Integration

1. Unit Introduction

This module provides an overview of an integrated approach to addiction in research, treatment and policy. Integration is illustrated using multiple examples of how addiction interacts with other issues such as mental health, violence, injury, and trauma, as well as how sex and gender influences these issues and should be taken into account.

This unit also outlines a harm reduction and trauma informed approach to addiction and provides examples of how an integrated approach can be operationalized in research, treatment and public health policy.

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2. Why take an integrated approach to addiction?

There is a tendency for addiction and substance use to be viewed separately from issues such as mental health, trauma, violence and as though they have unique causes and outcomes. The reality, however, is that mental health, substance use, violence, injury, and trauma overlap so significantly that it is often impossible to tease them apart into individual and separate problems. In fact, as we become aware of the intersecting relationships between these issues, it becomes evident that it makes more sense to consider them together than apart.

Taking an integrated perspective not only improves our understanding of addiction but also invites us to work together across disciplines rather than in silos. As identified in Module #1 Defining Addiction, recognition of the complexity of addiction requires a transdisciplinary approach, whereby different disciplines can work together to create more nuanced and effective approaches to research, policy, education and treatment. Furthermore, recognition of the intersecting relationships between addiction and related issues can influence policy initiatives and government structures, such as the merging of services for addiction and mental health so they can be addressed together. An integrated approach to understanding the relationships among substance use, mental health, violence, injury, and trauma among other issues will ultimately lead to a furthering of our knowledge in all these areas and allow us to improve how we respond to addictions. The following section outlines some examples of an integrated view of addiction, mental health, violence and injury, and trauma. The theme of sex and gender differences and implications is also discussed throughout.

Watch this video of IMPART mentors, Lorraine Greaves, Nancy Poole, Chris Richardson, Joanne Weinberg, Catherine Goldie and Christy Sutherland, discussing the importance and benefits of taking an integrated approach to addictions.

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2. 1 Mental Ill Health and Addictions

Mental health and addictions often overlap, and encompass a vast range of disorders affecting behaviour, thinking, and mood. Although they can be lumped together, the two terms refer to distinct issues that frequently co-occur. Examples of mental health diagnoses include depression and anxiety disorders, but also include substance use disorders.

The prevalence of mental health and addiction problems is alarming. Approximately 1 in every 5 Canadians experiences a mental health/addiction problem in any given year (Pearson, Janz, & Ali, 2013). In addition, the overlap between mental illness and substance use is significant, with 1 in 5 people experiencing a mental illness along with a co-occurring substance use problem (Merikangas et al., 1998). Indeed, people with mental illnesses are twice as likely to have a substance use problem compared to the general population. Further, 1 in 6 people with a substance use problem are suffering from a co-occurring mental illness and people with substance use problems are three times more likely to suffer from mental illness compared to the general population (Canadian Institute for Health Information, 2012).

Some of the most common co-occurring addictions and mental illnesses include:

• Alcoholism and anti-social personality disorder – individuals who drink excessively on a regular basis are 21 times more likely to suffer from anti-social personality disorder compared to those who do not drink excessively (Grant et al., 2004).
• Cocaine addiction and anxiety disorders – the continued use of cocaine can lead to symptoms of an anxiety disorder such as paranoia, suspiciousness, insomnia, and excessive worry (Grant et al., 2004).
• Opioid addiction and Post-Traumatic Stress Disorder (PTSD) – many individuals who suffer from PTSD are prescribed an opiate to deal with the consequences of the trauma, whether it be pain or sleep issues, and addictions develop to maintain the euphoric feeling (Seal et al., 2012).
• Heroin addiction and depression – the euphoria resulting from heroin use may only be achievable over time through use of the drug making an individual feel incapable of happiness without the presence of heroin (Canadian Centre on Substance Abuse, 2009).

Why is the co-occurrence for substance use problems and mental illness so high? While many factors come to bear, research has identified two primary explanations:

1. Self-medication – an individual may start using a substance to alleviate the negative affect or symptoms associated with a mental illness. Over time they may develop substance use problems due to the continued use of the drug and the perceived benefit that the drug provides. However, this can result in further negative effects on the individual, as prolonged substance use has been known to contribute the maintenance of many mental health symptoms, such as depression and anxiety (Harris & Edlund, 2005).

Drug use may exacerbate or increase the expression of mental illness – in some cases the use of some substances, or the withdrawal from substances may increase the presence or expression of the symptoms associated with mental illness. For example, long-term alcohol use is known to cause symptoms of anxiety and depression (Grant et al., 2004), and cannabis use is associated with an increase in symptoms for those who suffer from schizophrenia (Hall & Degenhardt, 2000). If these concerns are not addressed or persist beyond the drug use they may lead to mental illnesses.

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2.2 Violence, injury and substance use

Each year, hundreds of thousands of deaths occur due to intentional and unintentional injuries related to alcohol use. Alcohol impairs coordination as well as our ability to perceive and respond to hazardous situations making it more likely that we will experience injuries such as, head injuries, fractures or sprains, lacerations, burns, violence related injuries, and injuries resulting in death. Research shows the risk for injury increases as the amount of alcohol use increases. For example, someone consuming 5 or more drinks on one occasion is 10 times more likely to get injured in the following 6 hours.

Given that substance use is closely tied to injury suggests that an integrated approach is vital when researching and understanding these issues. As described in the previous section, individuals experiencing mental health difficulties may use alcohol in the maintenance of mental health symptoms, thereby making the consideration of both substance use and mental health simultaneously crucial in our understanding of these issues. Sex and gender have also been shown to influence who gets injured and how, highlighting the gendered nature of sexual assault involving alcohol in particular.

• About half of sexual assaults involve alcohol consumption by the perpetrator, victim or both (Graham and West, 2001).
• Alcohol use may contribute to violent behavior due to short-/long-term physiological effects including cognitive impairment (especially reduced frontal lobe functioning related to threat evaluation and problem solving), reduced inhibitions and ability to interpret social cues, elevated emotional states and alterations of hormonal/physiological function. (Boles et al. 2003)
• Incidents of alcohol-related violence may result from interactions between the cognitive and other physiological effects of alcohol, and many individual, situational, and social/cultural factors. (Boles et al. 2003)
• Alcohol intoxication may also make an individual a more likely target for violent victimization due to reduced ability to interpret social situation and threatening signals, and by their behavior. (Boles et al. 2003)

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2.3 Trauma and addiction

Increasingly, trauma and experiences of violence are being shown to be a key element in understanding addiction (Poole, 2015, Poole and Greaves, 2012). Women’s health researchers, Indigenous scholars, clinicians and neuroscientists are showing the links between various kinds of trauma, mental health and substance use problems for women and men.

According to the 2013 BC Trauma Informed Practice Guide, trauma is defined as “(an) experience(s) that overwhelm(s) an individual’s capacity to cope.” Trauma occurs in all stages of life; when early, examples include child abuse, neglect, witnessing violence and disrupted attachment, and later in life experiences such as violence, accidents, natural disaster, war, sudden unexpected loss and other life events that are out of one’s control can be devastating.

There are several dimensions to trauma, such as magnitude, complexity, frequency, duration, and whether it occurs from an interpersonal or external source. These dimensions have been included in descriptions of different forms of trauma, including:

• Single incident trauma g. an accident, natural disaster, a single episode of abuse or assault, sudden loss, witnessing violence
• Complex or repetitive trauma g. ongoing sexual abuse, domestic violence, war, ongoing betrayal, torture
• Developmental trauma g. trauma as infants, children and youth involving neglect, abandonment, physical abuse or assault, sexual abuse or assault, emotional abuse, witnessing violence or death, and/or coercion or betrayal
• Historical traumag. collective traumas inflicted by a dominant population such as genocide, colonialism (most relevant in Canada being residential schools), slavery and war
• Intergenerational trauma g. trauma experienced by living with another trauma survivor, and learning (maladaptive) coping patterns, often embedded in historical trauma

Trauma has many effects on the body, spirit and mind. In general, trauma can:

• Worsen memory and ability to recall events
• Involve repetitive flashbacks to overwhelming moments in life
• Be associated with nightmares, poor sleep, depression
• Be linked to or exacerbate chronic pain, gastrointestinal disorders, asthma, headaches, palpitations, and other chronic illnesses
• Be linked to or worsen mental health conditions, such as depression, anxiety, sexual dysfunction, dissociation, suicidality, self-harm, anger
• Develop or worsen addiction and substance use disorders, as some people use substances to ‘numb out’ the symptoms of repetitive trauma – see the resource box below for more

The following table illustrates the prevalence of trauma in those with substance use and mental health concerns in British Columbia and Canada.

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3. Physiological interactions in trauma, mental health, and addiction

On a neurobiological level, the overlap between mental health, trauma, and addiction, provides currency for integration in clinical work. The linkage is related to one major area of the brain’s limbic system: the amygdala and associated neurochemical responses (dopamine, endogenous opioids, serotonin, corticosteroids, catecholamines, etc.). When a situation is detected as threatening in the amygdala, it ‘turns on’ the sympathetic nervous system, initiating a cascade of neurochemicals involved in the ‘stress response’ that increase heart rate, respiration, oxygen flow to muscle tissue, and decrease to other organ systems including the decision making frontal cortex. (Fischer2003, Koob 2014) This is linked to many of the symptoms of trauma – dissociation, inattention, and hyper-anxiety.

In early childhood trauma and ongoing trauma, the amygdala becomes hyperactive and hypersensitive to cues, scripts and reminders, initiating a response even without a threat, creating feelings of anxiety. As such, one is left with a constant stress response, affecting impulse control and development of the frontal cortex (affecting the ability to make sound decisions, pay attention, etc.) (Fischer, 2003). In addiction, the amygdala stress response is activated during withdrawal from substances (Koob, 2014) In mental health, anxiety symptoms are mediated by similar mechanisms that turn on the ‘stress response’, thereby mimicking amygdala effects.

In addition to the amygdala’s stress response effect, other neurochemical cascades involving dopamine, endogenous opiates, and serotonin can be imbalanced in certain mood and anxiety disorders, as well as during drug withdrawal and ongoing stress from trauma.

With constant stress, imbalanced pleasure pathways, and lack of impulse control in trauma, mental health and addiction, it can be seen how the cycle of intoxication-withdrawal-craving, symptoms of trauma and mental ill health continue. Overall, there is significant overlap between the responses and neurochemical pathways of trauma, addiction and mental ill health processes, which require an integrated approach to care and research.

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4. Taking an integrated approach in research practice and policy

It is clear that there is overlap between substance use/addiction, trauma, injury, violence and mental ill health, but just how do we integrate them when designing policy, research methods, and treatments? Although complex, and sometimes difficult to execute, this section describes examples of research, treatment and policy for substance use problems and addiction that embrace principles of integration. The section outlines the basic tenets of Harm Reduction and Trauma Informed Care – two frameworks that have been applied in many settings to encourage an integrated and compassionate approach to addressing problematic substance use.

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4.1 Principle-based approaches: Harm reduction & trauma-informed approaches

4.1a Harm reduction

Some would suggest that the harm reduction model is a unique example of an integrated approach to care. Harm reduction refers to policies, programs and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. The principles of harm reduction are the focus on: the prevention of harm, rather than on the prevention of drug use itself; and on people to ensure they are using drugs as safely as possible. The policies and programs common to harm reduction utilize integration from diverse fields of research, mental health and medical practice, and from community based experiences. Three guiding principles of harm reduction are to make contact, maintain contact, and to support making change.

In a review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco, and illicit drugs conducted by Ritter and Cameron (2006), it was concluded that harm reduction strategies are effective. With regards to alcohol, there was strong evidence to support the reduction in road trauma in areas where alcohol harm reduction strategies (such as driving services) are utilized. Regarding tobacco, there is emerging evidence that products such as e-cigarettes are effective in the reduction of smoking tobacco, however this evidence is still considered controversial as there are no studies of the long-term effects. There is also strong evidence to support needle exchange programs and safe injection sites in reducing the harms associated with injection drug use.

One of the most prominent examples of a service based on harm reduction within Canada is Insite, a safe injection site based in Vancouver, Canada. Established in 2003, Insite was North America’s first legal safe injection sites and offers a secure non-judgmental and protected place for people to inject drugs, which uses health-focused principles to guide its practices. It helps to establish a connection between an IV drug user and health care services to provide primary care for disease and infection, resources for counseling and treatment for addiction, and social support for issues such as housing and financial needs.

• Watch this documentary about Insite and a harm reduction model of care »
• See Harm Reduction International’s 2014 Global State of Harm Reduction, for current strategies being utilized worldwide »

4.1b Trauma-Informed Approaches

Trauma-informed practice (TIP) is an overall stance to service provision rather than a specific treatment strategy or method. Trauma-informed services apply an understanding of trauma in all aspects of service delivery and place priority on an individual’s safety, choice, and control (Harris & Fallot, 2001). A trauma-informed approach is distinct from trauma-specific interventions or treatments that are designed to specifically address the consequences of trauma and to facilitate healing. TIP includes reflects recognition of the need for physical and emotional safety, as well as choice and control in decisions affecting one’s treatment.

According to SAMHSA, “A program, organization, or system that is trauma-informed:

• Realizes the widespread impact of trauma and understands potential paths for recovery;
• Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system;
• Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and
• Seeks to actively resist re-traumatization.”

In more detail, the BC Trauma Informed Practice Guide suggests that the main tenets of trauma informed practice include:

1. Trauma Awareness—awareness among staff and clients of the commonness of trauma experiences; how the impact of trauma can affect development; adaptations to cope with trauma; interaction between trauma, substance use, and mental health concerns.
2. Emphasis on Safety—Physical, emotional, and cultural safety for clients, established through welcoming intake procedures and physical space to be less threatening; providing clear information about the programming; ensuring informed consent; creating crisis plans; and demonstrating predictable expectations.
3. Opportunity for Choice, Collaboration and Connection—foster an environment with a sense of efficacy, self-determination, dignity, and personal control for those receiving care. This includes open communication, equalization of power imbalances, allowance to express feelings without fear of judgment, provide choices and work collaboratively.
4. Strengths and Skill Building—Clients are assisted to identify their strengths and to (further) develop resiliency and coping skills. Practitioners emphasize teaching and modeling skills for recognizing triggers, calming, centering, and staying present.

Trauma-informed approaches are similar to harm-reduction-oriented approaches, as both focus on safety and engagement. In general, the foundational aspect of trauma-informed services is to create an environment where service users do not experience further traumatization or re-traumatization, and where they can make informed decisions about their treatment in a way that feels safe.

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4.2 Taking an integrated approach in research

Pivotal to the intersections of mental health, trauma, and violence with addictions is how they are integrated into research. Because, trauma and violence tend to overlap with mental health issues and addictions, it is important that consideration is given to all aspects of these intersections when conducting research projects on addictions. Further, gendered factors also play a significant role in the findings arising from research.

Research example:

Prevalence and correlates of nonmedical prescription opioid use among a cohort of sex workers in Vancouver, Canada. Argento, E., Chettiar, J., Nguyen, P., Montaner, J., & Shannon, K. (2015). International Journal of Drug Policy, 26(1), 59-66.

• This study examines the public health concern that nonmedical prescription opioid uses (NPOU) poses for female sex workers, a marginalized and vulnerable population within Canada. The progressive availability of nonmedical prescription opioid use within street populations has become a growing concern due to the social, legal, and sometimes violent consequences associated with the drugs.
• .A total of 692 female sex workers were recruited within the metro area of Vancouver, Canada. Of those,130 (18.8%) disclosed nonmedical opioid use within the last 6 months. The multivariate analyses revealed that the variables that independently were most correlated to NPUO included: exchanging sex while under the influence, police harassment/arrest, having an intimate partner who injects drugs, and physical/sexual intimate partner violence.
• The authors conclude that these findings help to establish a link between prescription opioid use and alarming rates of gender-based violence against for female sex workers. They identify this gender-based violence as independently correlating with structural factors of homelessness, criminalization and poor access to drug treatment. The authors suggest that socio-legal reforms such as greater access to housing and drug treatment and increased violence prevention efforts are needed to alleviate NPOU use and violence against female sex workers.

Questions for consideration:

1. Would you expect the results of this study to have been similar for male sex workers? If not, where would differences be expressed?
2. The interview for this study included questions regarding socio-demographics, their experience in the sex industry and with their clients, their intimate partners, trauma and violence, and their patterns of drug use. Further, a clinical questionnaire was conducted that included variables related to their physical, mental, emotional, sexual and reproductive health. Are there other factors that should have been included in this study?
3. Can you think of further policy directions in addition to those suggested by the authors?

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4.3 Taking an integrated approach in service provision

Program example:

Sheway: A community program for women and children

A strong example of integrated service provision is found at Sheway located in Vancouver. Sheway provides services to women who use substances and who are pregnant, intrapartum, or up to 2 years post-partum. Framed within harm reduction and trauma informed approaches, this service is founded upon the belief that the health of women and their children is linked to the conditions of their lives and their ability to influence these conditions. Sheway ’s collocated services and care team demonstrates an understanding of the overlap between substance use problems, mental health concerns, violence, injury and trauma. The service includes:

• Integrated care team, including psychiatrists (both adult and child), psychological counsellor, family physicians with long term experience in perinatal addiction, nurses, medical support staff, art therapists, Aboriginal community support workers, child development and support workers, nutritionist, housing and outreach workers, social worker, obstetricians, pediatricians, and occupational therapists..
• Services available for women to choose to access on intimate partner violence safe housing, and establishment of early attachment with their children
• The care team meets weekly to discuss care plans and their observations of clients’ situations in order to develop the most integrated approach
• The care team teaches one another from their various lenses in order to deepen their understanding of the overlap between addiction, trauma, and mental health.

Other aspects to the programming that demonstrate an understanding of trauma informed care and harm reduction. These include:

• Regular clinic hours that are drop in, meaning no woman has to worry about keeping an appointment but can always count on the clinic being open at the same time
• Provides services in a flexible, welcoming, non-judgmental, nurturing and accepting way, whereby all staff are trained and screened for an understanding of how trauma affects mental and physical health before even being hired
• Supports women’s self-determination, choices and empowerment in each interaction, whether around housing for the family, relationship, food security and family nutrition, interaction with the Ministry of Child and Family Services, parenting, or physical and mental health care
• Offers respect and understanding of First Nations culture, history and tradition, including hiring members of different Nations to offer an experiential cultural perspective and approach to service provision
• Offers low barrier access to counselling, methadone maintenance, contraception, infection prevention, clean needles and other drug-using tools, take home naloxone kits, onsite nursing for wound care and abscess draining, and so much more to engage people in care and reduce the harm of their substance use
• Links women and their families into a network of health-related, social, emotional, cultural & practical support

Overall, the program includes comprehensive and trans-disciplinary service provision framed within trauma-informed and harm reduction principles.

Poole, N. (2000). Evaluation Report of the Sheway Project for High Risk Pregnant and Parenting Women. Vancouver BC: British Columbia Centre of Excellence for Women’s Health.

Figure reprinted with permission from author

Questions to consider:

• Can you think of examples in your own experiences where trauma informed practice was evident, compared to where it was not? What differences do you observe in client or patient responses/outcomes?
• Other than an interprofessional team approach, what other ideas do you have for integration of mental health, trauma and substance use in treatment provision?
• How can you implement gendered harm reduction and trauma informed care across the continuum of addiction treatment (i.e. detox, daytox, outpatient settings, hospital, residential treatment, recovery houses, family physician offices, and peer support groups)?

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4.4 Taking an integrated approach to public health policy

The interactions among substance use, gender, mental health and experience of violence are also crucial for informing public health policy. The examples below reflect research that takes an integrated approach and has led to important insights for policy making. These examples of improved practice and policy more effectively address significant public health issues such as alcohol related injury and violence that are impacted by gender and mental health.

Policy Example

Integrating substance use, gender and mental health for patients being treated for alcohol related injuries in Emergency Department

In a large-scale study based in Victoria, BC. researchers explored the intersection of trauma, mental health and addiction in Emergency Departments through strategic questionnaires. The study found that the risk for injury increased as the amount of alcohol use increased. The greatest risk of injury was found for men, and those consuming six or more drinks in the six-hour period prior to the injury event. Furthermore, the results indicated that mental health symptoms such as anxiety or depression exacerbated the effect of alcohol and the likelihood of injury among women. In other words, women who consumed alcohol and had mental health symptoms were almost twice as likely to be injured compared to women without mental health symptoms. While the exact reason behind the association among mental health, alcohol use, and injury is not entirely understood, these findings suggest the importance of treatment of an individual beyond the injury they are presenting.

The potential implications of this association are numerous and the excerpts from the project suggest one way we could begin to implement a more integrated treatment approach.

• Health care practitioners could use a quick measure to assess a patient’s psychological wellbeing while they are being treated in the Emergency Department, which could lead to the awareness of depressive or anxiety symptoms.
• A questionnaire could be administered to assess for alcohol abuse or alcohol-related problems. The awareness of such symptoms or problems could allow for the individual to could receive referral for treatment for alcohol use or for presenting mental health symptoms. The treatment of either substance use or mental health problems may target the underlying cause of injury; therefore potentially reducing injury recidivism and increasing overall wellbeing.
• These findings suggest that gender-specific interventions and prevention strategies are required, and may be more effective than universal ones.

Questions to consider:

1. What other factors may be important to consider when thinking about the relationship between mental health, addiction and trauma? How might these factors influence policy or intervention strategies?
2. What are some of the barriers we could anticipate in trying to implement integrated treatment or gendered prevention strategies? Consider current policies and regulations, as well as issues such as financing, staffing, and potential biases.

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5. Summary and suggested Reading

Key points

• Mental ill health, substance use/addiction, and experience of violence, injury, and trauma overlap so significantly that it makes it difficult to tease them apart into individual and separate problems
• An integrated perspective not only improves knowledge of addiction but supports working effectively in cross disciplinary and cross sectoral ways.
• Sex and gender are an essential aspect of an integrated approach for producing more accurate and equitable science, treatment and policy
• Harm reduction and trauma- informed approaches encourage an integrated and compassionate approach to addressing problematic substance use in research, treatment and public health policy.

Suggested reading

Alexander, B. K. (2000). The globalization of addiction. Addiction Research & Theory, 8(6), 501-526.

Maté, G. (2010). In the realm of hungry ghosts: Close encounters with addiction. North Atlantic Books.

Poole, N., & Greaves, L. (Eds.). (2012). Becoming Trauma Informed. Toronto, ON: Centre for Addiction and Mental Health

Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Tolin, David F.; Foa, Edna B. Psychological Bulletin, Vol 132(6), Nov 2006, 959-992

Trauma informed approach and trauma specific interventions by the Substance Abuse and Mental Health Services Administration

‘Matters of Substance‘ blog by the Centre for Addictions Research of BC at the University of Victoria. This blog is updated regularly on current Addictions and related issues including those discussing sex and gender.

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6. Unit References

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Argento, E., Chettiar, J., Nguyen, P., Montaner, J., & Shannon, K. (2015). Prevalence and correlates of nonmedical prescription opioid use among a cohort of sex workers in Vancouver, Canada. International Journal of Drug Policy, 26(1), 59-66.

Becker, J. B., & Hu, M. (2008). Sex differences in drug abuse. Frontiers in Neuroendocrinology, 29, 36-47.

Boles, S.M., Miotto, K. Substance abuse and violence: A review of the literature. Aggression and Violent Behavior 2003; 8: 155-174.

Callaghan, R.C., Gatley, J.M., Sykes, J., Taylor, L. (2015). The prominence of tobacco-related mortality among individuals with alcohol- or drug-use disorders. Unpublished, 2015.

Callaghan R.C., Gatley J.M., Sanches M., Asbridge M. Impacts of the minimum legal drinking age on motor vehicle collisions in Québec, 2000-2012. Am J Prev Med 2014a; 47(6): 788-95.

Callaghan R.C., Sanches M., Gatley J.M., Stockwell T. Impacts of drinking-age laws on mortality in Canada, 1980-2009. Drug Alcohol Depen 2014b. 138: 137-45.

Callaghan, R.C., Veldhuizen, S., Jeysingh, T., Orlan, C., Graham, C., Kakouris, G., Remington, G., Gatley, J. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psychiatr Res. 2014c;48(1):102-10.

Callaghan R.C., Sanches M., Gatley J.M. Impacts of the minimum legal drinking age legislation on in-patient morbidity in Canada, 1997-2007: a regression-discontinuity approach. Addiction 2013a; 108: 1590-600.

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Canadian Action Network for the Advancement, Dissemination, and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT). Canadian smoking cessation clinical practice guideline. Toronto, ON: Canadian Action Network for the Advancement, Dissemination, and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT), Centre for Addiction and Mental Health; 2011.

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Graham, K., Bernards, S., Osgood, D.W., Antonia, A., Parks, M., Flynn, A., Dumas, T., Wells, S. “Blurred lines?” sexual aggression and barroom culture. Alcoholism: Clinical and Experimental Research 2014;38(5):1416-1424.

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Harris, K. M., & Edlund, M. J. (2005). Self-medication of health problems: New evidence from a national survey. Health Services Research, 40, 117-134.

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Poole, N., & Greaves, L. (Eds.). (2012). Becoming Trauma Informed. Toronto, ON: Centre for Addiction and Mental Health

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