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For the purpose of this article, 'substance use' referred to includes both licit (eg. Alcohol, prescribed medications) and illicit (cannabis, non-prescribed opiates and opioids etc) and does not seek to make judgements on their use. Whilst this article primarily focuses on those in contact with services, it should be recognised that substance use is ubiquitous and embedded into culture, both on a national basis and with local cultural influences. Evidence-based interventions may be transferable to any area of practice, where it is appropriate and agreeable to explore the influence of individuals' substance use on their occupational participation. However, intervention should not necessarily be focused on the use of substances or abstaining. There may be benefits to supporting service users to explore the occupational impacts of their use.
Key definitions
There is no fixed definition of addiction, although many refer to the psychological and behavioural elements, incorporating repetitive behaviours that may result in a loss of controlled use, emotional distress and harm. Dependency refers to the physiological changes of which tolerance and withdrawal are evident. The experience of addiction can be equally as harmful without the presence of physical dependency.
Substance use, addiction and dependency
In 2021, there were over 275,000 adults in contact with substance use services, with over 130,000 entering treatment that year (UK Gov, 2021). More than half (56%) in treatment were over 40 years old, with 3:1 male to female. The harms of addiction and dependency are associated with:
premature death
insecure housing and homelessness
poorer physical health outcomes
stigma
insecurity of employment
poverty
relationship breakdown and isolation
unrecognised or untreated mental health needs
greater risk from blood-borne viruses and non-communicable diseases
(Department of Health and Social Care, 2017)
Individually, these inequalities have the potential to disrupt occupational performance in a wide-ranging and lasting way. Collectively, they present a substantial constellation of bio-psycho-social challenges.
Use of substances and addiction is present across the life course and is linked to adverse childhood experiences (ACEs) (Public Health Wales, 2017). The more ACEs an individual experiences, the more likely they are to use substances (Petley and Davies, 2022), with trauma in adulthood also associated with increased prevalence. In addition, the Drink Wise, Age Well project (2020) identified ‘life transitions’ in older adults as a factor increasing risk and hazardous alcohol use. The project found older adults (50+) to be at greater risk from the harms associated with alcohol and that divorce, retirement, bereavement, children leaving home and changes in health status were associated with greater risk. Substance use in this population has been found to go unrecognised, unaddressed and under-represented in policy (Royal College of Psychiatrists, 2018). Similarly, Addiction UK (2020) found a paucity of research concerning addiction and neurodiversity.
The dated, moralistic views on addiction and substance use remain, fuelling stigma and a lack of understanding that recovery does not rely on will power alone. The ‘disease model’ of addiction has been widely accepted and has increased understanding of neuroanatomy and challenged stigmatised thinking. Gutman (2006) detailed how the disease model contributes to the frequent relapsing nature of addiction and implications for occupational therapy intervention. Lewis (2017) challenges this model, arguing that it is ‘development, not disease’, as the brain is only doing what it was evolved to do when experiencing please or rewards. Morris, Cox, Moss and Reavey (2022) argue that the disease model has served to ‘other’ those experiencing addiction and drives narratives around abstinence and ‘positive new sobriety’, at the expense of more diverse representations of recovery.
Occupational Therapy, substance use and occupational participation
Occupational Therapy’s primary focus is on ‘occupations’, all those things in a day that we want to, need to or have to do. It is argued that occupational participation is an important determinant of health (Law, 2002) and that engagement in meaningful occupations promotes health and wellbeing (Wilcock and Hocking, 2015). This assumption has been challenged by Twinley (2021), who developed the concept of ‘the dark side of occupation’. Twinley suggest that not all participation is health-affirming and further research is required to develop our understanding of occupational participation, in occupations that may be detrimental to health.
The idiosyncratic nature of occupational performance may carry both health promoting and harming elements, influenced by individual contexts and environments.
Occupational therapists have practiced in addiction settings since the 1950’s (Hossack, 1952), but do not typically form part of the current substance use service multidisciplinary mix. There is evidence that some elements of ‘occupation-focused’ intervention are delivered through traditional approaches without occupational therapists’ involvement (Wasmuth, Pritchard and Kaneshiro, 2016). The value occupational therapists could bring to the setting was explored in depth by Wasmuth, Crabtree and Scott (2014), who coined the term ‘addiction as occupation’. They identified addictions as an attempt to ‘self-organise’, emphasising the importance for individual’s identities, roles, routines and social lives. When individuals attempted to abstain, a ‘breakdown of self’ is experienced, which may severely impact mental health and function, presenting a barrier to recovery. In later work, Wasmuth (2016) argued that recovery requires far more than simply replacing occupations, calling for ‘opportunities to engage in new occupations, geared specifically towards reshaping social life, identities, habits, roles and routines’.
‘By acknowledging addiction as an occupation and then focusing on this occupation’s gains and harms, occupational therapists may be in a position to gain trust of clients and help them to make adjustments to their occupational lives that are personally beneficial’ (Wasmuth, Crabtree and Scott, 2014).
More recently, Vegeris and Brooks (2022) built on this argument, drawing attention to the need for individuals to ‘assign new meaning’ to occupations. By ‘developing new patterns of occupation, in the form of roles, routines, and connections, which are congruent with the construction of one’s newfound occupational identity’, they argued this can alleviate the losses felt in the early stages of recovery, that are associated with frequent relapse. This underlines the necessity for early intervention that focuses on occupational participation.
Whilst recovery is both a highly subjective experience and a collective movement, it has also been explored in the context of substance use as an ‘occupational transition’ (Vegeris and Brooks, 2022; Nhunzvi, Galvaan and Peters, 2017; Luke and Began, 2014). Early work by Blair (2000) highlighted the ‘health protective’ influence of occupation throughout the ‘discontinuity’ experienced during transitions. Blair also drew attention to the voluntary/involuntary and planned/unplanned nature of occupational transitions and the link to health outcomes. This is especially relevant when substance use-related harms lead individuals to find themselves within the healthcare system, for example possibly requiring an unplanned detox, due to acute physical or psychiatric illness. When stripped of a way of coping, an identity, the means to connect with others, a structure to one’s life etc, relapse is the common experience and a harm reduction approach may be more suitable to the individual.
A recent scoping review of interventions for substance use (Ryan and Boland, 2021) found occupational therapy to be a good fit with most services. Ryan and Boland found the most reported interventions underpinned development of life skills and supported re-engagement in meaningful routines. They concluded that role restoration and maintenance is essential in recovery - and that going beyond teaching skills to prioritise occupational engagement was the most effective approach. Jarrard et al (2021) similarly concluded that occupational therapists can ‘apply their expertise and knowledge of daily occupations, time management skills and positive coping strategies to support restoration of healthy habits and routines in the recovery process’. Since there is no uniform intervention for substance use, occupational therapy’s client-centred approach, based on the dynamic interaction of multiple factors, furthers it’s suitability in this setting (Chaudhuri, 2018).
The presence of occupational therapists in the substance use setting is documented along with the types of interventions being delivered. A common theme in recent literature is a calling out of the lack of evidence on how effective interventions are (Vegeris and Brookes, 2021; Rojo-Mota, Pedrero-Pérez and Huertas-Hoyas, 2017; Amorelli, 2016).
There are complexities in describing occupational therapy interventions (RCOT, 2018), but we must decide on what we’re trying to measure, be it quality of life and satisfaction, occupation-focused goals achieved, or level of global occupational performance and participation.
Goals may be unrelated to substance use.
In summary
Use of substances can be associated with significant occupational disruption, but may also support performance. The conceptual framework is well established to articulate our role and evidence exists describing the common types of intervention delivered. Applying the occupational perspective - whilst understanding individuals’ dynamic of gains and harms - Occupational Therapy can influence recovery. Occupational Therapy in this setting should not necessarily be focused on substance-related outcomes, as individuals have needs and goals beyond this, which can influence occupational performance, quality of life and health status. Our presence in the multidisciplinary team can provide a different perspective on addiction and dependency, that challenges stigma, promotes social inclusion and may encourage engagement in services. We can apply our specialist skills to collaborate with individuals on recovery-orientated goals, that may reduce harm and create a life with renewed hope and purpose.
In addition
Occupational therapy in substance use arguably remains an emerging area of practice, until its effectiveness is proven. A recent networking exercise (Fisher, 2022) in the UK and Ireland has identified over 20 occupational therapists working in substance use services with more worldwide. Occupational Therapy practitioners were found to work within community specialist substance use services, adult social care, inpatient detox and residential rehabilitation services amongst others. An ‘Occupational Therapy and Substance Use Network’ (OTASUN) has been established, to consolidate professional identity; offer peer support; share resources and knowledge and ultimately further the evidence of occupational therapy in this setting.
For responses or discussion, please do not hesitate to contact the author on the credentials below:
@fisheraddiction
References
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