Tag Archive for: Substance Abuse


Enabling Clients in Lower-Risk Cannabis Use

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

Co-written by Kyra Posterski, MSc (OT) Candidate 2019 at McMaster University


In October of 2018, the Government of Ontario legalized cannabis in an effort to keep cannabis out of the hands of youth, keep profits out of the hands of criminals, and protect the public health and safety by allowing adults access to legal cannabis.

The number of Canadians who report using cannabis has increased since legalization. However, cannabis use is not without both short and long-term risks. These risks include cognitive and psychomotor impairments, hallucinations, impaired driving, and dependency, as well as mental health, pulmonary/bronchial, and reproductive problems.  One advantage of legalization is that it allows for a more open discussion of risk behaviours, and the steps that can be taken to reduce these.

Given that cannabis is being increasingly used by Canadians, it is likely that OT’s will continue to encounter clients that use this regularly as part of our practice. Knowing the actions that client’s can take to reduce their risk when using cannabis is thus important for clinicians to realize and understand.  The Lower-Risk Cannabis Use Guidelines has been developed as an evidence-based tool that offers recommendations for users of cannabis products to reduce risks and improve their health. Using these guidelines, occupational therapists are well-positioned to educate clients on the actions they can take to reduce their risk, enabling clients to engage in lower-risk cannabis use behaviours. These conversations are especially important for occupational therapists working with clients that are at an increased risk, such as adolescents, pregnant women and people with a family history of psychosis or substance use disorder.

These guidelines present 10 major recommendations for lower-risk use:

# 1 ABSTINANCE.  As with any risky behaviour, the most effective way to reduce risk is avoiding the behaviour.

# 2 START LATER.  Using cannabis at a young age (i.e. before age 16) increases the risks for adverse health and social outcomes.  It is recommended that usage not start until at LEAST the legal age.

# 3 and 4 PRODUCT CHOICES. It is recommended to use cannabis products with a low tetrahydrocannabinol (THC) content and to avoid using those with synthetic cannabinoids.

# 5 and 6 METHODS AND PRACTICES. Smoking combusted cannabis negatively affects respiratory health; therefore alternative, lower-risk methods, are recommended (e.g. vaporizers or edibles). Practices such as “deep-inhalation” or breath-holding should also be avoided since these practices increase the intake of toxic materials.

# 7 LIMIT USE TO OCCASIONAL (e.g. once a week). More frequent or intense cannabis use is associated with a number of health problems.

# 8 DON’T DRIVE. It is suggested that people refrain from operating a motorized vehicle for at least six hours or longer after using cannabis. Cannabis impairs skills that are critical for driving (e.g. attention) and driving while impaired from cannabis increases the risk of being involved in a motor vehicle accident.

# 9 CONSIDER YOUR UNIQUE SITUATION.  Some populations who are at a higher risk for cannabis-related health problems should abstain from using cannabis altogether. This includes pregnant women and people with a family history of psychosis or substance use disorder.

# 10 DON’T COMBINE.  Avoid combining cannabis use with other higher-risk behaviours—like those described already, as this may further amplify risks.

For more information about this topic, OT’s are encouraged to access the references below or to encourage clients to contact their treating physician for more information about safe use.



Centre for Addictions and Mental Health. (2017). Canada’s lower-risk cannabis use guidelines:

Fischer, B., Russell, C., Sabioni, P., Van Den Brink, W., Le Foll, B., Hall, W., … & Room, R. (2017). Lower-risk cannabis use guidelines: A comprehensive update of evidence and recommendations. American Journal of Public Health107(8), e1-e12.

Government of Canada. (2019). Cannabis act [PDF file]. Retrieved from

Statistics Canada. (2019, May 2). National cannabis survey, first quarter 2019.



Occupational Therapy Approaches for Substance Use in Clients with Brain Injuries

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)
Co-written by Ashley Best, Student Occupational Therapist

In our previous blog post titled “Brain Injury and Substance Use”, we discussed how the cognitive and emotional changes associated with brain injury can overlap with substance use.  But what wasn’t covered was the role of the Occupational Therapist when working with clients who have these challenges.  While our role is complex in cases like these, we have tried to simplify how we use function and meaningful activity in combination with direct treatment to address some common themes as outlined below.

1. Harm Reduction

Arguably the most important strategy of any professional working with someone who uses substances is Harm Reduction. An Occupational Therapist can work with a client to better understand the process of using a substance with the same skill used for analyzing other daily activities. By breaking down what a client’s substance use looks like, from the trigger to being under the influence, the OT can identify areas of potential harm or danger. Some common concerns with substance use, and some OT intervention examples are:











It is important to recognize that the above strategies are not meant to encourage substance use but ensure the safety of the client when they are not willing or able to stop.  Sometimes just reducing the harm is all we can offer until the harm can be eliminated.

Clinical Example: A man with previous regular alcohol use prior to an accident, now has seizures when he does not have alcohol in his system. Thus, it is actually more harmful to ask this client to not use alcohol. Instead, monitoring the amount he drinks and ensuring he has regular supports at home are two strategies that can reduce the harm that alcohol may cause.

2. Recognizing Substance Use as a Barrier to Goals

The financial, behavioural, and health effects of substance use often negatively impact a client’s ability to reach their goals. An occupational therapist can help a client to understand and hopefully address the gap between substance use and being able/unable to move forward in other areas of life. An OT may also strategize ways to achieve goals despite substance use by planning use around occupations and this, in turn, may help decrease use over time.

Clinical Example: An individual with a brain injury has a goal to return to work but does not have the insight to recognize how using narcotics would impact their success on the job. Thus, helping the client break down the requirements of a job, recognize poor fits, and then implementing strategies to change substance use behaviour so that it doesn’t impact work (in the case that abstaining from use is not an option) could be an intervention focus.

3. Using Activity to Avoid Triggers

Often, substance use is time-consuming between acquiring, using, and coming down from the influence. This becomes a major challenge when people stop using because there is a lot of free time that may lead to boredom and relapse. This is an important place for occupational therapists to intervene by helping the client identify meaningful activities to engage in when they are feeling an urge to use. This could involve interests and values, or just discussing past activities that the client would like to resume.

In the case of someone with a brain injury, more guidance may be required to identify triggers (if the client has low insight what is triggering). In addition, activities that the client can perform may be different following a brain injury, and thus they may need support in finding new meaningful activities to fill the time that was previously taken up with substance use.

What is the take-home message?

As the above indicates, implementing any of these strategies will require the client to exercise a high level of control over their addiction. Thus, an OT can help support and accommodate each client’s unique situation by providing remedial and compensatory strategies to help clients transition from the occupation of substance use, to other, ideally more meaningful and healthy alternatives.


Brain Injury and Substance Use

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)
Co-written with Ashley Best, Student Occupational Therapist

As clinicians working in the community with clients who have a brain injury, we all too often see the challenges of recovery impacted by the use of illicit drugs and alcohol.  And while we treat both the brain injury and substance use as they impact function and the ability to participate in life roles, we often wonder, which came first? 

Statistics show that individuals with brain injuries have higher rates of substance use than the general population. However, statistics also show that individuals with brain injuries have higher pre-injury rates of substance use.  While this does not explain a “causal relationship” or answer the “which came first” question, we know the interplay is complicated and that acquiring a brain injury can change the way the brain processes information which may influence substance use behaviours and patterns.

Here are some examples of how this can happen:

  1. Cognitive Changes: Having a brain injury can result in cognitive changes from mild to severe difficulties with memory and concentration, communication, processing speed, problem-solving, and more.
  2. Emotional and Personality Changes: A brain injury can also result in emotional and personality changes such as impulsivity, irritability, and lack of insight.

The changes and symptoms mentioned above occur as a result of injury to the brain’s frontal lobe. The frontal lobe is responsible for more complicated cognitive processes. It helps us to problem solve everyday challenges and consider the positive and negative impacts of our decisions. When a person hits their head or is jolted quickly, the frontal lobe will often impact against the skull – bruising, damaging, and disrupting the connections between the brain cells in this region.

So how does this relate to substance use?

Well, there are reward pathways in the brain which react and process substance use triggers and the associated emotional response. These pathways respond to the positive feelings associated with substance use and strengthen the more the substance is used, telling the brain to seek more. These pathways recognize triggers of substance use and respond by sending the “craving” to the frontal lobe. The frontal lobe determines whether or not the substance will be sought after, and if so, how the substance will be obtained and used.

When we think about individuals with brain injuries and associated cognitive and emotional challenges, we can see how if a person has difficulty with impulsivity, for example, then ignoring a craving may be more difficult than it would be pre-accident. In addition, when a person with a brain injury decides to engage in substance use, challenges such as poor planning and problem-solving may make the use even more unsafe.

Though we may not have evidence to connect brain injury to substance use directly, the cognitive changes in the brain are likely to make managing, using and even recovering from substance use much more difficult.

So now that we have talked about how substance use behaviours and patterns may change after acquiring a brain injury, the question remains, What can be done to help an individual who has both a brain injury and problems with substance use?  This question will be answered in part 2 of our blog post: The Comorbidity of Substances and ABI – the Role of the OT…stay tuned!



Bjork, J. M. & Grant, S. J. (2009). Does traumatic brain injury increase risk for substance abuse. Journal of Neurotrauma, 26, 1077 – 1082.

Ilie, G., Adlaf, E. M., Mann, R. E., Ialomiteanu, A., Hamilton, H., Rehm, J.,… Cusimano, M. D. (2015). Associations between a history of traumatic brain injuries and current cigarette smoking, substance use, and elevated psychological distress in a population sample of Canadian adults. Journal of Neurotrauma, 32, 1130 – 1134.

West, S. L. (2011). Substance use among persons with traumatic brain injury: A review. Neurorehabilitation, 29, 1 – 8.

WETA. (2017). Facts about concussion and brain injury. Retrieved from


Book Review: Licit, Illicit, Prescribed – Substance Use and Occupational Therapy

Julie Entwistle, MBA, BHSc (OT), BSc (Health / Gerontology)

As an occupational therapist working in private practice, I have been involved with many clients who have substance abuse issues sometimes before, but more so often after injury or trauma.  Sometimes these substances were prescribed and become misused, and sometimes clients turn to substances to cope with their new life circumstance.  Either way, it is essential that the OT role include understanding, assessing and treating the whole person while recognizing the role addiction can play in influencing a recovery path and overall function.

Released in 2016, the book Licit, Illicit, Prescribed by Dr. Niki Kiepek is an all-in-one resource to help Occupational Therapists to advance their foundational knowledge and practices skills when working with clients who have problems with substance abuse.

This book is so thorough at addressing the very complicated clinical facets of substance use and abuse that it could very readily become a textbook for OT’s in their schooling, job-training, and ongoing clinical work.  It starts by providing the important background into the occupational perspective on substance abuse and links this to the models of human occupation and engagement that are the essential backbone of our profession.   It then moves to really define addiction and the many factors that influence this and how it fits with models of health and behavior.  After a very detailed look at psychoactive substances and their pharmacological properties, and the concept of harm reduction, it dives deep into Occupational Therapy Assessment and Intervention. Complete with clinical scenarios, examples and direct techniques, any OT reading this book will be able to elevate their practice and work with clients who use substances – licit, illicit or prescribed.