Psychiatric perspectives on substance use

Canadians with high risk substance use or substance use disorders and co-occurring psychiatric disorders often experience persistent and recurrent difficulties that interfere with multiple aspects of their lives. The presence of both a substance use disorder and a psychiatric diagnosis is termed Concurrent Disorders. The majority of patients admitted to inpatient psychiatry acute settings and in the ER have complex concurrent disorders.

Despite frequently presenting for care, a lack of integration and continuity, insufficient availability of appropriate programs, and a lack of adequate training results in these patients often not receiving the care they need, perpetuating their problems at great cost to themselves and Canadian society.

Research tells us that the best outcomes for individuals with co-occurring psychiatric and substance use disorders are from integrated, comprehensive, progressive, and evidence-based services. All psychiatric trainees and practitioners encounter people with substance use disorders co-occurring with their psychiatric disorders with sufficient frequency that their presence must be anticipated in all practice settings and skill sets developed to be able to help them. It is crucial that care is engaging, understanding, hopeful, culturally sensitive and meets the person at the stage of change that they currently are at, to hopefully facilitate their recovery. Barriers to care need to be eliminated. Each disorder should receive specific and individualized treatment,

but in an integrated fashion that is responsive to the patient and their support system. Care needs to be ongoing and progressive, aiming for functional recovery.

Psychiatrists have skill sets that set them apart from other health care practitioners. They have extensive psychotherapy training and are used to trying to engage people in care who often have encountered institutional barriers to care, negative prior interactions with the system, and/or limited insight into their condition. Addiction psychiatry further expands on this unique set of skills with a particular knowledge, expertise, attitudes, and interest focused on high- risk substance use, substance use disorders and behavioural addictions. High-risk substance use and concurrent mental illness are health problems at the very centre of the clinical, academic and educational responsibility of addiction psychiatry. The expertise and interdisciplinary cooperation required to address the complex and unique needs of these patients requires subspecialist skill sets to provide the highest level of care to meet patient needs at all stages and in all settings of care, and with a high degree of expertise.

Based on the problems to address and the challenges for the system of care, addiction psychiatry needs to be in the focus of psychiatric training, research and health care system development.

Vision

➤

Promote comprehensive and high quality evidence-based practices for substance use disorders with co-occurring psychiatric disorders.
➤

Translate and disseminate evidence-based research to improve clinical practice and patient outcomes for those suffering from substance use disorders with co-occurring psychiatric disorders.
➤

Enhance training and foster careers in addiction psychiatry.
➤

Promote informed Canadian public policy for substance use disorders and co-occurring psychiatric disorders based on comprehensive and high quality evidence-based practices.
➤

Promote prevention, harm reduction, integration of addiction treatment, and recovery across the lifespan for people with high risk substance use, substance use disorders and co-occurring psychiatric disorders.
➤

Promote research on the etiology, prevention, identification and treatment of substance use and co-occurring psychiatric disorders.

Challenges to Address

High-risk substance use and co-occurring psychiatric disorders are a major challenge in society and, in particular, to the health care system given its impact on emergency departments, acute care services, and outpatient resources. Heightened morbidity and mortality of this patient group has reached historic levels and there is urgency for the health care system to respond in a manner that addresses all aspects of patient care to improve outcomes. It is evident that approaches that exclude the unique skill sets and attitudes of psychiatry have been inadequate. Psychiatry needs to address the following challenges:

Expertise development from medical school to a psychiatric subspecialty

The care for patients with substance use and psychiatric disorders needs specialized knowledge and training to change current systems. Leadership in addiction psychiatry is required to facilitate change and improvements in treatment outcomes. Expertise development requires advocacy and leadership in training in addiction psychiatry for medical students, residents, practicing physicians, and other health care providers. Establishing standards for training in addiction psychiatry will help build towards subspecialty status for addiction psychiatry.

Capacity building and resource allocation and innovation throughout an expanding clinical trajectory

Increasing quality of care needs to be made accessible throughout Canada, from urban to remote areas. Virtual care and online resources need to be expanded as well as specialized tertiary services to cover the needs of the patients including special needs related to age and specific risk constellations.

Health care system development, institutional support, policies and guidelines

The interdisciplinary collaboration and synergy of care between providers, disciplines and institutions creating an integrated system and coherent model is the foundation of a functioning clinical pathway required for best possible outcomes, especially in the times of a public health crisis in addiction and mental health. Psychiatrists need to be actively involved along side individuals with lived experiences to support decision making processes impacting those with substance use and psychiatric disorders.
Policies and guidelines need to be developed and implemented addressing the often neglected psychiatric components of care, based on the expertise and experience of addiction psychiatry guided by clinical and scientific evidence as a critical tool.

Clinical research with impact on outcomes

Research and innovation in this area needs to be expanded. More effective interventions are possible if there is systematic clinical research led by addiction psychiatry. Based on the experience with COVID we learned about the critical role of interventional and health care system research to inform the response to current and future challenges. We need to increase research capacity, involvement of psychiatrists and trainees, and strengthen support within our universities and funding agencies.

Stigma and neglect

Patients with substance use and psychiatric disorders are highly stigmatized and neglected within society and our healthcare system. Even healthcare professionals often avoid providing care for this highly vulnerable group. Psychiatry has the knowledge, skills, and attitudes required to best help those with substance use and psychiatric disorders and make them a priority based on their high risk of mortality and multi-morbidity. Health professionals should know better and we should contribute to openness, empathy and professionalism.

The current public health emergency based on the opioid overdose crisis and a historic mortality due to a mental illness is a critical challenge. We all need to step up our response through:

Research on the root causes, risks and effective interventions, strengthening infrastructure and funding. The existing patterns of use and disastrous consequences require and adaptation to the situation, like in a pandemic.
Engagement with high – risk patients to building on their needs early. Following positive experiences in other parts of care, we need early intervention structures and interventions.
A clinical trajectory providing the framework from prevention, lifestyle mentoring to counselling and early intervention to an intense crisis management with easy access, virtual care and patient empowerment.
Specialty interventions for the most vulnerable informed by scientific evidence.

The Canadian Academy for Addiction Psychiatry (CAAP) wants to attract every engaged professional in the field to strive towards outcome oriented collaboration to achieve high quality care and synergy caring for the most vulnerable.

Executive Structure and Committees

CAAP’S Executive Membership comprises a Board of Directors and four specialized committees, each dedicated to addressing critical gaps and challenges in the fields of addictions and psychiatry. These committees are united by a shared mission: to foster collaboration and drive transformative, harmonious change in these historically fragmented disciplines. By harnessing the diverse expertise of their members, CAAP is carving out a unique niche within the Canadian healthcare landscape. This innovative approach is designed to deliver high-quality, outcome-oriented care for the most vulnerable populations - those living with concurrent mental health and substance use disorders. Through collective efforts, CAAP is committed to making a lasting impact and improving the lives of those they serve.