Profile - Substance Abuse Treatment and Rehabilitation in Canada

Ongoing challenges and emerging issues

Key informants report that addiction treatment services typically serve a diverse population of clients and that many clients have multiple problems. Clients with cognitive impairments, those involved with the criminal justice system, who have HIV or AIDS, mental health or gambling problems, and those prone to violence are especially challenging from both a systems and clinical perspective.

In various jurisdictions, the coordination of services to best meet the needs of clients with co-occurring mental health and substance abuse problems looms as a significant emerging issue. For example, a task force report sponsored by the Ontario Division of the Canadian Mental Health Association noted that efforts at coordination need to occur both within and between the mental health and substance abuse systems. Collaboration between the sectors in the form of joint training, information sharing, cross-appointments of staff and protocols to integrate treatment with community support were highlighted (CMHA, 1997).

Similarly pressing is the need for services and policies to be adapted to address effectively HIV/AIDS and substance abuse among injection drug users. Although an issue in different parts of the country, both rural and urban, the problem is particularly acute in Vancouver where the rate of new HIV infections among injection drug users is the highest in North America (Strathdee et al., 1997). A recent National Task Force report on this issue recommended a better coordinated system staffed by providers knowledgeable about both AIDS and drug use and operating with a harm reduction approach (CCSA/CPHA, 1997).

At the clinical level, there is concern that some service staff lack the skills to address effectively clients with multiple problems and that some, in fact, have difficulty adapting to new approaches and ways of relating to clients. An example mentioned was the need for special efforts to be made to change the attitudes of addiction service providers to the use of medication by clients with psychiatric problems. This is contrary to the "abstinence only" philosophy that has historically dominated the addiction treatment field. The need to educate service providers about the use of medication was also evident from a recent survey of providers in Ontario (Ogborne, et al., 1996). Clearly, advanced training and development are essential for the provision of effective services to address this range of clients and problems.

The challenge of providing services to people in rural areas is a concern in several regions. This problem has been met in several ways, including the establishment of satellite offices from urban services and the use of urban residential services as supportive housing for out-of-town clients. Rush and Ogborne (1992) reported that some provinces were experimenting with "community mobile treatment," involving a visiting team of addiction, mental health and community development specialists providing intensive service over an extended period. While demonstrating promise W ( eibe, 1994), many of these efforts have dissipated, apparently due to cost cutting and system reforms.

New Brunswick addiction services are moving into telecounselling for clients with gambling problems, with the intention of expanding this to clients with substance abuse problems. Similarly, some agencies in Ontario can offer telephone assessment and limited counselling. Similarly, some agencies in Ontario are experimenting with telephone assessment and counselling. One region in Nova Scotia is using a team service delivery approach wherein representatives from various services (i.e. detox, inpatient, outpatient, adolescent and prevention services) meet regularly and work closely with the community to coordinate services.

Limited, and in many cases, diminishing resources for addiction services are compounding other challenges to providing effective treatment. Many agencies have received significant cutbacks in recent years. Possibly exacerbating the situation, substance abuse organizations are increasingly being asked to address problem gambling. While additional funding often accompanies this new mandate, there is some concern that attention given to problem gambling may draw scarce resources from substance abuse treatment.

Similarly, Bill C-41, which permits court-ordered substance abuse treatment at a judge's discretion, has an impact on substance abuse assessment and treatment resources. Bill C-41 includes extensive legal provisions for court-ordered treatment. The legislation endorses a general principle that for many offenders, community service and/or treatment is preferable to incarceration, when warranted by circumstances specific to the case. For offenders with substance abuse problems, Bill C-41 provides a legal mechanism for diverting offenders away from costly trial and incarceration procedures and toward treatment programs for alcohol and other drug abuse.

The issue of mandatory treatment has also arisen in Manitoba where the Supreme Court of Canada ruled against an appeal from Winnipeg Child and Family Services to be permitted to require an Aboriginal woman to take treatment for solvent abuse. The case raised fundamental issues around human rights and the efficacy of mandated treatment. Among the intervenors who appeared before this court was the Yukon government which has had the option to mandate treatment for pregnant women since the 1980s through its Child Protection Act.

Another area in which substance abuse services may be challenged to become more involved is with smoking cessation. Since over 80% of drug-dependent persons also smoke, it makes sense to consider the inclusion of cessation programming in substance abuse treatment programs - particularly in light of the fact that an alcohol-dependent person is more likely to die from smoking than from alcohol use (Abrams, 1993). Currently, 22% of substance abuse treatment programs in the country offer tobacco cessation support within their service.

Canadian treatment services may also be affected by increased referrals from business and industry. Corporate interest in substance abuse is occurring for a variety of reasons, but it is particularly due to US legislation which, as of July 1, 1997, requires all Canadian road transport carriers to drug test their drivers who cross the border and to send drivers who test positive to a "Substance Abuse Professional" for assessment, possible treatment and follow-up. The actual activity for substance abuse programs stemming from this legislation remains to be seen.

Turbulence in the administrative environments surrounding addiction services is posing a challenge in some regions. In Ontario, for example, addiction services are being restructured in the context of other significant changes to the health and social service system. As addiction services become more fully integrated with other health and social services across the country, there is concern that alcohol and drug services will suffer a loss of focus. The concern is perhaps most acute in those jurisdictions where government addiction agencies have closed (Newfoundland, Nova Scotia, New Brunswick, and Saskatchewan).

This loss of focus is being felt at the local levels as well, where regionalization of services is seen by some as creating a potentially competitive environment among treatment services and between substance abuse and other community health services providers. Above all, the regionalization of services is creating a requirement for new linkages among local providers. For example, AADAC is being called on to forge links with children's services authorities and regional health boards throughout the province. While these new linkages have the potential to offer more seamless service to individuals in their regions, it is suspected that the very process of fostering and maintaining these partnerships will place further pressure on scarce local resources. Finally, regionalization also requires a new relationship between provincial and local addictions treatment interests. As authority for decisions concerning the level and nature of substance abuse treatment moves to the regions, provincial funders are seeking new mechanisms to support and account for local treatment activity.

At the clinical level, the issue of coordination plays out as a concern for a continuum of care that will match a variety of clients to the most appropriate service. However, the lack of standardized assessment and the absence of research-based evidence to support matching was seen as limiting developments in these areas. More research is clearly needed on matching to maximize the cost-effectiveness of treatment systems.

Where there are challenges, there are also opportunities. As substance abuse practitioners forge new partnerships with other health and human service professionals, there should be strong opportunity for transfer of information and skills. This is important because the majority of people who experience problems with alcohol and other drugs do not seek treatment from specialized services; only when their problems become serious and resistant to change are they likely to come into contact with specialized services. While people need to be encouraged to seek help - and at an earlier stage - from substance abuse treatment services, it is also important to note that many people who experience alcohol and other drug problems resolve these problems on their own, through self-help/mutual aid groups or with brief interventions that can be provided by general health and social service agencies. In the past, these services have often failed to recognize alcohol and drug-related problems among their clients.

It is hoped that these new alliances will lead to greater opportunities for exchange of knowledge and skill among substance abuse and other human services providers. T h e growing contribution of these other providers as a complement to the work of treatment specialists and self-help groups has the potential to greatly improve the effectiveness of society's response to substance abuse problems.