By: Angie Hamilton, Executive Director, Families for Addiction Recovery (FAR)
Once again, thanks Marvin Ross for this opportunity to respond to The Pitfalls of Supportive Housing, Part 1 and Part 2. This feels like déjà-vu. In 2017 I wrote Addictions and Mental Illness: We Need to Stick Together in response to Addictions and Mental Illness Do Not Belong Together, Part 1 and Part Two.
David Ross, and everyone else living with mental illness, addiction or both, deserve a safe home and community. We have health laws and a Mental Health Act that are supposed to keep people with a “mental disorder” safe from themselves and others, and others safe from them. Sadly, these laws, as currently drafted and/or applied, are not keeping people safe.
It is not the job of those who are afflicted to fix these laws and how they are applied. It is the job of our governments, those who elect them, and the health care professionals who are responsible for interpreting and applying these laws. And there is growing recognition within the medical community that they have not been providing those with addiction the same protections under the Mental Health Act as those with other mental health conditions.
So, it is discouraging to see those who struggle with addiction being blamed and stigmatized for this sad state of affairs, especially by a psychiatrist. I have attached a response from two members of FAR’s Advisory Board, one an addiction medicine physician and the other a psychiatrist, which explain that addiction is a treatable chronic illness, like other mental health conditions. They also explain that concurrent conditions, where a person has an addiction and another mental health condition, are very common and that both conditions need to be treated together.
A recent Guest Essay in The New York Times by a member of their editorial board illustrates that:
- addiction is a pediatric illness;
- most continue to view it as a moral failing or lack of willpower;
- addiction psychiatry did not become a subspecialty until 1993;
- few psychiatrists are trained to treat addiction;
- a functioning, evidence-based system of care for addiction does not currently exist;
- those with concurrent conditions are less likely to get any treatment; and
- addiction receives only a fraction of the resources expended on other mental health conditions.
In Part Two, Dr. Dawson states that those with severe mental illness are vulnerable and easily victimized by “unscrupulous addicts and dealers”. Are those who also struggle with addiction not doubly vulnerable and at risk of being victimized? In fact, Marvin Ross refers to seven deaths at Parkdale Landing. One was natural causes. It is entirely possible that all of the other six deaths were of those struggling with addiction; three were suspected overdoses, two were suicides and one was murder, presumably of Michel, who used substances.
This raises a question about the state of our drug policies that further harm those with addiction. Decriminalization of the possession of drugs for personal use, together with strict regulation, would help address some of the concerns raised about supportive housing. The federal government has started down this path by decriminalizing possession of drugs for personal use in BC. Other jurisdictions will likely follow. Safer supply programs are an acknowledgement that one of the best ways to protect people who use illegal substances from overdosing is to ensure that they receive a regulated supply. In fact, it is the increased toxicity of the drug supply that has been identified as the cause of the increase in overdose deaths, not an increase in addiction.
Shockingly, acute drug toxicity has been the leading cause of death of Ontario youth aged 15-24 since 2017. This equates to roughly 1 in 4.5 deaths in this age group. The second leading cause of death is asphyxiation. Let that sink in.
Where we can agree is that those who struggle with a severe addiction and who are in early recovery are often not safe in the community where illegal and legal substances are easily accessible. A locked psych ward, however, is most likely not what they need. We need appropriate residential treatment facilities available on demand. Further, if they are not seeking treatment but meet the criteria of harm to self/others under the Mental Health Act, we need to amend that Act to ensure that a locked psych ward is not the only place that they can receive the care that they need. For example, for youth this could be a therapeutic boarding school.
Response from Dr. Mel Kahan, Addiction Medicine Physician
I am an addiction physician. I would like to address several errors in The Pitfalls of Supportive Housing, Part 2. The author states, “While we do not have a specific and effective treatment for addiction…” In fact, there are a number of highly effective treatments for addiction. For example, Opioid Agonist Treatment with methadone and buprenorphine has been shown to markedly reduce opioid use and its consequences, including overdose deaths, suicides and hospitalizations. Anti-craving medications such as naltrexone have been shown to improve drinking outcomes and reduce alcohol-related hospitalizations.
The author seems to believe that addiction is a lifestyle choice, not an illness or a disorder. On the contrary, there is strong evidence that genetic and neurological factors play a key role in the development of addiction. People with a strong family history of alcohol use disorder are far more likely to develop an alcohol use disorder themselves. This is, in part, because they have a different neurological response to alcohol – they have a higher tolerance to the effects of alcohol and they enjoy it more than the average person. Of course, psychological factors play an important role; people who have had a traumatic childhood are more likely to develop a substance use disorder. But this is also true for mental illnesses such as clinical depression.
Addiction is, at its root, a disorder of volition. Drugs of abuse “hijack” the brain’s reward pathway, causing the executive functions of the brain to drive the person to seek drugs. Other physiological processes, including tolerance and withdrawal, perpetuate and worsen addictive behaviours.
The author claims that the merging of addiction and mental health means reduced funding for mental health care and treatment. This is not true. Both mental illness and addiction treatments are dramatically underfunded relative to their impact on mortality, morbidity and health care utilization. Private donors and governments underfund mental illness and addiction treatments for the same reason: Stigma. Reducing funding for addiction treatment will not result in more funding for mental illness treatment, but it will severely harm the mentally ill. People with mental illnesses often use substances to control their symptoms, yet their substance use can worsen their symptoms and reduce compliance with treatment. Patients with both mental illness and addiction need effective, high-quality treatment of both disorders.
Mel Kahan, MD CCFP FRCPC
META:PHI program (Mentoring, Education and Clinical Tools for Addiction: Partners in Health Integration)
Response from Dr. Tony George, Psychiatrist
First, people with serious mental illness like schizophrenia, bipolar disorder, PTSD and chronic depression have high rates of addictions – cannabis, cocaine, opioids, alcohol thus worsen their psychiatric illness, and lead to poorer outcomes including quality of life. Therefore, treating these conditions together is essential, and thus it behooves us to build a mental health treatment system that embraces addictions as part of the mental disorder.
Moreover, there is substantial evidence to support the assertion that addiction (the negative psychosocial consequences of drug and alcohol misuse) has an involuntary component, which CAN be successfully treated by medications and behavioural supports (e.g., addiction counselling). This is especially true for serious addictions (e.g., opioid use disorder) and concurrent mental and addictive disorders. While there is a voluntary (choice) element to drug use, it is clearly overcome when this progresses to an addiction (e.g., a substance use disorder, as defined by the DSM-5 of the American Psychiatric Association).
Tony P. George, MD FRCPC
Professor of Psychiatry,
University of Toronto
Scientific Advisor, Families for Addiction Recovery (FAR)