits of change but are ambivalent about making that change.ActivitiesHow could you determine if a client is in contemplation?What are three questions you could ask a client who you believe is in contemplation?What should you be aware of in this stage?Decision (also called Preparation): In this stage, the behaviour has been acknowledged and the person has made the decision to make a change. It may be a small change, for example, a reduction in the amount of substance used, or the type, it could be a change in behaviour (safer injection). Whatever the change, it is exciting to get to this stage, as it is a critical stage for a person with a substance use disorder. The person has moved from ambivalence to planning to change. This is also a critical stage for you, the Social Service worker. This is an opportunity to reflect on the behaviour of the individual and develop a set of goals. Starting small is helpful, rather than going “cold turkey”. Whatever the goal is, it is the choice of the individual and respecting the goal is paramount to building a relationship. The preparation stage is simply planning, so using a SMART goal model may be helpful.ActivitiesHow could you determine if a client is in preparation?What are three questions you could ask a client who you believe is in preparation?What should you be aware of in this stage?Action: You have helped your client set goals, now they are going to do the work to achieve them. This can be the easy period in some cases, there is excitement and hope. In the first few days of the action phase, people with substance use disorders should receive a lot of encouragement. This may be the first time or the fiftieth time a person has tried to change their behaviour; every time should be praised.ActivitiesHow could you determine if a client is in action?What are three questions you could ask a client who you believe is in action?What should you be aware of in this stage?Maintenance: This is the make-or-break stage, as the person with the substance use disorder is maintaining their behavioural change, whether a reduction in the amount of substance use, a reduction in risky behaviours, a change in substances or whatever their initial goal was. Continuing to encourage and praise is helpful in this stage. Peer support can be very helpful in the maintenance phase, and programs like AA and NA that use a peer support model that allow for check in’s can be helpful for some people. Being able to provide appropriate referrals to other services is helpful in the maintenance phase.ActivitiesHow could you determine if a client is in maintenance?What are three questions you could ask a client who you believe is in maintenance?What should you be aware of in this stage?Relapse: Relapse is part of substance use disorders, which is why it is part of the model. While we want to help people prevent relapse, depending on their life circumstances, relapse may happen frequently or infrequently. We are there to help individuals understand that relapse is ok, and don’t quit quitting! If we discourage an individual, they may give up entirely. The reality is many individuals will go through the stages of change more than once. Just like you, it takes time to make a change. Reflect on your habits and any habits you have tried to change. If you were successful the first time, congratulations! If not, you’re human!What are SMART Goals?2Statements of the important results you are working to accomplish.Designed in a way to foster clear and mutual understanding of what constitutes expected levels of performance and successful professional development.What is the SMART criteriaSSpecificWhat will be accomplished? What actions will you take?MMeasurableWhat data will you measure? How much? How well?AAchievableIs the goal doable? Do you have the necessary skills and resources?RRelevantHow does the goal align with broader goals? Why is the result important?TTime-BoundWhat is the time frame for accomplishing the goal?ActivitiesReview the SMART goal model.Review the website Addiction Rehab TorontoBrainstorm any missing concerns you think would be important to include.Imagine you are providing a program for women with substance use disorders. What would you need to do to ensure your program meets UNODC recommendations?For a exploration on how to use the Stages of Change to help people quit smoking, let’s watch this video narrated by Dr. Mike Evans.2One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=58#oembed-1 An interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.nscc.ca/substanceuse/?p=58#h5p-6 Now that we understand the reasons why people use substances, we will move forward into understanding substances and their impacts on the brain and body in Chapter 3. If you would like more information on why people use substances and substance use disorders, as well as concurrent disorders, check out the additional resources.Image CreditsDiagram of the states of change from: Lunn, S., Restrick, L. & Stern, M. (2017). Managing respiratory disease: The role of a psychologist within the multidisciplinary team. Chronic Respiratory Disease, 14, 45-53. https://www.researchgate.net/figure/Stages-of-change-model-as-in-the-study-of-Prochaska-and-DiClemente-56_fig1_314110814Boston University School of Public Health. (2019). The transtheoretical model (stages of change). https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/behavioralchangetheories6.htmlBoston University School of Public Health. (2019). The transtheoretical model (stages of change). https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/behavioralchangetheories6.htmlZimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). A ‘Stages of change’ approach to helping patients change behavior. American Family Physician, 61(5), 1409-1416. https://www.aafp.org/afp/2000/0301/p1409.htmlUniversity of California. (2017). Smart goals: A how to guide. https://www.ucop.edu/local-human-resources/_files/performance-appraisal/How%20to%20write%20SMART%20Goals%20v2.pdfCentre for Addiction and Mental Health. (2013). Quitting smoking is a journey. [Video]. Youtube. https://www.youtube.com/watch?v=nyIJo7VCdPE142.6 Self CareIn the past few decades, the concept of mindfulness has been enjoying a boom in popularity with many people endorsing its power to improve health and well-being.LISTENThis self care module Brief Meditation: Arriving in Mindful Presence – (5 min) will provide you with a mindfulness activity, facilitated by Tara Brach.4To give mindfulness a chance, try practising the brief meditation activity below at least 5 times per week. Note how you are feeling, your location and the time of day you practice. Brach, T. (2021). Brief meditation: Arriving in mindful presence [Video]. https://www.tarabrach.com/brief-meditation-5-minute/15Additional ResourcesAdditional ResourcesTestimonials on substance use videos Government of Canada website on the Opioid CrisisA family guide to concurrent disorders A 2007 guide created by the Centre for Addiction and Mental Health with information about how you can support familiesPerformance Management Tool for Withdrawal Management (Behavioural Competencies for Canada’s Substance Use Workforce) A 2021 manual written by the Canadian Centre on Substance Use and Addiction.Canadian resources on help for substance use Government of Canada resources posted on the Health Canada website pages on Substance Use. IIIChapter 3: What are psychoactive substances?Learning ObjectivesBy the end of this chapter you should be able to:Identify substance classification groupingsDefine terminology related to substanceDiscuss substance interactions and multi-substance useDiscuss the medical usefulness of psychoactive substances 163.1 OverviewLet’s start Chapter 3 with a little quizAn interactive H5P element has been excluded from this version of the text. You can view it online here: https://pressbooks.nscc.ca/substanceuse/?p=68#h5p-7 A cup of cappuccino with a leaf design.Cappuccino Art. Credit: Drew CoffmanWho knew that a cup of coffee could be a work of art? A talented barista can make coffee look as good as it tastes. According to the Coffee Association of Canada, 2/3 of all Canadians drink at least one cup of coffee a day.2 That is a lot of “jo”! If you are a coffee drinker, what is it about the coffee that you enjoy? Perhaps it is the heat of the beverage, which feels nice during our long Canadian winters. Maybe it is how it makes you feel? Coffee can make you more alert, and it may improve your concentration. That is because the caffeine in coffee is a psychoactive substance. In fact, “caffeine is the most widely consumed psychoactive substance in the world”. 4Along with caffeine there are numerous other psychoactive substances, this is what we will explore next.ActivitiesBrainstorm a list of terms you have heard for psychoactive substances.Do you think psychoactive substances should be controlled? Why or why not?What is a psychoactive substance (drug)? Psychoactive substances change the function of the brain and result in alterations of mood, thinking, perception, and/or behaviour. Psychoactive substances may be used for many purposes, including therapeutic, ritual/cultural, or recreational purposes. Psychoactive substances come in many forms and are identified in many ways. Uppers, downers, X, bennies, oxy or whatever street name you may have heard or use, these are all examples of what are commonly known as street drugs. In fact, when most people mention the word drug, they will think of street drugs. We use the term psychoactive substance or substance, rather than drug in this text. This is to reduce some of the stigma associated with the term “drug” or “drug user”.There are many psychoactive substances you can purchase legally at your neighbourhood coffee spot or gas station, pharmacy, or local liquor store. What is the difference between these substances? Why are some psychoactive substances considered legal and others illegal? Why are some substances controlled and others not? This is where we will explore the various categories of psychoactive substances, look at where these substances come from, how they are made and how they can be obtained (prescription, over-the-counter, supplements, in a store, coffee spot, mini mart or on the street.In Canada, psychoactive substances are controlled by the Controlled Drug and Substances Act (CDSA). Controlled Drugs and Substances Act. Credit: Screenshot of Government of Canada Legislation. Long Description.Health Canada administers the CDSA and its regulations to:allow access for lawful purposes;reduce the risk that controlled substances and precursors will be used for illegal purposes.2Lawful purposes include using substances like aspirin or ibuprofen for aches and pains as well as any medication that may have been prescribed to you.Food For ThoughtDo you think prescription medication is without risk? Why or why not?Why do you think some substances require a prescription?Let’s check out the list below and take a look at some of the most commonly used psychoactive substances. You will note some of these substances are “scheduled” by the CDSA, which means they are controlled substances and are associated with laws in Canada. A controlled substance means a substance included in Schedule I, II, III, IV or V and except as authorized under the regulations, no person shall possess a substance included in Schedule I, II or III unless prescribed from a licensed physician.6While you may dig deeper into the schedule of substances, for the purpose of this text the psychoactive substances we will explore have all been grouped into 5 categories based on their impact on the body, rather than their schedule according to the CDSA.3DepressantsAlcoholBarbiturates (schedule 4)GHB/Rohypnol (schedule 4)StimulantsCaffeineNicotineCocaine (schedule 1)Amphetamine (schedule 1)Ecstasy (schedule 3) HallucinogensPsylocibin mushrooms (schedule 3)CannabisLSD (schedule 3)Mescaline (schedule 3)OpiatesMorphine (schedule 1)Oxycodone (schedule 1)Fentanyl (schedule 1)Heroin (schedule 1)Carfentanil (schedule 1)Psychotherapeutic agentsValium (schedule 4)Efexor (schedule 4)Anabolic steroids (schedule 4)ActivitiesWatch the following educational playlist from Bevel Up. https://www.nfb.ca/film/topics-street-drugs-101/ What did you learn about methadone? Do you believe methadone can help everyone who uses opiates? Why or why not?What is one thing you learned about multi-substance use?Choose a category of psychoactive substances and become a subject matter expert (SME). Once you have learned everything you can about this category, choose another category. Compare and contrast categories and two substances in each category.What stood out to you?What do you want to know more about?For more information on these substances and others, check out the Centre for Addiction and Mental Health.Chapter CreditAdapted from 8.8 Psychoactive Drugs by CK-12 Foundation contained in Human Biology by Christine Miller published by Thompson Rivers University. CC BY-NC . This unit is updated with new Canadian content.Image CreditsCappucino Art by Drew Coffman / Unsplash LicenseGovernment of Canada. (2021). Controlled drug and substances act [screenshot]. Justice Laws website. https://laws-lois.justice.gc.ca/eng/acts/c-38.8/Coffee Association of Canada. (2018). Coffee facts. https://coffeeassoc.com/coffee-facts/ Centre for Addiction and Mental Health. (2021). Caffeine, (para. 12). https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/caffeineGovernment of Canada. (2021). Controlled drug and substances act. https://laws-lois.justice.gc.ca/eng/acts/c-38.8/Ibid.Ibid.173.2 Opioids (an overview)Opioids are a category of psychoactive substance that refer to substances derived from opium, opium derivatives, and their semi-synthetic substitutes. Examples you may be aware of include heroin, morphine, methadone and fentanyl.What is their origin?The poppy Papaver somniferum is the source of all-natural opioids, whereas synthetic opioids are made entirely in a lab and include meperidine, fentanyl, and methadone Semi-synthetic opioids are synthesized from naturally occurring opium products, such as morphine and codeine, and include heroin, oxycodone, hydrocodone, and hydromorphone.Two blue pills next to a stone like lump of dark grey matter.Narcotics, Drugs of Abuse (2017). United States Drug Enforcement AdministrationWhat do they look like?Opioids come in various forms, including tablets, capsules, skin patches, powder, chunks in varying colors (from white to shades of brown and black), liquid form for oral use and injection, syrups, suppositories, and lollipops. Opioids can be swallowed, smoked, sniffed, injected or used transdermally.What is their effect on the brain?Besides their medical use, opioids produce a general sense of well-being by reducing tension, anxiety, and aggression. These effects are helpful in a therapeutic setting but contribute to misuse. Opioid use comes with a variety of unwanted effects, including drowsiness, inability to concentrate, and apathy.What is their effect on the body?Opioids are prescribed to treat pain, suppress a cough, cure diarrhea, and put people to sleep. Effects depend heavily on the dose, how it is taken, and previous exposure to the substance. Negative effects include slowed physical activity, constriction of the pupils, flushing of the face and neck, constipation, nausea, vomiting, and slowed breathing. As the dose is increased, both the pain relief and the harmful effects become more pronounced. A single dose can be lethal to an inexperienced person or someone who has been in recovery.DependenceContinuing use of opioids can create both physical and psychological dependence. Physical dependence is a consequence of chronic opioid use, and withdrawal takes place when the use is discontinued. The intensity and character of the physical symptoms experienced during withdrawal are directly related to the substance, the daily amount used, the interval between doses, the duration of use, and the health and personality of the person using the opiate. These symptoms usually appear shortly before the time of the next scheduled dose, increasing dependence.Early withdrawal symptoms often include watery eyes, runny nose, yawning, and sweating. As the withdrawal worsens, symptoms can include: Restlessness, irritability, loss of appetite, nausea, tremors, drug craving, severe depression, vomiting, increased heart rate, and blood pressure, and chills alternating with flushing and excessive sweating. Without intervention, the withdrawal usually runs its course, and most physical symptoms disappear within days or weeks, depending on the particular substance. Withdrawal is extremely uncomfortable, and is one reason why people continue to use opioids. Long after the physical need for the substance has passed, people may continue to think and talk about using and feel overwhelmed coping with daily activities. Relapse is common if there are no changes to the physical, biological, social, or other factors that contributed to the use/abuse of the opioid.OverdoseOverdoses are common and can be fatal with opiate use. Physical signs of opioid overdose include:constricted (pinpoint) pupilscold clammy skin, confusionconvulsionsextreme drowsinessslowed breathingOpioid overdose is a crisis in Canada and tens of thousands of lives have been needlessly lost; between 2016 and September 2021 over 22,000 people died, that is twenty people per day who lost their lives to an opiate overdose.2 Review the map below to see the impact of opiate overdose in each province and territory in Canada.Opioid- and stimulant-related harms in Canada. Credit: Government of Canada. Long Description.Overdose from opiates is not a phenomenon that impacts any group more than others, the deaths cut across social and economic lines. There are groups that are considered more vulnerable, for example people who are homeless are at higher risk of death from overdose.2 Indigenous people are significantly over-represented in the loss of lives in Canada. Recent data from Alberta and British Columbia, the provinces most heavily impacted by the crisis, indicates that First Nations people are five times more likely to experience an overdose and three times more likely to die from overdose than non-First Nations people.2 While men aged 30 to 39 make up the biggest group of deaths across the country, women are dying at a similar rate in the Prairies and eastern provinces.9Food For ThoughtWhy are marginalized groups, including Indigenous communities at higher risk for overdose?Where would you go for information about opioid overdose in Nova Scotia?Preventing OverdoseNaloxone kits have been available to the community since 2017 in Nova Scotia. Naloxone is used to treat an opioid overdose, it is a temporary opiate antagonist (a substance which blocks or reverses the effects of opioids, including extreme drowsiness, slowed breathing, or loss of consciousness). This temporarily reverses an overdose; however medical intervention is still required. Naloxone is NOT permanent. NS health recommends that if a person who has overdosed is not taken to a hospital, the overdose victim can fall back into the overdose within 30 minutes; therefore Naloxone should not be considered as step 1, in a multi-step process for addressing an opiate overdose. Please review the 5 steps by the NS Take Home Naloxone Program.Naloxone only works for opioids, if someone has overdosed on a stimulant or depressant, Naloxone will not work, but it will also not cause harm. If an overdose involves multiple substances, including opioids, Naloxone helps by temporarily blocking or removing the opioid.2 Watch the following video from Nova Scotia Health promoting the importance of accessing naloxone kits.4One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=73#oembed-1 In Nova Scotia, Naloxone kits are free and available to adults over the age of 18. Below you will find more information on the NS Take Home Naloxone Program. PictureProgram Overview [Infographic]. Credit: NS Take Home Naloxone Program. Long Description.As you are learning, opiates are having an impact on all communities in Canada. As Social Service workers, you may consider accessing a naloxone kit. You can save a life.Chapter CreditAdapted from the Unit 3.2 in Drugs, Health & Behavior by Jacqueline Schwab. CC BY-NC-SA. Updated with Canadian Content.Image CreditsNarcotics, Drugs of Abuse from: U.S. Department of Justice Drug Enforcement Administration. (2017). Drugs of abuse (p. 38). https://www.dea.gov/sites/default/files/2018-06/drug_of_abuse.pdfSpecial Advisory Committee on the Epidemic of Opioid Overdoses. (2022, March). Opioid- and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulantsNS Take Home Naloxone Program. (2021). Program Overview [Infographic]. http://www.nsnaloxone.com/uploads/1/1/2/0/112043611/thn_orig.png Government of Canada. (2021). Opioid- and stimulant-related harms in Canada. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulantsBauer, L. K., Brody, J. K., León, C., & Baggett, T. P. (2016). Characteristics of homeless adults who died of drug overdose: A retrospective record review. Journal of health care for the poor and underserved, 27(2), 846–859. https://doi.org/10.1353/hpu.2016.0075Jongbloed, K., Pearce, M., Pooyak, S., Zamar, D., Thomas, V., Demerais, L., Christian, W., Henderson, E., Sharma, R., Blair, A., Yoshida, E., Schechter, M.,& Spittal, P. (2017). The cedar project: mortality among young Indigenous people who use drugs in British Columbia. Canadian Medical Association Journal, 189(44), 1352-1359. https://doi.org/10.1503/cmaj.160778CATIE. (2020). The positive side magazine. https://www.catie.ca/en/positiveside/spring-2020/lessons-not-learnedNS Take Home Naloxone Program. (2021b). Learn more. http://www.nsnaloxone.com/learn-more.htmlNova Scotia Health. (2018). Naloxone: Who is your kit for? [Video]. Vimeo. https://vimeo.com/300496867183.3 Examples of opioidsWhat is Fentanyl?Fentanyl is a potent synthetic opioid drug approved by the CDSA for use as an analgesic (pain relief) and as an anesthetic. It is approximately 100 times more potent than morphine and 50 times more potent than heroin as an analgesic.What is its origin?Fentanyl was first developed in 1959 and introduced in the 1960s as an intravenous anesthetic. It is legally manufactured in the United States.How it is administered?Fentanyl products are prescribed and are currently available orally, transdermally and injectable formulations. Fentanyl can be injected, snorted/sniffed, smoked, taken orally by pill or tablet, and spiked onto blotter paper. Fentanyl patches can be used other than prescribed by removing its gel contents and then injecting or ingesting these contents. Patches have also been frozen, cut into pieces, and placed under the tongue or in the cheek cavity.What is the effect on the body?Fentanyl, similar to other commonly used opioid analgesics (e.g., morphine), produces effects such as relaxation, euphoria, pain relief, sedation, confusion, drowsiness, dizziness, nausea, vomiting, urinary retention, pupillary constriction, and respiratory depression.IN THE NEWS: READNova Scotia Health warns drugs laced with fentanyl sold in Cape Breton posted December 31, 2020 to CBC News Nova Scotia.What is Heroin?Heroin is a highly addictive substance and it is a rapidly acting opioid.What is its Origin?A powdery brown substance.Heroin, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationHeroin is processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants grown in Mexico, South America, Southwest Asia (Afghanistan and Pakistan), and Southeast Asia (Thailand, Laos, and Myanmar (Burma). What Does it Look Like?Heroin is typically sold as a white or brownish powder, or as the black sticky substance known as “black tar heroin.” Although purer heroin is becoming more common, most “regular” heroin is “cut” with other psychoactive substances or substances like sugar, starch, powdered milk, or quinine.How is it administered?Heroin can be injected, smoked, or sniffed/snorted. High purity heroin is usually snorted or smoked.What is its effect on the body?One of the most significant effects of heroin use is the frequency of the development of a substance use disorder. With regular heroin use, tolerance to the substance develops. Once this happens, the person must use more heroin to achieve the same intensity. As higher doses of the substance are used over time, physical dependence and psychological dependence deepens and a substance use disorder can develop. Effects of heroin use include drowsiness, respiratory depression, constricted pupils, nausea, a warm flushing of the skin, dry mouth, and heavy extremities.IN THE NEWS: WATCHPrescription heroin offered in Vancouver outside of clinical trial for first time. Aired on CBC News:The National November 26, 2014. Available via YouTube. One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=77 What is Hydromorphone?Hydromorphone has an analgesic potency of two to eight times greater than that of morphine and has a rapid onset of action.What is its origin?Hydromorphone is legally manufactured and distributed in the United States and shipped to Canada.How it is administered?Hydromorphone comes in tablets, capsules, oral solutions, and injectable formulations.What is its Effect on the Body?Hydromorphone may cause constipation, pupillary constriction, urinary retention, nausea, vomiting, respiratory depression, dizziness, impaired coordination, loss of appetite, rash, slow or rapid heartbeat, and changes in blood pressure.IN THE NEWS: WATCHVending machine dispenses heroin substitute for at-risk drug users by The Canadian Press, January 27, 2020. Available via YouTube.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=77 What is Methadone?Cup with orange liquid, a vile of liquid, and white powder.Methadone, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationMethadone is a synthetic (person-made) drug. It is considered an opioid agonist therapy (OAT); used to treat opioid addiction. It is also used to treat severe pain.What is its origin?German scientists synthesized methadone during World War II because of a shortage of morphine. Methadone was introduced to Canada in 1964.2tHow is it administered?Methadone is available as a tablet, oral solution, or injectable liquid.What is its effect on the body?When an individual uses methadone, they may experience physical symptoms like sweating, itchy skin, or sleepiness. There is a risk for developing tolerance and subsequent dependence on the methadone. When use is stopped, individuals may experience withdrawal symptoms similar to other opioids including: Anxiety, muscle tremors, nausea, diarrhea, vomiting, and abdominal cramps. A person can overdose on methadone, in which case Naloxone may be used to treat the overdose. Learn more about methadone in this short clip below.2One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=77#oembed-1 IN THE NEWS: READIt’s the end of the road for Halifax’s methadone busby Elizabeth Chiu, posted Aug 30, 2018 to CBC News Nova Scotia.What is Morphine?Morphine is a non-synthetic opioid, it is derived from opium and is considered an analgesic. It is used for the treatment of pain, and is the most widely used pain treatment medication in the world.2What is its origin?Morphine was isolated from opium by Friedrich Serturner in 1805. Morphine is made from opium, which has been known for millennia to relieve pain. The Sumerian clay tablet (about 2100 BC) is considered to be the world’s oldest recorded list of medical prescriptions2 and includes morphine. It was not until the development of the hypodermic needle and syringe nearly 50 years later that the use of morphine became widespread using morphine for postoperative pain relief.4How is it administered?Traditionally, morphine was almost exclusively used by injection, today it can be taken by all routes of administration. This includes oral solutions, immediate-and extended-release tablets and capsules, subcutaneous, transdermal and intramuscular.What is its effect on the body?Morphine use results in relief from physical pain, a decrease in hunger, and inhibition of the cough reflex.IN THE NEWS: READ WATCH(WARNING, the article and attached video may cause activation).Investigations launched after Atikamekw woman records Quebec hospital staff uttering slurs before her death posted September 9, 2020 to CBC News Montreal.What is Oxycodone?Oxycodone is a semi-synthetic opioid used to treat pain. Oxycodone was developed in 1995, beginning as OxyContin. It was created to provide long-lasting pain relief and was widely prescribed. It was hailed as a miralce drug for long lasting pain; however those who had been perscribed oxy found it had highly addictive qualities.2What is its origin?Oxycodone is synthesized from thebaine, a constituent of the poppy plant.How is it administered?Oxycodone is administered orally or intravenously. The tablets can be crushed and sniffed or dissolved in water and injected. It can also be inhaled.What is its effect on the body?Physiological effects of oxycodone include pain relief, sedation, respiratory depression, constipation, papillary constriction, and cough suppression. Extended or chronic use of oxycodone containing acetaminophen may cause severe liver damage. IN THE NEWS: READAbuse-resistant OxyContin under consideration by The Associated Press, posted September 22, 2009 to CBC News.Chapter CreditAdapted from Unit 3.3 Narcotics Continued in Drugs, Health Behavior by Jacqueline Schwab. CC BY-NC-SA. Updated with Canadian Content.Image CreditsHeroin and Methadone, Drugs of Abuse from: U.S. Department of Justice Drug Enforcement Administration. (2017). Drugs of abuse, (pp. 42, 44). https://www.dea.gov/sites/default/files/2018-06/drug_of_abuse.pdfEibl, J. K., Morin, K., Leinonen, E., Marsh, D. C. (2017). The state of opioid agonist therapy in Canada 20 years after federal oversight. Canadian Journal of Psychiatry, 62(7), 444–450. https://doi.org/10.1177/0706743717711167Neuroscientifically Challenged (2019). Two minute neuroscience: Methadone. [Video]. Youtube. https://www.youtube.com/watch?v=dw6laQ4-Zgsfeature =emb _imp_woytHamilton, G. R., Baskett, T. F. (2000). In the arms of Morpheus; the development of morphine for postoperative pain relief. Canadian Journal of Anaesthesia, 47(4), 367-74. https://pubmed.ncbi.nlm.nih.gov/10764185Norn, S., Kruse, P. R., Kruse, E. (2005). History of opium poppy and morphine. Danish Medicinhist Arbog, 33, 171-184. https://pubmed.ncbi.nlm.nih.gov/17152761/Hamilton, G. R., Baskett, T. F. (2000). In the arms of Morpheus; the development of morphine for postoperative pain relief. Canadian Journal of Anaesthesia, 47(4), 367-74. https://pubmed.ncbi.nlm.nih.gov/10764185Centre for Addiction and Mental Health. (2021). Straight talk-Oxycodone. https://www.camh.ca/en/health-info/guides-and-publications/straight-talk-oxycodone193.4 Stimulants (an overview)What are Stimulants?Stimulants speed up the body’s systems. This class of drugs includes: methamphetamine and cocaine, prescription drugs such as amphetamines [Adderall and Dexedrine], and Methylphenidate [Concerta and Ritalin]. What is their origin?Stimulants have a long and varied use throughout the world. For example, the leaves of the coca plant were chewed and aoca chewing has a long history of Indigenous use in South American countries.2 When cocaine was isloated from coca in 1859, widespread use became the norm in Canada; a medical publication in 1884 was even created to promote its benefits.4Chunks of crack cocaine.Crack Cocaine, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationWhat do they look like?Stimulants come in the form of pills, powder, rocks, and injectable liquids.How are they administered?Stimulants can be pills or capsules that are swallowed. Smoking, snorting, or injecting stimulants produces a sudden sensation known as a “rush” or a “flash.” Substance use disorders reflect a pattern of “binge” use (sporadically consuming large doses of stimulants over a short period of time). Heavy use may include injecting every few hours, continuing until the supply is gone or a point of delirium, psychosis, and physical exhaustion is reached. During heavy use, all other interests often become secondary to recreating the initial euphoric rush.What is their effect on the mind?When used as part of a substance use disorder, stimulants are frequently taken to “get high” (produce a sense of exhilaration, enhance self-esteem, improve mental and physical performance, increase activity, reduce appetite, or extend wakefulness for a prolonged period). Chronic, high-dose use is frequently associated with agitation, hostility, panic, aggression, and suicidal or homicidal tendencies. Paranoia, sometimes accompanied by both auditory and visual hallucinations, may also occur. Tolerance, in which more and more of the substance is needed to produce the usual effects, can develop rapidly, and psychological dependence occurs. The strongest psychological dependence observed occurs with the more potent stimulants, such as amphetamine, methylphenidate, methamphetamine, cocaine, and methcathinone. Abrupt cessation is commonly followed by a “crash” (depression, anxiety, craving, and extreme fatigue).What is their effect on the body?Stimulants are sometimes referred to as uppers and reverse the effects of fatigue on both mental and physical tasks. Therapeutic levels of stimulants can produce exhilaration, extended wakefulness, and loss of appetite. These effects are greatly intensified when large doses of stimulants are taken. Taking too large a dose at one time or taking large doses over an extended period of time may cause such physical side effects as dizziness, tremors, headache, flushed skin, chest pain with palpitations, excessive sweating, vomiting, and abdominal cramps.What is their legal status in Canada?Stimulants are controlled under the CDSA as a Schedule I substance. Some prescription stimulants are not controlled (for example ephedrine can be found in some allergy and cold medicine) and some stimulants like tobacco and caffeine do not require a prescription. Food For ThoughtWhy do you believe tobacco and nicotine are not controlled under the CDSA?If Indigenous communities were using coca leaves for a millennia, why are stimulants now considered unsafe?Chapter CreditAdapted from Unit 3.4 Stimulants in Drugs, Health Behavior by Jacqueline Schwab. CC BY-NC-SA. Updated with Canadian Content.Image CreditsCrack Cocaine, Drugs of Abuse from: U.S. Department of Justice Drug Enforcement Administration. (2017). Drugs of abuse, (p. 48). https://www.dea.gov/sites/default/files/2018-06/drug_of_abuse.pdfThoumi, F. E. (2003). Illegal drugs, economy, and society in the Andes. Woodrow Wilson Center Press with Johns Hopkins University Press.Ciccarone, D. (2011). Stimulant abuse: pharmacology, cocaine, methamphetamine, treatment, attempts at pharmacotherapy. Primary care, 38(1), 41–58. https://doi.org/10.1016/j.pop.2010.11.004203.5 Examples of stimulantsWhat are Amphetamines?Amphetamines are stimulants that speed up the body’s system. Many are legally prescribed and used to treat attention-deficit hyperactivity disorder (ADHD).What is their origin?Stimulants like amphetamine were developed as pharmaceutical drugs in the late 1920s, treating ashtma and other bronchial ailments. Amphetamine was first marketed in the 1930s as Benzedrine in an over-the-counter inhaler to treat nasal congestion. By 1937 amphetamine was available by prescription in tablet form and was used in the treatment of the sleeping disorder narcolepsy and ADHD. As for amphetamine, its pharmacological effects on attention and cognition, emotions, and appetite were explored thoroughly in the 1930s and 1940s.2 Amphetamines began to be controlled by the Narcotic Control Act in 1961 which is now Canada’s Controlled Drug and Substances Act.What do they look like?Amphetamines can look like pills or powder.How are they administered?Amphetamines are generally taken orally or injected. However, the addition of “ice,” (the slang name of crystallized methamphetamine hydrochloride) has promoted smoking as another mode of administration. Just as “crack” is smokable cocaine, “ice” is smokable methamphetamine.What is their effect on the mind?The effects of amphetamines and methamphetamine are similar to cocaine, but their onset is slower and their duration is longer. In contrast to cocaine, which is quickly removed from the brain and is almost completely metabolized, methamphetamine remains in the central nervous system longer, and a larger percentage of the drug remains unchanged in the body, producing prolonged stimulant effects. Chronic use produces a psychosis that resembles schizophrenia and is characterized by paranoia, picking at the skin, preoccupation with one’s own thoughts, and auditory and visual hallucinations. Violent and erratic behavior is frequently seen among people use have an amphetamine or methamphetamine use disorder.What is their effect on the body?Physical effects of amphetamine use include increased blood pressure and pulse rates, insomnia, loss of appetite, and physical exhaustion.What is their legal status in Canada?Amphetamines are Schedule I stimulants, and are available only through a prescription.What is Methamphetamine?Methamphetamine (meth) is a stimulant.What is its origin?Methamphetamine (meth) is a derivative of amphetamine and was synthesized in Japan in 1919. According to Parsons,2 methamphetamine was used to treat a number of chronic illnesses, including asthma, schizophrenia, depression, Parkinson’s disease, and narcolepsy.What does it look like?Regular meth is a pill or powder. Methamphetamine also comes in crystal forms (crystal meth), which resembles glass fragments or shiny blue-white “rocks” of various sizes.How is it administered?Meth is swallowed, snorted, injected, or smoked.Methamphetamine in a powdery form inside of a container.Methamphetamine, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationWhat is its effect on the mind?Meth is a potent substance with central nervous system (CNS) stimulant properties. People who smoke or inject it report a brief, intense sensation, or rush. Oral ingestion or snorting produces a long-lasting high instead of a rush, which reportedly can continue for as long as half a day. Both the rush and the high are believed to result from the release of very high levels of the neurotransmitter dopamine into areas of the brain that regulate feelings of pleasure. Long-term meth use results in many damaging effects, including the development of a substance use disorder.Researchers have reported that as much as 50 percent of the dopamine-producing cells in the brain can be damaged after prolonged exposure to relatively low levels of meth. Researchers also have found that serotonin-containing nerve cells may be damaged even more extensively.What is its effect on the body?Methamphetamine use can result in increased wakefulness, increased physical activity, decreased appetite, rapid breathing and heart rate, irregular heartbeat, increased blood pressure, and “hyperthermia” (overheating). High doses can elevate body temperature to dangerous, sometimes lethal, levels, and cause convulsions and even cardiovascular collapse and death. Meth use may also cause extreme anorexia, memory loss, and severe dental problems. High usage may result in death from stroke, heart attack, or multiple organ problems caused by overheating. Please review this overview of methamphetamine use in Canada.What is its legal status in Canada?Methamphetamine is a Schedule I stimulant under the CDSA. IN THE NEWS: READCaught in a crisis: While Canada is preoccupied with opioid addiction, crystal meth is on the rise — and threatens to deepen the country’s drug emergency by Nicole Ireland posted January 14, 2020 to CBC News Interactive.What is Cocaine?Cocaine is an intense, euphoria-producing stimulant.What is its origin?Cocaine is derived from coca leaves grown in some countries in South America. Acording to the UNODC2 from the end of World War II until the late 1990s, almost all the world’s coca bush was grown in Peru and the Plurinational State of Bolivia, and since the 1970s, most of this output was refined into cocaine in Colombia. The cocaine manufacturing process takes place in remote labs where the raw product undergoes a series of chemical transformations. Colombia now produces about 50% of the cocaine powder reaching North America.What does it look like?Cocaine is usually distributed as a white, crystalline powder, it is often diluted (“cut”) with a variety of substances. In contrast, cocaine base (crack) looks like small, irregularly shaped chunks (or “rocks”) of a whitish solid.How is it administered?Powdered cocaine can be snorted or injected into the veins after dissolving in water. Cocaine base (crack) is smoked. Cocaine is also used in “speedballing” (a practice where the cocaine is combined with opioids, like heroin). Although injecting, snorting, and smoking are the common ways of using cocaine, all mucous membranes readily absorb cocaine.A penny next to powdered cocaine.Cocaine, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationWhat is its effect on the mind?The intensity of cocaine’s euphoric effects depends on how quickly the drug reaches the brain, which depends on the amount and method of use. Following smoking or intravenous injection, cocaine reaches the brain in seconds, with a rapid buildup in levels (check section 3.1 for routes of administration). This results in a “rush” (a rapid-onset, intense euphoric effect).By contrast, the euphoria caused by snorting cocaine is less intense and does not happen as quickly due to the slower build-up of the substance in the brain. Other effects include increased alertness and excitation, as well as restlessness, irritability, and anxiety.Tolerance to cocaine’s effects develops rapidly, causing people to take higher and higher doses. Taking high doses of cocaine or prolonged use can cause paranoia. The crash that follows euphoria is characterized by mental and physical exhaustion, sleep, and depression lasting several days. Following the crash, people often experience a craving to use cocaine again.What is its effect on the body?Physiological effects of cocaine use include increased blood pressure and heart rate, dilated pupils, insomnia, and loss of appetite. The use of highly pure cocaine has led to many severe adverse health consequences such as cardiac arrhythmias, ischemic heart conditions, sudden cardiac arrest, convulsions, strokes, and death. In some people, the long-term use of inhaled cocaine has led to a unique respiratory syndrome, and chronic snorting of cocaine has led to the erosion of the upper nasal cavity.What is its legal status in Canada?Cocaine is a Schedule I drug under the CDSA. IN THE NEWS: READOn Canada’s East Coast, an Unexplained Influx of Pure Cocaine by Matthew Bonn posted March 25, 2021 in Filter Magazine.What is Khat?Khat is a flowering evergreen shrub that is used for its stimulant-like effect. Khat has two active ingredients, cathine, and cathinone.What is its origin?Khat is native to countries in Eastern Africa including Ethiopia and the Arabian Peninsula, where the use of it is an established cultural tradition for many social situations. “Cultures in East Africa and the Arabian Peninsular have used khat as a stimulant since the seventh century and the practice of coming together to chew the leaves of the khat plant has acquired unique cultural importance”.2 Khat use is prevalent in Ethiopia in particular amongst the Oromo people; it is used not only at weddings, births, funerals and other celebratory events, but can be used daily as part of “barcha” or the afternoon chew.4Bunches of khat.Khat, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationWhat does it look like? Khat is a flowering evergreen shrub, the leaves of the shrub are used.How is it administered?Khat is typically chewed like tobacco, then retained in the cheek and chewed intermittently to release the active drug, which produces a stimulant-like effect. Dried Khat leaves can be made into a tea or a chewable paste, and Khat can also be smoked and even sprinkled on food.What is its effect on the mind?Khat can induce a stimulant-like alertness, but has a very low potency. According to Mitchell2 the ephedrine-like effects in khat are closer to cigarettes than a cup of coffee. It’s more like a nicotine patch.What is its effect on the body?Khat causes an increase in blood pressure and heart rate. Khat can also cause a brown staining of the teeth, insomnia, and gastric disorders. The amount needed to constitute an overdose is not known. Symptoms of toxicity include delusions, loss of appetite, difficulty with breathing, and increases in both blood pressure and heart rate.What is its legal status in Canada?Khat is a Schedule IV substance under the CDSA.IN THE NEWS: READWoman who brought khat to Canada wins appeal: A court panel upholds the woman’s absolute discharge, saying the Crown failed to show that the mild, leafy drug was harmful. by Betsy Powell posted April 20, 2012 in the The Toronto Star.What is Tobacco?Tobacco Leaves Drying in the Sun.Air curing of tobacco leaves in Cuba. Credit: Alexander Klink, CC BY 4.0.Tobacco is a plant grown for its leaves, which are dried and fermented before being put in tobacco products. Tobacco contains nicotine.What is its origin?Tobacco was grown in countries in South America and North America and has been used by Indigenous communities as a cultural and traditional herb. Tobacco “used in ritual, ceremony, and prayer, tobacco was considered a sacred plant with immense healing and spiritual benefits and was used by Indigenous cultures across Canada”.2Watch the video Traditional Tobacco Use by Alberta Health Services2One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=87#oembed-1 How is it administered?People can smoke, chew, or sniff tobacco. Smoked tobacco products include cigarettes, cigars, bidis, and kreteks. Some people also smoke loose tobacco in a pipe or hookah (water pipe). Chewed tobacco products include “chew” (chewing tobacco), snuff, dip, and snus; snuff can also be sniffed.What is it’s effect on the mind?The nicotine in any tobacco product readily absorbs into the blood when a person uses it. Upon entering the blood, nicotine immediately stimulates the adrenal glands to release the hormone epinephrine (adrenaline). Epinephrine stimulates the central nervous system and increases blood pressure, breathing, and heart rate. As with other stimulants, nicotine activates the brain’s reward circuits and also increases levels of the chemical messenger dopamine, which reinforces rewarding behaviors. Studies suggest that other chemicals in tobacco smoke, such as acetaldehyde, may enhance nicotine’s effects on the brain.What is its effect on the body?Prolonged use can lead to lung cancer, chronic bronchitis, and emphysema. It increases the risk of heart disease, which can lead to stroke or heart attack. Non traditional use of tobacco has also been linked to other cancers, leukemia, cataracts, and pneumonia. Chew increases the risk of cancer, especially mouth cancers. Non traditional tobacco smoking can impact women who are pregnant and the fetus. People who are exposed to secondhand smoke are at a higher risk of lung cancer and heart disease. It can cause health problems in both adults and children, such as coughing, phlegm, reduced lung function, pneumonia, and bronchitis. Children exposed to secondhand smoke are at an increased risk of ear infections, severe asthma, lung infections, and death from sudden infant death syndrome.What is its legal status in Canada?The 2018 Tobacco and Vaping Products Act regulates the manufacture; sale; packaging and labeling; and advertising, promotion and sponsorship of tobacco and vaping products.2ActivitiesThere are many ways to use tobacco as a tradition. Listen to the following podcast to see how Indigenous communities in Canada are using tobacco as a way to heal from abuse and trauma. Tobacco Nation Episode 3 – Tradition by the First Nations Health Authority (Please note this podcast discusses sexual abuse and trauma and may activate listeners)List other ways tobacco can be used in traditions.Food For ThoughtDo you think e-cigarettes or vapes are a healthier alternative to smoking?Is it possible to overdose on nicotine?IN THE NEWS: WATCHE-cigarettes: Welcome back big tobacco, aired October 21, 2016 on CBC’s current affair program The Fifth Estate. Available via YouTube.One or more interactive elements has been excluded from this version of the text. You can view them online here: https://pressbooks.nscc.ca/substanceuse/?p=87#oembed-2 Chapter CreditAdapted from Unit 3.4 in Drugs, Health Behavior by Jacqueline Schwab. CC BY-NC-SA. Updated with Canadian Content.Image CreditsMethamphetamine, Cocaine, and Khat, Drugs of Abuse from: U.S. Department of Justice Drug Enforcement Administration. (2017). Drugs of abuse, (pp. 51, 53, 54). https://www.dea.gov/sites/default/files/2018-06/drug_of_abuse.pdfAir curing of tobacco leaves in Cuba by Alexander Klink via Wikimedia Commons is licensed under CC BY 4.0Rasmussen N. (2015). Amphetamine-type stimulants: The early history of their medical and non-medical uses. International Review of Neurobiology, 120, 9-25. https://pubmed.ncbi.nlm.nih.gov/26070751/Parsons, N. (2013) Meth mania; A History of methamphetamine. Lynne Rienner Publishers.UNODC. (2010). The global cocaine market. https://www.unodc.org/documents/wdr/WDR_2010/1.3_The_globa_cocaine_market.pdfStevenson M., Fitzgerald, J., Banwell, C. (1996). Chewing as a social act: cultural displacement and khat consumption in the East African communities of Melbourne. Drug Alcohol Review, 15(1), 73-82. https://pubmed.ncbi.nlm.nih.gov/16203354/Gebissa, E. (2012). Khat: Is it more like coffee or cocaine? Criminalizing a commodity, targeting a community. Sociology Mind, 2, 204-212. https://www.researchgate.net/publication/267381622_Khat_Is_It_More_Like_Coffee_or_Cocaine_Criminalizing_a_Commodity_Targeting_a_CommunityMitchell, C. (2001). Brooklyn Yemenis indignant over police raids to seize leaves of the stimulant khat. The Journalism School, Columbia University. http://web.jr n.columbia.ed u/studentwork/h umanrig hts/khat- mitFirst Nations Health Authority. (2021). Respecting Tobacco, (para. 1). https://www.fnha.ca/Documents/FNHA-Respecting-Tobacco-Brochure.pdfAlberta Health Services. (2016, January 29). Traditional tobacco use. [Video]. Youtube. https://www.youtube.com/watch?v=PXFPBD6k73IGovernment of Canada. (2018). Tobacco and vaping products act. https://www.canada.ca/en/health-canada/services/health-concerns/tobacco/legislation/federal-laws/tobacco-act.html213.6 Depressants (an overview)What Are Depressants?Depressants will put you to sleep, relieve anxiety and muscle spasms, and prevent seizures. Barbiturates, an older type of depressant, include Phenobarbital, Pentothal, Seconal, and Nembutal. Benzodiazepines, a newer type of depressant, were developed to replace barbiturates. Some examples are Valium, Xanax, Halcion, and Ativan. Other depressants inlcude Lunesta, Ambien, and Sonata, sedative medications approved for the short-term treatment of insomnia that share many of the properties of benzodiazepines. Other depressants include Quaalude, GHB and Rohypnol, and alcohol.What is their origin?Various depressants have different origins. Alcohol has a long history, back many thousands of years, some pharmaceutical depressants were identified in the 1950’s.Klonopin 5mg tablet and a blister pack of Rohypnol tablets.Klonopin, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationWhat do they look like?Depressants come in the form of pills, syrups, and injectable liquids.How are they administered?Individuals may use oral administration, injection, or snorting to take depressants.What is their effect on the mind?Depressants induce sleep, relieve anxiety and muscle spasms, and prevent seizures. They can also cause amnesia, leaving no memory of events that occur while under the influence of the substance, reduce reaction time, impair mental functioning and judgment, and cause confusion. Long-term use of depressants produces psychological dependence and tolerance.What is their effect on the body?Some depressants can relax the muscles. Other physical effects include slurred speech, loss of motor coordination, weakness, headache, light-headedness, blurred vision, dizziness, nausea, vomiting, low blood pressure, and slowed breathing.Three vials containing GHB and a white powdery substance in front of them.GHB, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationProlonged use of depressants can lead to physical dependence even at doses recommended for medical treatment. Unlike barbiturates, large doses of benzodiazepines are rarely fatal unless combined with other drugs or alcohol. But unlike the withdrawal symptoms seen with most other substances, withdrawal from depressants can be life-threatening.What is their legal status in Canada?Most depressants are controlled substances that range from Schedule I to Schedule IV under the CDSA.ReadCanadian Drug Summary: Sedatives by Canadian Centre on Substance Use and Addiction3Chapter CreditAdapted from Unit 3.6 in Drugs, Health Behavior by Jacqueline Schwab. CC BY-NC-SA. Updated with Canadian Content.Image CreditsKlonopin and GHB, Drugs of Abuse from: U.S. Department of Justice Drug Enforcement Administration. (2017). Drugs of abuse, (pp. 56, 57). https://www.dea.gov/sites/default/files/2018-06/drug_of_abuse.pdfCanadian Centre on Substance Use and Addiction. (2019). Sedatives (Canadian Drug Summary). https://ccsa.ca/sites/default/files/2019-06/CCSA-Canadian-Drug-Summary-Sedatives-2019-en.pdf223.7 Examples of DepressantsWhat is Alcohol?A black and white image of a table of drinks and empty alcohol bottles.A table of drinks and empty alcohol bottles. Credit: palette by ebrkut CC BY-ND 2.0.Alcohol is a widely available depressant in Canada and alcohol use in Canada is significant. According to the Canadian Centre on Substance Use and Addiction2 alcohol is the most commonly used substance by Canadians.What is its origin?Alcohol use is not new, in fact, historians have found evidence of use of alcohol for many centuries; “for most of the past 10,000 years, alcoholic beverages were the most popular and common daily drink among people in Western civilization”.2 Alcohol is produced by fermenting or distilling various fruits, vegetables or grains. Fermented beverages include beer and wine, and have a maximum alcohol content of about 15%. Liquor (distilled beverages such as rum, whisky and vodka) have a higher alcohol content (Centre for Addiction and Mental Health, 2021a).What does it look like?Alcohol is a liquid substance; ethyl (pure) alcohol is a clear, colourless liquid.2 You will find alcohol in beer, wine, spirits, rubbing alcohol, hand sanitizer, cough syrup, perfume, various extracts (like vanilla for baking), aftershave, mouthwash and some body washes.How is it administered?Alcohol is consumed orally.What are the effects on the mind?Alcohol is a depressant that suppresses central nervous system activity (CNS). At rather low doses, alcohol use is associated with feelings of euphoria. As the dose increases, people report feeling sedated. With excessive alcohol use, a person might experience a complete loss of consciousness and/or difficulty remembering events that occurred during a period of intoxication.2 Psychological dependence is high with alcohol, due to the impact on the CNS.What are the effects on the body?Generally, alcohol is associated with decreases in reaction time and visual acuity, lowered levels of alertness, and reduction in behavioral control. Alcohol can cause birth defects such as Fetal Alcohol Spectrum Disorder (FASD) for women who are pregnant. Physical dependence of alcohol is high, as tolerance increases with the amount and frequency the alcohol is consumed. For people who have an alcohol use disorder, withdrawal can be life-threatening and should only be done under medical supervision.What is the legal status in Canada?Alcohol is legal in Canada and can be consumed by individuals ages 18 and over, depending on province. Provinces set their age limit for consumption as well as licensing for sale of alcohol.ActivitiesBrainstorm the ways that alcohol might impact an individual, a family, a community, a province, a countryCreate your own marketing campaign for safe consumption of alcohol.Review current alcohol marketing. How does marketing impact alcohol use in Canada?Develop a social media post that addresses alcohol use among youth, adults or seniors.IN THE NEWS: READAlcohol and cannabis sales across Canada rose by over $2.6B during the pandemic, study suggests by Samantha Craggs posted November 4, 2021 to CBC News Hamilton.What Are Barbiturates?Barbiturates are depressants that produce a wide spectrum of central nervous system depression from mild sedation to coma. They have been used as sedatives, hypnotics, anesthetics, and anticonvulsants. (a) Advertisment for Elixir Veronal (barbituate), a practical treatment of insomnia. Marketed as secure and harmless. (b) Advertisement for Abbott sodium pentobarbital (barbituate) in an American medical journal of 1933, highlighting its “short but powerful hypnotic effect and prolonged sedative action from small dosage”.(a) Advertisment for Elixir Veronal (barbituate), a practical treatment of insomnia. Marketed as secure and harmless. (b) Advertisement for Abbott sodium pentobarbital (barbituate) in an American medical journal of 1933, highlighting its “short but powerful hypnotic effect and prolonged sedative action from small dosage”. Source: The history of barbiturates a century after their clinical introduction.What is their origin?Barbiturates were first introduced for medical use in the 1900s. “The clinical introduction of barbiturates begun a century ago (1904) when the Farbwerke Fr. Bayer and Co. brought onto the market the first agent of this type, diethyl-barbituric acid, giving rise to profound changes in the pharmacological approach to the psychiatric and neurological disorders of the time”.2What do They Look Like?Barbiturates come in a variety of multi-colored pills and tablets as well as in liquid form.How are they administered?Barbiturates are most often consumed orally or by injecting a liquid. Barbiturates are generally administered to reduce anxiety and decrease inhibitions. Barbiturates can be extremely dangerous because overdoses can occur easily and lead to death.What is their effect on the mind?Barbiturates cause mild euphoria, lack of inhibition, relief of anxiety, and sleepiness. Higher doses cause impairment of memory, judgment, and coordination; irritability; and paranoid and suicidal ideation. Tolerance develops quickly and larger doses are then needed to produce the same effect, increasing the danger of an overdose.What is their effect on the body?Barbiturates slow down the central nervous system and cause sleepiness. Overdose can occur easily.What is their legal status in Canada?Barbiturates are Schedule IV depressants under the CDSA.IN THE NEWS: READNewly available drug secobarbital could boost number of self-administered assisted deaths by Joan Bryden, The Canadian Press posted November 17 2017 to CBC News Politics.What are Benzodiazepines?Benzodiazepines are depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures. They are used to induce sedation for surgery and other medical procedures, and in the treatment of seizures and alcohol withdrawal. Benzodiazepines are also called minor tranquillizers, sedatives or hypnotics. The most common benzodiazepines are the prescription drugs Valium, Xanax, Halcion, Ativan, and Klonopin. Tolerance can develop, although at variable rates and to different degrees. Shorter-acting benzodiazepines used to manage insomnia include Halcion and Versed, used for sedation, anxiety, and amnesia in critical care settings and prior to anesthesia. Benzodiazepines with a longer duration of action are utilized to treat insomnia in patients with daytime anxiety. These benzodiazepines include Xanax, Librium, Valium, Ativan and. Clonazepam. Clonazepam is also used as an anticonvulsant. They are the most widely prescribed psychoactive drugs in the world.2What is their Origin?In 1955, Hoffmann-La Roche chemist Leo Sternbach identified the first benzodiazepine, chlordiazepoxide (Librium).2 Benzodiazepines are only available through prescription.What do They Look Like?Benzodiazepines come in both pill and liquid form.How are they administered?Benzodiazepines are taken orally, or crushed to snort. They can also be injected.What is their Effect on the Mind?Benzodiazepines are associated with amnesia, hostility, irritability, and vivid or disturbing dreams.What is their Effect on the Body?Benzodiazepines slow down the central nervous system and may cause sleepiness. Death by overdose is possible.What is their Legal Status in Canada?Benzodiazepines are controlled in Schedule IV of the CDSA.IN THE NEWS: WATCHBenzodiazepines on the rise in street opioids, drug checking services say by CBC News posted December 27, 2021 to CBC News: Health.What is GHB?Gamma-Hydroxybutyric acid (GHB) is another name for the generic drug sodium oxybate. It is a substance naturally present in your body. GHB is often called a date-rape drug, because its sedative effects prevent victims from resisting sexual assault.What Does it Look Like?GHB comes in liquid and powder form.Three vials containing GHB and a white powdery substance in front of them.GHB, Drugs of Abuse. Credit: U.S. Department of Justice Drug Enforcement AdministrationWhat is its origin?GHB was first synthesized in 1960 as an alternative anesthetic to aid in surgery because of its ability to induce sleep and reversible coma.2How is it administered?In Canada, doctors can prescribe GHB for narcolepsy (a serious sleep disorder) and it is taken orally.What is its effect on the mind?GHB occurs naturally in the central nervous system in very small amounts. It acts as a depressant, slowing and calming the activity of the Central Nervous System (CNS). Effects including euphoria, drowsiness, decreased anxiety, confusion, and memory impairment. GHB can also produce both visual hallucinations and — paradoxically — excited and aggressive behavior. GHB greatly increases the CNS depressant effects of alcohol and other depressants, which increases the risk of overdose.What is its effect on the body?GHB takes effect in 15 to 30 minutes, and the effects last 3 to 6 hours. Low doses of GHB produce nausea. At high doses, GHB overdose can result in unconsciousness, seizures, slowed heart rate, greatly slowed breathing, lower body temperature, vomiting, nausea, coma, and death. Regular use of GHB can lead to tolerance and withdrawal that includes insomnia, anxiety, tremors, increased heart rate and blood pressure, and occasional psychotic thoughts. “Effective antidotes to reverse the sedative and intoxicating effects of GHB do not exist”.2 GHB can cause nausea, vomiting, incontinence, loss of consciousness, seizures, liver damage, kidney failure, respiratory depression, and death. GHB overdose can cause death.What is its legal status in Canada?GHB is a Schedule IV controlled substance by the CDSA.IN THE NEWS: READ(warning, this story may cause activation).Toronto man jailed for drugging friend with date rape drug by Alyshah Hasham posted February 7, 2017 to the Toronto Star.Food for ThoughtWhich depressant did you know the most about? The least?Chapter CreditAdapted from Unit 3.7 in Drugs, Health Behavior by Jacqueline Schwab. CC BY-NC-SA. Updated with Canadian Content.Image Creditspalette by ebrkut via flickr is licensed under CC BY-ND 2.0.Images of historical advertisements for barbiturates from: López-Muñoz, F., Ucha-Udabe, R., Alamo, C. (2005). The history of barbiturates a century after their clinical introduction. Neuropsychiatric disease and treatment, 1(4), 329–343. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424120/GHB, Drugs of Abuse from: U.S. Department of Justice Drug Enforcement Administration. (2017). Drugs of abuse (p 57). https://www.dea.gov/sites/default/files/2018-06/drug_of_abuse.pdfCanadian Centre on Substance Use and Addiction. (2017). Canadian drug summary-alcohol. https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Canadian-Drug-Summary-Alcohol-2017-en.pdfStewart, S. (2004). The history, current prevalence, and consequences of drinking problems in Canada, (para. 1) https://www.researchgate.net/publication/228688984_The_History_Current_Prevalence_and_Consequences_of_Drinking_Problems_in_CanadaCentre for Addiction and Mental Health. (2021a). Alcohol. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/alcoholMcKim W. A. Hancock S. (2013). Drugs behavior : introduction to behaviorial pharmacology plus mysearchlab with etext -- access card package (Seventh). Pearson Education.López-Muñoz, F., Ucha-Udabe, R., Alamo, C. (2005). The history of barbiturates a century after their clinical introduction. Neuropsychiatric disease and treatment, 1(4), 329–343. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424120/Centre for Addiction and Mental Health. (2021b). Anti-anxiety medications (benzodiazepines). https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/anti-anxiety-medications-benzodiazepinesWick J. Y. (2013). The history of benzodiazepines. The Journal of the American Society of Consultant Pharmacists, 28(9), 538-548. https://pubmed.ncbi.nlm.nih.gov/24007886/O’Connell T., Kaye L., Plosay J.J. 3rd. (2000, Dec. 1). Gamma-hydroxybutyrate (GHB): A newer drug of abuse. American Family Physician, 62(11), 2478-2483. https://pubmed.ncbi.nlm.nih.gov/11130233/Busardò, F. P., Jones, A. W. (2015). GHB pharmacology and toxicology: acute intoxication, concentrations in blood and urine in forensic cases and treatment of the withdrawal syndrome. Current neuropharmacology, 13(1), 47–70. https://doi.org/10.2174/1570159X13666141210215423PK
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