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An Epidemic of Incompetence: A Critical Review of Addictions Curriculum in Canadian Residency Programs

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Anees Bahji at University of Calgary
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This article was migrated. The article was marked as recommended. In Canada and the United States, the rising number of apparent opioid-related deaths have given to the aptly-named opioid epidemic. Despite the criticism physicians have received for their role in opioid overprescribing, physicians may very well be in the position to vanquish the opioid epidemic. While the importance of the importance of Addictions training in psychiatry and other disciplines has been recognized in Canada at a national level, training resources are scarce and difficult to implement, even when delivered in online formats. Many have speculated that the delivery of high-quality Addictions training has been hampered by multiple roadblocks endemic to the Canadian medical education system, particularly stigma towards individuals with substance use disorders. In navigating the winds of change in the Competency-Based Medical Education (CBME) era, it remains unclear how Addictions will be embraced. To date, there are no defined addictions competencies in the Canadian CBME infrastructure, despite the critical findings of the Association of Faculties of Medicine report in 2017, which was generated in response to the opioid epidemic. Despite these challenges, those who struggle with addiction can lead full, happy, productive lives if they have the right resources. With time, we can only hope that the increasing visibility of addiction will translate to improved training and curricula for the next generation of physicians.
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Review of the literature Open Access
An Epidemic of Incompetence: A Critical Review of
Addictions Curriculum in Canadian Residency
Programs
Anees Bahji[1]
Corresponding author: Dr Anees Bahji anees.bahji@gmail.com
Institution: 1. Queen's University
Categories: Comparative Medical Education, Students/Trainees, Postgraduate (including Speciality Training),
Curriculum Evaluation/Quality Assurance/Accreditation, Undergraduate/Graduate
Received: 21/11/2018
Published: 03/01/2019
Abstract
In Canada and the United States, the rising number of apparent opioid-related deaths have given to the aptly-named
opioid epidemic. Despite the criticism physicians have received for their role in opioid overprescribing, physicians
may very well be in the position to vanquish the opioid epidemic. While the importance of the importance of
Addictions training in psychiatry and other disciplines has been recognized in Canada at a national level, training
resources are scarce and difficult to implement, even when delivered in online formats. Many have speculated that
the delivery of high-quality Addictions training has been hampered by multiple roadblocks endemic to the Canadian
medical education system, particularly stigma towards individuals with substance use disorders. In navigating the
winds of change in the Competency-Based Medical Education (CBME) era, it remains unclear how Addictions will
be embraced. To date, there are no defined addictions competencies in the Canadian CBME infrastructure, despite
the critical findings of the Association of Faculties of Medicine report in 2017, which was generated in response to
the opioid epidemic. Despite these challenges, those who struggle with addiction can lead full, happy, productive
lives if they have the right resources. With time, we can only hope that the increasing visibility of addiction will
translate to improved training and curricula for the next generation of physicians.
Keywords: Humans; United States; Canada; Education, Medical; Curriculum; Analgesics, Opioid; Behavior,
Addictive; Substance-Related Disorders; Psychiatry
Background
In Canada and the United States, the rising number of apparent opioid-related deaths have given to the aptly-named
opioid epidemic (Government of Ontario, 2016; Health Canada, 2018). The significant abuse potential of opioids
and the ever-increasing prevalence of high potency opioids, such as heroin, fentanyl and its derivatives, have been
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named as key drivers of the opioid epidemic (Bahji and Bajaj, 2018). However, with growing certainty, research has
indicated that inappropriate prescribing of opioids in vulnerable individuals may underlie a large proportion of
opioid overdose fatalities (Butler et al., 2016; Health Quality Ontario, 2018). As a result of this finding, physicians
have come under fire from multiple sources for their contributions to the current opioid crisis.
Addictions Training in Psychiatry
Despite the criticism we have received, physicians may very well be in the position to vanquish the opioid epidemic.
Fortunately, the evidence is quite clear that problematic substance use is a health condition that can be managed and
treated effectively (U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, 2012).
However, as the delivery of evidence-based care in Addictions demands a specific and exquisitely-complex skill set,
many have turned to psychiatry for guidance (American Academy of Addiction Psychiatry, 2018; Shorter and
Dermatis, 2012). During psychiatric training, we gain an unprecedented amount of exposure to a highly stigmatized
patient population, which encourages the development of nonjudgmental attitudes towards individuals from all
walks of life. We also gain the ability to screen and diagnose a selection of complex mental disorders and are able to
utilize these skills to support a population of patients that are perhaps the most challenging in all of medicine. As
well, our proficiency with biopsychosocial formulation, our knowledge of complex pharmacotherapy, our expertise
with multiple modalities of psychotherapy, and our burgeoning utilization of evidence-based psychiatry equip us
with a full armamentarium for individuals with complex, severe, and persistent forms of mental illness, including –
but not limited to – substance use disorders. In some ways, the practice of psychiatry embodies the belief that the
opposite of Addiction is not abstinence, but connection (Hari, 2015).
Fortunately, the importance of Addictions training in psychiatry has been recognized in Canada at a national level. In
2015, the Canadian Psychiatric Association (CPA) released a two-part position paper, which specifically outlines
training in Addictions (Crockford et al., 2015; Fleury et al., 2015). In the first part (Supplementary Table 1), the
authors provided an overview of training, defining six domains of competence in Addictions, and made six
recommendations for how these ought to implemented in Canadian psychiatric residency programs. In the second
part (Supplementary Table 2), the authors updated the Addictions training objectives and provided detailed
recommendations for the clinical and seminar content in the Addictions curriculum. Overall, the authors proposed
stage-specific competencies in Addictions, organized into knowledge and skills domains across the training
spectrum.
Barriers to Providing Addictions Training
Despite the dissemination of the CPA guidelines, the potential of psychiatry to spearhead the response to the opioid
epidemic has not yet been realized. In 2017, the Association of Faculties of Medicine of Canada reviewed the
accreditation standards for best practices of teaching in Addictions (as well as opioid prescribing and chronic pain
management) across all Canadian medical schools and residency programs. Expectedly, they found significant
heterogeneity, identifying diverse methodologies of teaching, curricula, and definitions of competency and divergent
pedagogies. In the postgraduate medical education category, none of the seventeen Canadian psychiatry programs
were deemed to be offering best practice standards in Addictions education (The Association of Faculties of
Medicine of Canada, 2017). Thus, while psychiatrists play a key role in the treatment of patients with Addictive
disorders, the next generation of psychiatrists is clearly not receiving training in Addictions.
Not surprisingly, physician surveys have identified that the majority report a lack of confidence in working in the
area of Addictions (O’Gara et al., 2005). Logically, it would follow that Addictions training should be clinically
grounded to alleviate these perceived low levels of reported clinical training and the resulting lack of confidence.
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Unfortunately, while many have suggested that medical students, residents, and allied health practitioners (such as
nursing students and practicing nurses) be provided with more resources so that they can acquire the key concepts
and skills in Addiction, resources are scarce and difficult to implement, even when delivered in online formats.
Some have speculated that the delivery of high-quality Addictions training in psychiatry has been hampered by
multiple roadblocks endemic to the Canadian medical education system (van Boekel et al., 2013). Although illness
of any kind need not define an individual, mental and physical illnesses are often regarded differently, and nowhere
is that more apparent than in Addictions. A recent systematic review found that negative attitudes of physicians
towards patients with substance use disorders were not only highly prevalent, but also a key contributor to
suboptimal health care delivery for these patients (van Boekel et al., 2013). Thus, the undue propagation of stigma
towards Addictions is a likely culprit.
However, the inherent characteristics of Addictions also contribute to the difficulties in providing high-level training
to the next generation of physicians. For example, the inherent multidisciplinary and interprofessional demands of
Addictions mean that it is impossible to assign a single discipline or role to accept the full responsibility of its
management. Yet, society has encouraged Addictions scapegoating in the wake of the opioid epidemic, with an
expectation that at a certain point, someone (or something) will be held accountable for the ‘problem’. Furthermore,
the complexity of Addictions is often difficult to align with the conventional model of medical education, which has
often led to the inappropriate distillation to "substance use disorders" or "screening for red flags".
These issues may be propagated further by the current infrastructure of subspecialty training in Canada and the
United States, where there are two competing medical disciplines dedicated to Addictions – Addiction Medicine and
Addiction Psychiatry. In the United States, the former receives recognition from the Addiction Medicine
Foundation and the American Society of Addiction, while the latter is governed by the Accreditation Council for
Graduate Medical Education and the American Academy of Addiction Psychiatry. In Canada, Addiction Psychiatry
is not yet a Royal College-recognized discipline in the way that Geriatric, Child, or Forensic Psychiatry are. While it
is important to create training pathways in Addictions, this divergence suggests there is a substantive distinction
between Addiction Medicine physicians and Addiction Psychiatrists that does not exist. Leading specialists in both
disciplines agree on the definition of Addiction and that its treatment is both an art and a science, which requires a
multidisciplinary approach. Despite this extensive accord, practitioners of each draw sharp distinctions between
Addiction Medicine and Addiction Psychiatry to serve historical, economic, and professional interests, revealing the
importance to both disciplines of recognition from their distinctive colleges, and thus, jurisdiction over the medical
treatment of addiction.
Despite this, the findings of some key ethnographic research studies have been particularly staggering. For example,
in Philadelphian studies of patients who interviewed about their experience with the health care system by outreach
nurses, one man said "I don’t want to live under the bridge, but I can’t stop. I don’t know how to access treatment…I
don’t have internet…I don’t have phone" (Carlson et al., 2009). These findings suggest that providers may be
unfamiliar with the sociodemographic factors that patients inevitably return to upon discharge from hospital, which
exponentially increases the odds of recidivism. This, then, informs the so-called vicious cycle of addiction
(Mazhnaya et al., 2016).
Additional barriers lie in bureaucracy around access to Addictions treatments. For example, while physicians must
receive extensive training and certification before they are able to prescribe opioid agonist therapies (like methadone
and buprenorphine), similar requirements are not currently in place for the prescription of other controlled
substances, such as psychostimulants, benzodiazepines, and even other opioids (like fentanyl). This discrepancy
discourages training in and pursuit of clinical work in Addictions, which is already heavily steeped in stigma from
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multiple levels.
Unfortunately, internalized stigma towards Addictions exists within psychiatry, too. Historically, the relationship
between psychiatry and addictions has been complicated by divergent ideologies and attitudinal beliefs and has
resisted the inclusion of Addictions in the Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 2013). Although there is a gradual move towards integrated care, the remnants of a
longstanding tradition that Addiction is not truly a psychiatric illness persist, even today (Avery et al., 2017; Gertler
and Ferneau, 1974; Kochański and Cechnicki, 2017). For example, we still refer to Addictive disorders as
‘concurrent’, which implies that the substance use is a separate – or non-psychiatric – entity (Danda, 2012). While
psychiatry is one – if not the only – discipline that aims to formally incorporate Addictions into its training
curriculum (Royal College of Physicians and Surgeons of Canada, 2015), few psychiatrics manage patients with
Addictive disorders (Kochański and Cechnicki, 2017). Thus, the division between Addictions and psychiatry is ever
present.
The Relationship between CBME and Addictions
In navigating the winds of change in the Competency-Based Medical Education (CBME) era, it remains unclear how
Addictions will be embraced (Khenti et al., 2017). To date, there are no defined Addictions competencies in the
Canadian CBME infrastructure, despite the critical findings of the AFMC report in 2017 (The Association of
Faculties of Medicine of Canada, 2017). With that in mind, the multidisciplinary and inherently complex nature of
Addictions makes it difficult to generate an entrustable professional activity or discipline-specific tasks. However,
simplified Addictions EPAs, such as ‘management of substance use disorders’ and ‘management of substance
intoxication and withdrawal’, have been created in other countries (The Royal Australiand and New Zealand College
of Psychiatrists, 2012: 3). This suggests that there are possibilities of applying the CBME model to Addictions, even
though it may not efficiently address the full breadth of Addictions. If created, this may staunch ongoing criticism
that the medical profession has divorced competence from promotion (Prost, 2018).
Surveys of trainees in Addictions Fellowship Programs have identified preferred curricula. For example, reflection
techniques were endorsed as extremely valuable by students, especially in the development of professional attitudes
that will help clinicians effectively engage and provide appropriate care for individuals suffering from Addictive
disorders. These reflective practices could be used more extensively in psychiatric training in order to build and
establish reflexive self-awareness as a core professional competence, which is essential to working effectively in
clinical practice, especially in the most demanding contexts (Ballon and Skinner, 2008).
The Future of Addictions: Interdisciplinary Collaboration
As the management of Addictions is a multidisciplinary endeavor, provision of care for individuals with Addictive
should be a shared responsibility between physicians and health care providers of diverse backgrounds. Several
organizations have made concerted efforts to promote addictions stewardship and education among multiple
specialties (Lagisetty et al., 2017; MetaPHI, 2017; Ng, 2018). Mentoring, Education, and Clinical Tools for
Addiction: Primary Care-Hospital Integration (META:PHI) is one such example. META:PHI is a provincial
initiative based out of Women’s Hospital in Toronto and is mandated to support health care providers in treating
individuals struggling with addiction. They provide free open-access information about models of addiction care,
clinical addiction tools for health care providers, resources for patients, and information about rapid access addiction
medicine (RAAM) clinics across the province.
As innovative approaches to Addictions are desperately needed, interdisciplinary collaboration will be key.
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Collaboration with public health specialists, epidemiologists, and community services may very well be the missing
piece in addressing the educational deficiencies in Addictions. By exploring patterns of Addictions-related health
service use at population and community levels, this will enable our medical education system target and address its
own deficiencies. Collaboration between provincial and local health organizations can address challenges in
operationalizing Addictions services, such as RAAM clinics. Collaboration with knowledge translation agencies, like
the Canadian Society of Addiction Medicine, will be helpful in disseminating the evidence-based in Addictions and
in unifying our approaches to national issues, such as position papers regarding the implications of the recent
legalization of cannabis (Fischer et al., 2017; Tibbo et al., 2018). Collaboration between hospitals and academic
institutions will identify the most cost-effective interventions to maximize finite resources, and can address the local
impacts of Addiction; for example, Addictions training on the psychiatric management of bacterial endocarditis
related to injection drug use has enabled local cardiac surgeons to be more aware of addictions and understand
addictions a bit better (Yanagawa et al., 2018).
Reducing Harm by Reducing Stigma
Ideally, we should respond to Addiction in a manner akin to cancer, where recovery is celebrated and even
encouraged, and the individual is not blamed for their current state. Admittedly, individuals with Addictive disorders
often cut an intimidating figure – with a formidable combination of psychosocial shortcomings, medical frailties,
and bold personalities, and often, this rationalizes stigma. But ultimately, they are still regular people, as are addicted
women who become pregnant – they have the same right to a healthy pregnancy as any other woman and could do
without incessant reminders that they are morally bereft. But physicians are people too, and we must be kind to each
other if we are to move forward. We increasingly understand that removing the stigma associated with Addictions is
a timely solution as the humanity we all share is more important the illness we may not. The American Society of
Addiction Medicine has posted extensively about stigma on their website, which is informed by the findings of
international research, such as the decriminalization of illicit drugs in Portugal (Laqueur, 2015). Such harm
reduction programs have unequivocally demonstrated that stigma can be reduced by focusing on rehabilitation,
which Canada has emulated with the recent legalization of cannabis. Harm reduction approaches like these respects
the frailties of the human condition and acknowledges that unwanted outcomes still happen even with best intentions
and best services. However, harm reduction is the first step on the continuum of Addictions recovery, which also
includes prevention, treatment, post-treatment, reintegration into society, and ways to inspire others.
There is a tremendous need to implode the myths of Addiction – to put a face on it and to show people that having
an Addiction does not have to lead to a painful and oblique life. In recent years, there is a move to recovery capital
— the lifelong journey of self-treatment and discipline that guides many Addictions programs. However, the idea
remains controversial as managing a severe mental illness is more complicated than simply avoiding certain
behaviours. In the words of Elyn Saks, "approaches include medication (usually), therapy (often), a measure of good
luck (always) — and, most of all, the inner strength to manage one's demons, if not banish them. That strength can
come from any number of places: love, forgiveness, faith in God, a lifelong friendship" (Saks, 2014).
Conclusion
Despite these challenges, those who struggle with addiction can lead full, happy, productive lives if they have the
right resources. With time, we can only hope that the increasing visibility of addiction will translate to improved
training and curricula for the next generation of physicians.
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Take Home Messages
In Canada and the United States, the rising number of apparent opioid-related deaths have given to the aptly-
named opioid epidemic; physicians have come under fire from multiple sources for their varying
contributions to the current opioid crisis.
Delivery of optimal addictions education and training for the next generation of physicians is hampered by
multiple barriers, including stigmatized views towards patients with substance use disorders, the inherently
complex demands of patients who struggle with addiction, current infrastructure of subspecialty training
which lacks clearly defined roles for training in addictions, and administrative roadblocks to the provision of
evidence-based addictions therapies.
In navigating the winds of change in the Competency-Based Medical Education (CBME) era, it remains
unclear how Addictions will be embraced; to date, there are no defined Addictions competencies in the
Canadian CBME infrastructure.
As the management of Addictions is a multidisciplinary endeavor, provision of care for individuals with
Addictive should be a shared responsibility between physicians and health care providers of diverse
backgrounds.
Ideally, we should respond to Addiction in a manner akin to cancer, where recovery is celebrated and even
encouraged, and the individual is not blamed for their current state.
Despite these challenges, those who struggle with addiction can lead full, happy, productive lives if they have
the right resources.
Notes On Contributors
Dr. Anees Bahji is a PGY4 resident in the Department of Psychiatry at Queen's University. He is also enrolled in
the Clinician Investigator Program (CIP) at Queen's University, where he is pursuing a concurrent MSc in
Epidemiology in the Department of Public Health Sciences. His primary clinical and research interests are evolving,
but he has a special interest in addictions, mental health stigma, concurrent disorders, and psychiatric epidemiology.
Anees Bahji: https://orcid.org/0000-0002-3490-314X
Acknowledgements
None.
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Appendices
None.
Declarations
The author has declared that there are no conflicts of interest.
This has been published under Creative Commons "CC BY 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)
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... The adoption of this recommendation is essential within the Canadian healthcare system. In 2015, the Canadian Psychiatric Association (CPA) released specific guidelines on how addiction should be taught, outlining six areas of critical competence(Bahji, 2019). The Canadian curriculum was then amended to incorporate these proficiencies. ...
... Despite this update, a 2017 review of all medical schools and residency programs in Canada, completed by the Association of Faculties of Medicine of Canada (AFMC), revealed that the programs were inadequate and failed to fulfil the standards set by the CPA. The AFMC also reviewed all 17 post-graduate psychiatry programs and discovered that none of the courses provided addiction information that met the criteria for best practice (AFMC, 2017, as cited byBahji, 2019).In a survey provided to Ontario nursing students in their final year of study, only 4.5% of participants displayed adequate knowledge of when opioids should be used for pain, and few held positive attitudes toward PWUD(Hrock et al., 2019). Furthermore,Fowler et al. (2020) found that paediatric doctors in Canadian EDs were minimally concerned about addiction when prescribing opioids to youth. ...
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  • Sep 2023
This paper explores the stigmatization of drug users in Canada and its impact on the opioid epidemic. The study particularly focuses on how British Columbia, heavily affected by the crisis, responded by decriminalizing opioids. The research aims to uncover Canadian attitudes towards drug use and the basis of these attitudes. It also investigates whether educational interventions can positively change these stigmatizing attitudes. The study involved 145 participants, mainly from British Columbia and Saskatchewan. Key findings indicate that concern for personal safety, gender, age, familiarity with substance abuse, and religion are significant predictors of stigmatizing drug use. Importantly, educational vignettes used in the study positively influenced participants, suggesting that education could effectively address stigmatization. These findings are critical for understanding public opinion's role in shaping drug policies. The study underscores the importance of addressing stigmatization to improve public health responses to the opioid crisis and the potential of decriminalization in reducing stigma. It also highlights the economic implications of the crisis, considering the costs associated with healthcare and the criminal justice system.
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... We organized study findings into tables according to the PICOS framework (Methley et al., 2014). Our review's methods were consistent with previous narrative reviews with addiction themes (Bahji, 2019;Bahji et al., 2020;Bahji andBajaj, 2018, 2019;Bahji and Mazhar, 2016;Bahji and Stephenson, 2019). ...
... We organized study findings into tables according to the PICOS framework (Methley et al., 2014). Our review's methods were consistent with previous narrative reviews with addiction themes (Bahji, 2019;Bahji et al., 2020;Bahji andBajaj, 2018, 2019;Bahji and Mazhar, 2016;Bahji and Stephenson, 2019). ...
Misuse and dependence of dimenhydrinate: A mixed studies systematic review
Article
  • Oct 2020
  • J PSYCHIATR RES
Background Dimenhydrinate (DMH) is an antihistamine used to treat nausea and vomiting. Although widely available in pharmacies as an over the counter medication, there have been reports of potential DMH tolerance and dependence and a possible euphoric potential accompanying heavy use (>100 mg/day). Despite the potential for misuse, there is a gap in the literature concerning patterns, characteristics, and potential mechanisms of DMH misuse. Aims This review aimed to synthesize evidence on the pharmacology, clinical effects, and management of DMH misuse and dependence to inform clinical decision making and relevant drug policy. Methods We conducted a systematic review in accordance with the PRISMA guidelines and using Cochrane collaboration methods. We searched seven databases from their inception through July 2019. To be included in the review, studies needed to measure or focus on one or more dimensions of morbidity or mortality related to the misuse of DMH. Quantitative, qualitative and mixed-method studies were included in order to capture the breadth of possible studies. Studies were excluded if they did not fit into the conceptual framework of the study of if they focused primarily on the misuse of other substances. A narrative synthesis of study findings was pursued given the limited capacity for a quantitative meta-analysis. Findings We identified 24 studies, which described a range of neuropsychiatric sequelae related to DMH consumption, including seizures, psychosis, depression, intoxication (resembling anticholinergic syndrome) and withdrawal. The sedative and euphoric properties, readily available nature, and low cost of DMH appear to facilitate DMH dependence, which were more commonly reported among individuals who had concurrent psychiatric disorders, displaying symptoms such as low motivation, poor concentration, and delirium. The overall quality of studies identified by this review was low—largely because the majority of studies were case reports or review articles, with few intervention or cohort studies. Conclusions There is some evidence to suggest the existence of DMH-related syndromes involving intoxication, withdrawal, and dependence, more commonly among long-term, heavy DMH consumers. However, higher quality studies are needed to confirm preliminary findings that there may be a biological basis for such syndromes.
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... Although there was insufficient homogeneity to enable meta-analysis, we summarized findings across studies by describing their population, intervention, comparison, outcome, and design features as per previous descriptive reviews in addiction medicine (Bahji, 2019;Bahji & Bajaj, 2018Bahji et al., 2021). ...
Neurobiology and Symptomatology of Post-Acute Alcohol Withdrawal: A Mixed-Studies Systematic Review
Article
  • Jul 2022
  • J STUD ALCOHOL DRUGS
Objective: This study aims to review the neurobiology and symptomatology of post-acute alcohol withdrawal syndrome (PAWS). Method: We conducted a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-guided systematic review of articles from two databases for English-language randomized and nonrandomized studies involving PAWS published between database inception and December 2020. Results: Twenty-seven studies met inclusion criteria. PAWS involves predominantly negative affect, which develops in early abstinence and can persist for 4-6 months or longer. Symptoms include anxiety, dysphoria, anhedonia, sleep disturbance, cognitive impairment, cravings, and irritability. PAWS symptoms appear to be risk factors for recurrent alcohol consumption. They have been associated with reported neurobiological differences in evoked potentials; measures of orexins, cortisol, serotonin, and pancreatic polypeptides; and neuroadaptation changes in the nucleus accumbens and the prefrontal cortex. Conclusions: There is credible evidence to support the concept of PAWS based on this review's findings. There remains a need to develop and test specific criteria for PAWS. High-quality treatment studies involving agents addressing its neurobiological underpinnings are also recommended.
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... [6][7][8] As most clinicians consider psychiatrists experts in mental illness and addictions, this discrepancy between professional responsibility and real-world practice points to a systemic problem in psychiatry residents' training. 9 The recognition of this unfortunate reality has mobilized attention and action among medical education experts, leading to increased addiction training opportunities. While psychiatry programs are only mandated to dedicate 1 month of training to addictions, increasingly, programs are expanding the focus of activity. ...
Concurrent Disorders Management in Psychiatric Care: Opportunities and Challenges
Article
  • Sep 2021
Despite increased awareness of the prevalence and burden of substance use disorders, there is limited access to addiction treatment services in Canada, including in psychiatric settings. While substance use disorders are highly comorbid and confer a poorer prognosis on psychiatric illnesses, psychiatric services are often ill-equipped in managing comorbid addictions. While there has slowly been an increase in recognition of this deficit in psychiatric training, there continues to be a deficit in concurrent disorder services in psychiatric care. A potential strategy to address this gap in clinical services is a concurrent disorder consult model. Herein, we outline a model for improved access to addiction treatment in psychiatric care and outline considerations for developing concurrent disorder consult services.
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... While not ideal, the current EPAs represent a good start. Still, given the increasing demands for addiction competency for Canadian psychiatrists, 70,71 better mapping of the EPAs onto identified competencies is required. This is how competency is determined for the specific EPAs. ...
Towards competency-based medical education in addictions psychiatry: a systematic review
Article
Full-text available
  • May 2021
Background: Current curriculum guidelines for addiction training in psychiatry need to be adapted to the competency by design framework to integrate clinical skills in addiction. Objective: We conducted a systematic review to identify curricular and educational interventions to build competency among psychiatry residents and fellows in addiction psychiatry. Methods: We followed the PRISMA guidelines, searching five databases from inception to August 2020 for relevant evaluation-type studies exploring addiction psychiatry competency among psychiatry residents and fellows. We appraised study quality using the Joanna Briggs Institute's risk of bias tool for observational designs. Results: From 1600 records, 17 studies met inclusion criteria. Addiction psychiatry competencies spanned themes involving core knowledge development; attitudinal, communication and leadership skills; screening, assessment, diagnosis; management; and special populations. Examples of effective educational interventions to enhance addiction competency include specific modules for substance use disorders and integrated clinical rotations that simultaneously combine multiple types of skills. Lived experience improved trainee attitudes towards addiction psychiatry. Conclusions: While there is current evidence supporting strategies for developing competency in addiction psychiatry, the lack of studies measuring sustained competence over a longer-term follow-up period and the absence of randomized controlled trials limit the overall strength of evidence in this review. Current psychiatry entrustable professional activities (EPAs) involving addiction only partly overlap with curriculum training guidelines and studies identified in this review. These EPAs need to be better identified for training programs, competence in those EPAs better delineated for residents and preceptors, and evaluations should be done to ensure that adequate competence in addictions is attained and sustained.
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... Ein anderer Ansatz zielt auf die Aus-und Weiterbildung des Fachpersonals im Gesundheitswesen. Es geht darum, alle Themen im Zusammenhang mit psychoaktiven Substanzen, ihrem Konsum und der Entwicklung von Abhängigkeit sowie der Behandlung von Menschen mit Suchtproblemen besser in der Ausbildung von Studierenden der Medizin, der Pflege, der Sozialen Arbeit und anderer einschlägiger Berufsgruppen fest zu verankern (z.B. Bahji, 2019;Crockford et al., 2015;Fleury et al., 2015;Hoffmann et al., 2020;Lancaster et al., 2018;Rapid Response Service, 2018;Schomerus et al., 2017;Singleton, 2011;Strobel et al., 2012). ...
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... The overall overdose-specific CMR was 6 overdose deaths per 1000 PY of follow-up (95% CI, 5-7 deaths per 1000 PY). Again, mortality rates were substantially higher among methadone users (CMR = 6 overdose deaths per 1000 PY, 95% CI, 5-7) than buprenorphine users (CMR = 3 overdose deaths per 1000 PY, 95% CI, [3][4]. ...
Reduction in Mortality Risk with Opioid Agonist Therapy: A Systematic Review and Meta‐Analysis
Article
  • Aug 2019
Introduction: Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in- and out-of-treatment. Objective: This systematic review and meta-analysis explored the association between methadone or buprenorphine with cause-specific mortality among opioid-dependent persons. Methods: We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in- and out-of-treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in-versus-out of treatment. Results: 32 cohort studies (representing 150,235 participants, 805,423.6 person-years, and 9112 deaths met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time in-treatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first four weeks of treatment. Mortality estimates were substantially heterogeneous, and varied significantly by country, region, and by the nature of the treatment provider. Conclusion: Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid tolerance, ongoing monitoring during the induction period, education of patients about the risk of overdose, and coordination within healthcare services.
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The Value of Hospitalization in the Opioid Epidemic: A Scoping Review
Article
  • Jun 2019
Background: Opioid use disorder (OUD) is a potentially chronic, relapsing condition associated with a great degree of morbidity and mortality. In Canada, OUD is at the forefront of the opioid epidemic, which has claimed more than 8000 lives between January 2016 and March 2018. As individuals with OUD are more likely to receive health services from the emergency department and acute hospitalizations, it makes logical sense for there to be a move toward improving the quality of hospital-based services. Hospitalization represents a golden opportunity to connect patients who have OUD with evidence-based treatments. Objectives: To evaluate the effectiveness and offering of hospital-based interventions for individuals with OUD by way of a scoping review. Data sources: Five online databases were searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Study selection: Randomized and nonrandomized intervention studies were considered eligible for inclusion in this scoping review. Results: Twenty two of 354 retrieved papers met inclusion criteria. Detoxification programs (n = 7), relapse prevention programs (n = 11), maternal–perinatal programs (n = 2), and combination programs (n = 2) were identified. Both interventions and outcome measures varied widely between studies, but the overall findings demonstrated the effectiveness of the interventions considered with regard to improved retention in treatment, reduction of illicit opioid use, and reduced hospital length of stay. Conclusions: The findings of our study demonstrate that there is a high degree of congruence between the effectiveness of interventions initiated in the community versus hospital-based treatments for individuals with OUD. Hospitalization represents a golden opportunity to connect patients who have OUD with evidence-based treatments.
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Towards a shared mental model of progressive competence in postgraduate medical education
Article
Full-text available
  • Jul 2018
Many professions have hierarchies and a promotion structure. Postgraduate medicine has a tradition of promoting residents based on time spent in a certain specialty. The military, too, may promote its personnel based on factors other than just merit. Both professions have been criticized for divorcing competence from promotion. While Competency-Based Medical Education (CBME) partly solves this problem in medicine, many models of CBME, including the Canadian one, retain distinct stages of training. We urgently need a shared mental model of what a learner in each stage looks like. Some models have been proposed but fall short.
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Opioids on Trial: A Systematic Review of Interventions for the Treatment and Prevention of Opioid Overdose
Article
Full-text available
  • Mar 2018
Background Canada is in the midst of an opioid epidemic. In 2016, there were more than 2800 apparent opioid-related deaths. Although improved access to naloxone has saved countless lives, it is unclear if there are other effective pharmacological or nonpharmacological interventions for the treatment and prevention of opioid overdose. In this systematic review, we aim to synthesize published findings on such interventions. Methods We searched 5 electronic databases for randomized controlled studies using either pharmacological or nonpharmacological interventions to treat or prevent opioid overdose, and subsequently extracted and synthesized data from appropriate studies. Results Twelve studies met our inclusion criteria. Naloxone, nalmefene, and physostigmine were effective in reversing opioid overdose, whereas naltrexone was effective in preventing opioid overdose. Opioid agonists, including methadone, buprenorphine, and diacetylmorphine, were effective in improving secondary outcomes with variable effects on overdose prevention. No trials using primarily nonpharmacological interventions were identified. Conclusions In this systematic review, naloxone, nalmefene, and physostigmine emerged as effective in treating opioid overdose, whereas naltrexone showed evidence in preventing opioid overdose. Opioid agonists were found to be effective in improving retention in treatment and in reducing illicit opioid use. Pharmacological interventions play a key role in addressing the opioid epidemic; however, evidence for a multidisciplinary approach involving harm reduction and addressing psychosocial barriers could be the topic of subsequent literature reviews.
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Endocarditis in the setting of IDU: Multidisciplinary management
Article
Full-text available
  • Dec 2017
Purpose of review: The purpose of this article is to provide a brief overview of the medical and surgical management of infective endocarditis secondary to IDU, with a focus on the underlying substance use disorder. Recent findings: Patients with infective endocarditis secondary to IDU are often young with unique comorbidities including mental illness, chronic hepatitis C, HIV infection, which are often compounded by limited social and familial supports. The focus of management has been treatment of endocarditis using IV antibiotics alongside surgery. Surgical outcomes compare favorably with those of infective endocarditis in the general population but long-term outcomes of IDUs are significantly worse. This is primarily due to the high rate of recidivism of drug use and the risk of prosthetic valve infective endocarditis. Contemporary management of addiction utilizes an integrative approach, combining both pharmacologic and nonpharmacologic strategies while remaining patient-centered. Given the complexity of care required, we advocate for a multidisciplinary team-based approach including psychiatry, infectious disease, cardiology, cardiac surgery and social services. Summary: Infective endocarditis secondary to IDU remains a medical and surgical challenge with dismal outcomes. Here we offer practical suggestions on the multidisciplinary management of this challenging and high-risk patient cohort.
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Mental health and addictions capacity building for community health centres in Ontario
Article
Full-text available
  • Oct 2017
  • CAN FAM PHYSICIAN
Problem addressed: In recent years, there has been increased recognition in Canada of the need to strengthen mental health services in primary health care (PHC). Collaborative models, including partnerships between PHC and specialized mental health care providers, have emerged as effective ways for improving access to mental health care and strengthening clinical capacity. Primary health care physicians and other health professionals are well positioned to facilitate the early detection of mental disorders and provide appropriate treatment and follow-up care, helping to tackle stigma toward mental health problems in the process. Objective of program This 4-year mental health and addiction capacity-building initiative for PHC addressed competency needs at the individual, interprofessional, and organizational levels. Program description The program included 5 key components: a needs assessment; interprofessional education; mentoring; development of organizational mental health and addiction action plans for each participating community health centre; and creation of an advanced resource manual to support holistic and culturally competent collaborative mental health care. A comprehensive evaluation framework using a mixed-methods approach was applied from the initiation of the program. A total of 184 health workers in 10 community health centres in Ontario participated in the program, including physicians, nurses, social workers, and administrative staff. Conclusion Evaluation findings demonstrated high satisfaction with the training, improved competencies, and individual behavioural and organizational changes. By building capacity to integrate holistic and culturally appropriate care, this competency-based program is a promising model with strong potential to be adapted and scaled up for PHC organizations nationally and internationally.
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Primary care models for treating opioid use disorders: What actually works? A systematic review
Article
Full-text available
Background Primary care-based models for Medication-Assisted Treatment (MAT) have been shown to reduce mortality for Opioid Use Disorder (OUD) and have equivalent efficacy to MAT in specialty substance treatment facilities. Objective The objective of this study is to systematically analyze current evidence-based, primary care OUD MAT interventions and identify program structures and processes associated with improved patient outcomes in order to guide future policy and implementation in primary care settings. Data sources PubMed, EMBASE, CINAHL, and PsychInfo. Methods We included randomized controlled or quasi experimental trials and observational studies evaluating OUD treatment in primary care settings treating adult patient populations and assessed structural domains using an established systems engineering framework. Results We included 35 interventions (10 RCTs and 25 quasi-experimental interventions) that all tested MAT, buprenorphine or methadone, in primary care settings across 8 countries. Most included interventions used joint multi-disciplinary (specialty addiction services combined with primary care) and coordinated care by physician and non-physician provider delivery models to provide MAT. Despite large variability in reported patient outcomes, processes, and tasks/tools used, similar key design factors arose among successful programs including integrated clinical teams with support staff who were often advanced practice clinicians (nurses and pharmacists) as clinical care managers, incorporating patient “agreements,” and using home inductions to make treatment more convenient for patients and providers. Conclusions The findings suggest that multidisciplinary and coordinated care delivery models are an effective strategy to implement OUD treatment and increase MAT access in primary care, but research directly comparing specific structures and processes of care models is still needed.
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Lower-Risk Cannabis Use Guidelines: A Comprehensive Update of Evidence and Recommendations
Article
  • Jun 2017
  • AM J PUBLIC HEALTH
Background: Cannabis use is common in North America, especially among young people, and is associated with a risk of various acute and chronic adverse health outcomes. Cannabis control regimes are evolving, for example toward a national legalization policy in Canada, with the aim to improve public health, and thus require evidence-based interventions. As cannabis-related health outcomes may be influenced by behaviors that are modifiable by the user, evidence-based Lower-Risk Cannabis Use Guidelines (LRCUG)-akin to similar guidelines in other health fields-offer a valuable, targeted prevention tool to improve public health outcomes. Objectives: To systematically review, update, and quality-grade evidence on behavioral factors determining adverse health outcomes from cannabis that may be modifiable by the user, and translate this evidence into revised LRCUG as a public health intervention tool based on an expert consensus process. Search methods: We used pertinent medical search terms and structured search strategies, to search MEDLINE, EMBASE, PsycINFO, Cochrane Library databases, and reference lists primarily for systematic reviews and meta-analyses, and additional evidence on modifiable risk factors for adverse health outcomes from cannabis use. Selection criteria: We included studies if they focused on potentially modifiable behavior-based factors for risks or harms for health from cannabis use, and excluded studies if cannabis use was assessed for therapeutic purposes. Data collection and analysis: We screened the titles and abstracts of all studies identified by the search strategy and assessed the full texts of all potentially eligible studies for inclusion; 2 of the authors independently extracted the data of all studies included in this review. We created Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow-charts for each of the topical searches. Subsequently, we summarized the evidence by behavioral factor topic, quality-graded it by following standard (Grading of Recommendations Assessment, Development, and Evaluation; GRADE) criteria, and translated it into the LRCUG recommendations by the author expert collective on the basis of an iterative consensus process. Main results: For most recommendations, there was at least "substantial" (i.e., good-quality) evidence. We developed 10 major recommendations for lower-risk use: (1) the most effective way to avoid cannabis use-related health risks is abstinence; (2) avoid early age initiation of cannabis use (i.e., definitively before the age of 16 years); (3) choose low-potency tetrahydrocannabinol (THC) or balanced THC-to-cannabidiol (CBD)-ratio cannabis products; (4) abstain from using synthetic cannabinoids; (5) avoid combusted cannabis inhalation and give preference to nonsmoking use methods; (6) avoid deep or other risky inhalation practices; (7) avoid high-frequency (e.g., daily or near-daily) cannabis use; (8) abstain from cannabis-impaired driving; (9) populations at higher risk for cannabis use-related health problems should avoid use altogether; and (10) avoid combining previously mentioned risk behaviors (e.g., early initiation and high-frequency use). Authors' conclusions: Evidence indicates that a substantial extent of the risk of adverse health outcomes from cannabis use may be reduced by informed behavioral choices among users. The evidence-based LRCUG serve as a population-level education and intervention tool to inform such user choices toward improved public health outcomes. However, the LRCUG ought to be systematically communicated and supported by key regulation measures (e.g., cannabis product labeling, content regulation) to be effective. All of these measures are concretely possible under emerging legalization regimes, and should be actively implemented by regulatory authorities. The population-level impact of the LRCUG toward reducing cannabis use-related health risks should be evaluated. Public health implications. Cannabis control regimes are evolving, including legalization in North America, with uncertain impacts on public health. Evidence-based LRCUG offer a potentially valuable population-level tool to reduce the risk of adverse health outcomes from cannabis use among (especially young) users in legalization contexts, and hence to contribute to improved public health outcomes. (Am J Public Health. Published online ahead of print June 23, 2017: e1-e12. doi:10.2105/AJPH.2017.303818).
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The attitudes of psychiatrists toward people suffering from mental illnesses in Poland.
Article
  • Feb 2017
Cel pracy Celem: pracy było zbadanie opinii polskich psychiatrów wobec osób chorujących psychicznie i porównanie ich z analogicznymi badaniami w populacji ogólnej. Metoda Badaną grupą byli polscy psychiatrzy. Zastosowano sondaż diagnostyczny wykorzystując kwestionariusz do samodzielnego wypełnienia. Analizie poddano 232 ankiety.. Wyniki Wyniki porównano z populacją ogólną. 61,5% respondentów (59% w populacji ogólnej) uważa, że osoba, która zachorowała psychicznie ma szanse na wyzdrowienie a 79% (v. 77%), że przymus w polskiej psychiatrii stosowany jest odpowiednio często. 95% (v.75%) zaliczyło choroby psychiczne do problemów zdrowotnych, które ukrywa się przed innymi. 43% (v. 56%) uważa, że przebyta choroba psychiczna ogranicza istotnie zdolność do wykonywania pracy zarobkowej, 13,5% (v 30%), że zespołowej a 33% (v 71%), że ogranicza pracę wymagającą dużej samodzielności. 16% (22%) wyraża sprzeciw, aby w pobliżu ich miejsca zamieszkania znalazły się placówki dla osób chorujących psychicznie. Psychiatrzy częściej deklarowali bliską znajomość z osobami chorującymi psychicznie (87,5% v. 32% ), oraz życzliwy stosunek do osób chorujących psychicznie i ich uczestnictwa w życiu społecznym (86,5% v. 65%). Wnioski 1. Stosunkowo duża grupa badanych psychiatrów w porównaniu z populacją ogólną posiada członka rodziny chorującego psychicznie lub sama jest osobą chorującą psychicznie. 2. Polscy psychiatrzy, pomimo wykształcenia i misji zawodowej, prezentują podobnie stygmatyzujące postawy wobec osób chorujących psychicznie co populacja ogólna. 3. Poprzez swoje postawy polscy psychiatrzy współtworzą system wsparcia, ale również uczestniczą w procesie stygmatyzacji.
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Changes in psychiatry residents’ attitudes towards individuals with substance use disorders over the course of residency training
Article
  • Oct 2016
  • AM J ADDICTION
Background and objectives: Psychiatry residents provide care for individuals diagnosed with co-occurring mental illness and substance use disorders (SUDs). Small studies have shown that clinicians in general possess negative attitudes towards these dually diagnosed individuals. This is a serious concern, as clinicians' stigmatizing attitudes towards individuals with mental illnesses may have a particularly potent adverse impact on treatment. The goal of this study was to examine the attitudes of psychiatry residents towards individuals with diagnoses of schizophrenia, multiple SUDs, co-occurring schizophrenia and SUDs, and major depressive disorder. Methods: A questionnaire was sent to psychiatry residents (N = 159) around the country. It was comprised of two sections: (i) demographic information, which included information about level of training; and (ii) the 11-item Medical Condition Regard Scale (MCRS) for individuals with the four different diagnoses. Results: Psychiatry residents had more stigmatizing attitudes towards individuals with diagnoses of SUDs with and without schizophrenia than towards those individuals with diagnoses of schizophrenia or major depressive disorder alone. Senior residents possessed more negative attitudes towards individuals with SUDs than junior residents. Discussion and conclusions: The attitudes of psychiatry residents' towards individuals with SUDs with and without schizophrenia were negative and were worse among senior residents. There were many potential reasons for these findings, including repeat negative experiences in providing care for these individuals. Scientific significance: The negative attitudes of psychiatry residents towards individuals with SUDs are worrisome. Future work is needed to better understand these attitudes and to develop interventions to improve them. (Am J Addict 2017;26:75-79).
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In Their Own Voices: Breaking the Vicious Cycle of Addiction, Treatment and Criminal Justice Among People who Inject Drugs in Ukraine
Article
  • Feb 2016
Aims: To understand how perceived law enforcement policies and practices contribute to the low rates of utilization of opioid agonist therapies (OAT) among people who inject drugs (PWIDs) in Ukraine. Methods: Qualitative data from 25 focus groups (FGs) with 199 opioid-dependent PWIDs in Ukraine examined domains related to lived or learned experiences with OAT, police, arrest, incarceration, and criminal activity were analyzed using grounded theory principles. Findings: Most participants were male (66%), in their late 30s, and previously incarcerated (85%) mainly for drug-related activities. When imprisoned, PWIDs perceived themselves as being "addiction-free". After prison-release, the confluence of police surveillance, societal stress contributed to participants' drug use relapse, perpetuating a cycle of searching for money and drugs, followed by re-arrest and re-incarceration. Fear of police and arrest both facilitated OAT entry and simultaneously contributed to avoiding OAT since system-level requirements identified OAT clients as targets for police harassment. OAT represents an evidence-based option to 'break the cycle', however, law enforcement practices still thwart OAT capacity to improve individual and public health. Conclusion: In the absence of structural changes in law enforcement policies and practices in Ukraine, PWIDs will continue to avoid OAT and perpetuate the addiction cycle with high imprisonment rates.
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