Integrating recovery-oriented mental health and addictions services directed by clients

This article focuses on the planning, process, and outcomes of integrating multiple services into a system that is based on the client's journey. It demonstrates the incorporation of the client voice and shared decision-making throughout the process. This article provides guidance for leaders looking for ways to engage clients in the planning process. The discussion describes the process used by Frontenac Community Mental Health and Addiction Services to implement a client designed and centred, functionally integrated substance use and mental health service using the Mental Health Commission of Canada's recovery-oriented strategy. The reality is that although integrated services are evidence based best practices, in only rare cases has this translated into practice. Key messages are that the client voice and direction can be used successfully in designing an integrated mental health and substance use system.

Tabac et précarité : l’enjeu central de l’accès aux soins

The prevalence and severity of smoking are particularly high in populations in precarious situations and make smoking an essential determinant of social inequalities in health, due to its particularly catastrophic impact on the health of these populations. The general reduction in smoking, less significant in disadvantaged populations, contributes to further increasing these inequalities, and smoking tends to be concentrated in the most vulnerable populations. The relationships between tobacco and precariousness are examined by identifying, based on a review of the literature, the main common factors of vulnerability: stress and social adversity, self-stigma, a low feeling of self-efficacy, the social function of tobacco use, the ambivalence of demands, associated addictions, the severity of tobacco dependence, distance from support and care systems, etc. Specific attention is paid to certain particular conditions: mental health disorders, addictions (other than tobacco), inadequate housing, detention, migration. On this basis, courses of action are proposed to improve access to care and its effectiveness for the people concerned. Emphasis is placed on the mobilization of professionals who often tend to neglect issues of smoking in view of the immediate severity of the problems at the origin of the demands of the people received. A support offer for harm reduction (vaping in particular) seems particularly suited to often-ambivalent demands. The importance of networking and the involvement of CSAPAs/CAARUDs is also underlined. At the systemic level, all of this must be accompanied by political advocacy to reduce these inequalities and social determinants of health..

Comparing Cannabis Use Disorder in the General Population with Cannabis Treatment Seekers Using Multi-Source National Datasets: Who Receives Treatment?

INTRODUCTION

Given the increased prevalence of cannabis use in Ireland and increase in cannabis potency, this study aimed to estimate the size of the potential population in Ireland that may be in need of cannabis treatment and the percentage of people with cannabis use disorder (CUD) who actually access treatment. We also compared the profile of those with CUD in the general population to those who receive treatment for their cannabis use to explore whether certain subgroups are more or less likely to enter treatment.

METHOD

This was a retrospective, multi-source database study. Data were obtained from (1) Ireland's 2014/2015 national general population survey (GPS) on drug use and (2) treatment data from the Irish National Drug Treatment Reporting System (NDTRS) for 2015. The profiles of GPS cases with CUD and NDTRS cases were compared using 2-sided t tests designed for independent samples.

RESULTS

The prevalence of last year cannabis use among adults aged 15 and older was 6.5% and the prevalence of CUD was 2.6%, representing 94,515 of the Irish population. A total of 4,761 cases entered treatment for problem cannabis use. NDTRS treatment cases were significantly more likely than GPS cases to be unemployed (63.7% vs. 26.6%) and have no or primary level only educational attainment (56.3% vs. 21.2%). Over half (53.3%) of NDTRS cases first used cannabis before the age of 15 years, compared to 14.7% of CUD cases in the population.

DISCUSSION/CONCLUSION

Our findings suggest that earlier users and those with more complex or disadvantaged lives are more likely to seek treatment. A broad population health approach that engages multiple sectors such as health, social welfare, and education is recommended to ensure that there is increased opportunity for people with CUD to be identified and signposted towards treatment.

The early impact of COVID-19 on the incidence, prevalence, and severity of alcohol use and other drugs: A systematic review

BACKGROUND

The aim of this paper was to examine the early impact of COVID-19 on substance use to assess implications for planning substance use treatment and support systems.

METHOD

A systematic review of literature published up to March 2021 was conducted to summarize changes in prevalence, incidence, and severity of substance use associated with COVID-19 and the accompanying public health measures, including lockdown, stay-at-home orders, and social distancing.

RESULTS

We identified 53 papers describing changes to substance use at the population level. The majority of papers described changes related to alcohol use and most relied on self-reported measures of consumption during the COVID-19 pandemic, compared with pre-pandemic use. There was less evidence to support changes in non-alcohol substance use. In general, risky pre-pandemic alcohol use, caregiving responsibilities, stress, depression, anxiety, and current treatment for a mental disorder were found to be associated with increased substance use.

CONCLUSION

This review provides preliminary data on changes in substance use, indicating that certain segments of the population increased their alcohol use early on in the COVID-19 pandemic and may be at greater risk of harm and in need of additional services. There is a need for additional population-level information on substance use to inform evidence-based rapid responses from a treatment system perspective.

Current emergency response in montreal: How does it fit in the services offered to homeless people who use substances?

Background This paper presents an assessment of the current emergency response to homeless people who use substances in Montreal, a major North American city. This project addresses the rising concern about homelessness in high-income countries. Several studies have shown that homeless people frequently use emergency services (i.e., police, paramedical, and hospital), especially in the context of substance use. Yet, the key actors' perspectives are poorly documented. Method Our team conducted a needs analysis using a deliberative democratic evaluation. Data collection strategies included an intersectoral World Café (n = 34, including police, specialized professionals, community stakeholders, political representatives, researchers, and people who have been homeless) and individual interviews with health professionals (n = 5) and homeless people (n = 8). We performed a thematic content analysis based on a conceptual framework of access to health care and of collaboration. Findings This study provided key information on the role of emergency services and the needs of key actors, in terms of the dimensions of access to health care (approachability, acceptability, availability, and appropriateness) and continuity. Our main results show that, according to the participants, the emergency response is relevant when homeless people are a danger to themselves or to others, and during episodes of acute physical and psychological care. However, emergency service providers still stigmatize homelessness and substance use, which negatively affects intervention quality. Finally, our main results highlight the interdependence between the emergency services and health, social, and community services. Conclusion The emergency response is necessary and appropriate in some situations. It remains important to intervene upstream and to improve the attitudes and practices of emergency service providers. Finally, it is necessary to adapt services to the needs of homeless substance users and improve service continuity, for example, by adopting a population-based approach.

Brief interventions for cannabis use in emerging adults: A systematic review, meta-analysis, and evidence map

PURPOSE

This systematic review summarizes and critically appraises the existing literature on brief interventions (BIs) for cannabis use among emerging adults.

METHODS

Eligible BIs were operationalized as 1-2 sessions focused exclusively on cannabis use for samples with mean ages between 15 and 30. Outcomes related to cannabis use, other substance use, mental health, help-seeking, or functional status were included. Two independent reviewers screened a total of 3638 records, identifying 244 studies for full-text screening. In total, 32 BIs in 26 primary studies with 6318 participants were included.

RESULTS

Participants were typically not seeking treatment and using cannabis at least once a month. Most interventions were motivational, single sessions, and delivered in person. Few discussed concurrent psychiatric conditions. Pooling results at 1-3 months post-intervention, BIs compared to passive control slightly reduced symptoms of cannabis use disorder (SMD -0.14 [95% CI -0.26 to -0.01]) and increased the odds of abstinence (OR 1.73 [95% CI 1.13-2.66]). Other outcome results often favored BIs but were not significant. Results of studies comparing types of BIs (k = 8) or BIs to longer interventions (k = 1) are discussed narratively. Quality assessment suggested low to very low-quality evidence.

CONCLUSIONS

This review indicates that BIs targeting non-treatment seeking emerging adults result in significant reductions in symptoms of cannabis use disorder and an increased likelihood of cannabis abstinence, however evidence is of low quality.

“No papel é bonito, mas na prática…” Análise sobre a rede de atenção aos usuários de drogas nas políticas e instrumentos normativos da área

Resumo Este estudo objetivou compreender como as redes de atenção aos usuários de drogas são apresentadas nas atuais políticas brasileiras sobre o tema. Trata-se de uma pesquisa documental com abordagem qualitativa, tendo sido os resultados agrupados em três categorias: caracterizações gerais sobre as redes de atenção aos usuários de drogas; componentes da rede; e modelo de atenção. De maneira geral, os documentos analisados expressam que as redes devem ser constituídas por diferentes níveis e dispositivos, diversificando as estratégias e modalidades de cuidado, e buscando o estabelecimento da integralidade de acordo com as características socioculturais e dos sujeitos. Contudo, contradições foram constatadas no que se refere aos modelos assistenciais, intersetorialidade, relação entre Estado, terceiro setor e iniciativa privada, e concepção sobre determinados dispositivos. Neste sentido, há que se pensar em empregar tais documentos de maneira crítica com o intuito de absorver as dificuldades ainda existentes para sua efetiva concretização, o que significa um constante exercício de ação e reflexão, repensando, inclusive, as inter-relações entre papel e prática.

Co-Occurrence of Substance use Disorders with other Psychiatric Disorders: Implications for Treatment Services

Introduction

This paper critically evaluates the literature on the co-occurrence of substance-use disorders (SUDs) with other psychiatric conditions. Our review considers the variety of different associations between the two, and suggests the implications of the literature for the design of treatment services that address both types of disorders. Methods: A narrative review of research and theory was conducted, covering epidemiology of co-occurring psychiatric disorders worldwide, mechanisms underlying co-occurrence, and treatment models. Results: Epidemiological research has documented a high prevalence of co-occurring disorders in both clinical samples and the general population, although the literature is based primarily on studies in high-income countries and some of the overlap might be due to the co-occurrence of milder forms of both types of disorders. Consistent with what has been reported in other reviews, we conclude that clients with co-occurring disorders tend to have a more severe course of illness, more severe health and social consequences, more difficulties in treatment, and worse treatment outcomes than clients with a single disorder; we address the implications of these findings for the design of treatment services. Conclusions: Much of the evidence shows that separately, treatments for both SUD and other psychiatric disorders are effective in reducing substance use and in improving behavioral, familial, and psychosocial outcomes. The evidence further suggests that these outcomes might be improved when treatment modalities are offered in combination within an integrated treatment plan that simultaneously addresses substance abuse and psychiatric problems. It is concluded that there is potentially more to be gained from taking a public health perspective and working on efforts to implement existing evidence-based practices at the systems level, than from the current tendency to look for ever more powerful individual-level interventions at the clinical level.

Evaluating the Complex: Alternative Models and Measures for Evaluating Collaboration among Substance use Services with Mental Health, Primary Care and other Services and Sectors

Many planners and administrators now look to “collaboration” or “integration” as a solution, or at least a partial solution, to challenges related to access and delivery of substance use and mental health services and health services in general. Among the major constraints in identifying best practices in this area and recommending optimal evaluation strategies are the plethora of terms and concepts used in the literature to describe collaboration or integration as well as the many alternative approaches and outcome expectations. It is helpful, therefore, to follow concrete steps to plan the evaluation, including the engagement of multiple stakeholders in the planning process and subsequent execution of the evaluation. The concrete evaluation strategies employed can follow a traditional, often linear model, of impact and are often categorized under the common typologies of process, outcome or economic evaluations. Each approach examines different domains of interest and can be at the individual/service level or at the level of the overall treatment system. Other less traditional evaluation models and methods based on systems theory, complex adaptive systems and developmental evaluation have much to offer the evaluation of interventions aimed at improving the collaboration and integration of substance use services with other health and social services and sectors. Realist evaluation is a particularly helpful approach that integrates many of the traditional approaches with these other models and methods.

Unravelling the skein of care networks on drugs: a narrative review of the literature

Heated debates on given models of treatment for drug users have raged in the halls of academia, in public policies, not to mention in the media. The care network on drugs is presented in this context as an important mechanism for users, but its construction turns out to be a challenge. Therefore, a critical analysis and narrative review of the scientific literature on the care network on drugs was conducted, seeking to pinpoint the challenges and opportunities for its consolidation. The results found include: a) a lack of specific studies on the care network on drugs; b) insufficient and disjointed coverage regarding the demand for treatment; c) the need to rethink the role of the Psychosocial Care Centers for Alcohol and other Drugs, seeking to strengthen, expand, structurally improve and readjust their practices; d) lack of critical analysis about the construction process of care models on drugs in public services; and e) the State's responsibility to provide better alternatives to the existing panorama revealed, making progress on strengthening intersectorial actions, structuring care and improving working conditions.

Cost of specialized addiction treatment of clients with fetal alcohol spectrum disorder in Canada

Background

Individuals with Fetal Alcohol Spectrum Disorder (FASD) constitute a special population that may be at particularly high risk for substance use. The purpose of the current study was to estimate the utilization of specialized addiction treatment services (SATS) and the associated cost, as a part of the total cost of health care associated with FASD in Canada.

Methods

The current study was a modeling study. Data on SATS by lifetime mental disorder status were obtained from the Drug and Alcohol Treatment Information System (DATIS) in Ontario, Canada for 2010/11. The number of clients with FASD who received SATS in Ontario in 2010/11 was estimated, assuming that approximately 37% (confidence interval: 21.6%-54.5%) of individuals with FASD abuse or are addicted to alcohol and/or drugs and that their utilization rate of SATS is the same as those for people with a lifetime mental disorder. The data from DATIS was then extrapolated to the total Canadian population.

Results

The cost of SATS for clients with FASD in Canada in 2010/11 ranged from $1.65 million Canadian dollars (CND) to $3.59 million CND, based on 5,526 outpatient visits and 9,529 resident days. When the sensitivity analysis was performed the cost of SATS ranged from $979 thousand CND to $5.34 million CND.

Conclusions

Special attention must be paid to at-risk groups of individuals such as those with FASD, in order to reduce the likelihood of the development of co-morbid substance abuse problems, and thus, reducing the overall burden on Canadian society.

Reflections on capacity‐building initiatives in an Australian state

Purpose

The integration of health or social services is an enduring challenge and especially so in relation to people experiencing “dual diagnosis”, the co‐occurrence of mental health and substance use problems. The emergence of the “dual diagnosis” concept has highlighted the tension between specialist treatment for single problems and complex, individualised care. The purpose of this paper is to examine the evolving nature of dual diagnosis initiatives in an Australian state during recent decades.

Design/methodology/approach

Interpretive, case study analysis of policy documents and key informant interviews (19) illuminates the experience of dual diagnosis initiatives.

Findings

In the case of Victoria, dual diagnosis responsiveness has evolved slowly over the last 20 years, delayed by the inherent difficulty of practice change, a weak perception of need, interprofessional tensions and shortcomings in data collection, coordination and resources. Key enablers have been champions and leaders in policy, management and clinical practice, directive government policy and targeted funding. Achieving a wrap‐around service system entails investment in interpersonal relationship‐building and stigma reduction, as well as technical or structural changes.

Originality/value

The paper presents a unique and independent view of a 20‐year period and indicates progress in attitudinal change that merits wider acknowledgement and application to other settings throughout health and social care.