November 2023

This month's brainbuzz™ features a new Canadian guideline for treating high-risk drinking and alcohol use disorder; new principles to guide the successful transition of ALC patients from hospitals to community settings; and the CAMH Simulation Centre's implementation of opioid overdose virtual reality training. If you have any questions or feedback, please reach out at any time. 

Aristotle Voineskos
VP Research, CAMH
 

Treating high-risk drinking, alcohol use disorder: New Canadian guideline

A new Canadian guideline for treating high-risk drinking and alcohol use disorder (AUD) with 15 evidence-based recommendations to reduce harms associated with high-risk drinking and to support people’s treatment and recovery from AUD is published today in CMAJ (Canadian Medical Association Journal).

High-risk drinking, AUD and alcohol-related harms are common in Canada. Nearly 18 per cent of people aged 15 years or older in Canada will meet the clinical criteria for an AUD in their lifetime, and over 50 per cent of people in Canada aged 15 years or older currently drink more than the amount recommended in Canada’s Guidance on Alcohol and Health.

Despite the high prevalence of high-risk drinking and AUD, these conditions frequently go unrecognized and untreated in the health care system. Even if recognized, AUD does not receive evidence-based interventions. It’s estimated that less than 2 per cent of eligible patients receive evidence-based alcohol treatment in the form of evidence-based pharmacotherapies, likely owing to low awareness. Conversely, according to the guideline, many Canadian patients receive medications that may be ineffective and potentially harmful.

Guideline developed in partnership with Canadian Research Initiative on Substance Misuse

To address this health issue, Health Canada funded the Canadian Research Initiative on Substance Misuse (CRISM) and the BC Centre on Substance Use (BCCSU) to develop the “Canadian Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder.” The guideline provides recommendations for the clinical management of high-risk drinking and AUD to support primary health care providers to implement evidence-based screening and treatment interventions.

The guideline, developed by a 36-member committee, is based on the latest evidence, expert consensus, and lived and living experience, as well as clinical experience from across Canada. It makes 15 recommendations for care providers about how to ask about alcohol, diagnose AUD, manage alcohol withdrawal, and create treatment plans based on the individual’s goals. These treatment plans can include medications, counselling, harm reduction or a combination.

“High-risk drinking and alcohol use disorder frequently go unrecognized and untreated in our health care system, leaving individuals without access to effective treatments that can improve their health and well-being,” says Dr. Jürgen Rehm, co-chair of the guideline writing committee and senior scientist in the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario.

“These guidelines give primary care providers the tools to support early detection and treatment, and connect patients and families with specialized care services and recovery-oriented supports in their communities.”

The website Helpwithdrinking.ca will be available to raise awareness of resources and treatments available to people in Canada based on the new guidelines.

Practice article highlights potential harms of prescribing medications not recommended in guideline

A related practice article highlights the complexity of providing treatment to patients with AUD and the possible negative effects of selective serotonin reuptake inhibitor (SSRI) therapy, which can worsen the disease in some people.

“Although the initiation of an SSRI appeared to be a likely explanation for the escalation in this patient’s alcohol use, other factors may also have played an important role,” writes Dr. Nikki Bozinoff, associate scientist at CAMH, with co-authors. “This case illustrates that although it may be common practice to prescribe SSRIs for people with AUD, SSRIs may not be effective for depressive symptoms in people with concurrent active AUD, and may worsen alcohol use in some.”

The guideline recommends against SSRI antidepressants in patients with AUD, or AUD and concurrent anxiety or depression.

“Despite the burden of illness, there remains a tremendous gap between what we know is effective treatment and the care Canadians are actually receiving,” says Dr. Evan Wood, co-chair of the guideline writing committee and an addiction medicine specialist. “Unfortunately, in the absence of effective care, people are being routinely prescribed potentially harmful medications that can, unknown to most prescribers, actually increase alcohol use in some patients. These guidelines seek to close that gap and ensure Canadians are accessing the safest and most effective treatments that meet their needs.”

"Canadian guideline for the clinical management of high-risk drinking and alcohol use disorder" is published October 16, 2023.
 

Culturally appropriate addictions care

CAMH develops new principles to ease the transition for this unique group with complex needs

Ontario is in the midst of a hospital crisis. 

Hospitals were already facing severe bed shortages before the COVID-19 pandemic, and a combination of factors, including staff shortages, delayed care due to COVID and access issues across the health care system, has made it even more challenging to meet the need for hospital care. 

Amid this crisis, there is a pressing need to address the issue of supporting patients who require an alternate level of care (ALC). Patients are designated ALC when they no longer require hospital care but there is nowhere appropriate for them to be discharged to. The result is these patients remain in hospital beds that are no longer appropriate for them and the hospital is left with fewer beds for other critical care patients. 

People with developmental disabilities are more at risk of becoming ALC patients. A recent study found they are 6.5 times more likely to become ALC patients than people without developmental disabilities, and almost half of people with developmental disabilities also have a psychiatric condition, or, in other words, a dual diagnosis. 

Those with a dual diagnosis often have complex needs, including co-occurring physical disabilities and chronic health conditions, making them even more likely to become an ALC patient. 

“Often hospitals don’t know how to support ALC patients with a dual diagnosis to leave the hospital or how to get connected with the right resources in the community,” says Dr. Avra Selick, Project Scientist, Provincial System Support Program. “Right now the system can be very complex, confusing and variable across the province.”

Responding to this need, the Azrieli Adult Neurodevelopmental Centre’s H-CARDD team, in partnership with CAMH’s Provincial System Support Program, has developed Supporting Alternate Level of Care Patients with a Dual Diagnosis to Transition from Hospital to Home: Practice Guidance, a comprehensive set of principles and core components designed to provide guidance for the successful transition of ALC patients with a dual diagnosis from hospitals to community settings in Ontario. 

As part of creating the guidance document, the team spoke with more than 100 people across Ontario from diverse sectors, including specialty psychiatric hospitals, general hospitals, community health and developmental services. Within these sectors, the team spoke with individuals in leadership, planning, and managerial roles, direct service providers, researchers, and those who had personally experienced an ALC hospitalization, and their families. 

“While drafting this guidance we heard many tragic stories about what happens when these supports are not in place, but we’ve also learned that it doesn’t have to be this way,” says Dr. Yona Lunsky, Scientific Director, Azrieli Adult Neurodevelopmental Centre. “With the right supports, people can thrive in homes in their communities.” 

At its core, the report serves as a valuable resource for health care practitioners, developmental service providers, policymakers, service planners, ALC patients, and their families. Moreover, many of the transition principles and components described in this report, if made available prior to hospital admission as well as once hospitalized, may also help to prevent some people who are hospitalized from becoming ALC in the first place. 

“We hope that this report will give providers in the health and developmental services sectors guidance on how to work with each other, as well as with patients and families, to support successful transitions,” says Dr. Selick. 

Some key takeaways include:

• Transition planning should be person-centred, culturally sensitive and trauma-informed. It should begin by understanding what the person, and those who know them best, think is most important to support a successful life in the community and live as independently as possible. 
• A successful transition requires clear, consistent communication and coordination among the patient, their family and their hospital, community health, mental health and developmental services providers. 
• Health equity, anti-racism and anti-oppression should be foundational to all aspects of care, including transitions, with particular attention to ensuring equitable access, positive service experiences and optimal outcomes for diverse individuals living with a dual diagnosis. 

On their experiences, former ALC patients, family members and service provides note:

• “You need to believe in yourself that you can do it. Have confidence in yourself, because it can be really hard,” says a former ALC patient. 
• “Lines of communication are number one – you have to be able to communicate with every partner – agencies, community – with the patient at the top of it. Don’t leave him out because this is his life. Everything branches out from him,” shares a family member. 
• “We can’t really plan a good positive outcome in transition if we haven’t actually figured out what’s going on in the first place… So we have to understand what’s going on medically, psychiatrically and then we can plan for the transition out,” a hospital provider says. 

The complete report, executive summary, easy read version, and first-person stories from former ALC patients and their families can be accessed here. 
 

Virtual reality overdose response training

As part of the No One Left Behind campaign, we are proud to highlight some of the ways CAMH is providing leadership in addictions by offering people new and effective treatments, and inspiring hope through innovative research.

The CAMH Simulation Centre delivers a learning experience to help health care providers and the public identify an opioid overdose and administer life-saving treatment.

What is opioid overdose virtual reality training?

The CAMH Simulation Centre is North America's first simulation centre focused on teaching, research and quality improvement at all levels of mental health education. An innovative initiative currently being led by the Simulation Centre is virtual reality training for health care providers and the public on how to respond to an opioid overdose.

This training approach has been designed to help people:

• assess a collapse for safety;
• identify an opioid overdose and call for help;
• administer the required treatment and monitor the patient’s response;
• and support the patient after an overdose.

Learners can complete these steps either in a virtual reality headset or on a desktop computer. At the end of the experience, learners get individualized feedback and can complete the experience as many times as they would like to ensure they respond effectively to an opioid overdose.
 

use and help learners build skills and knowledge on how to support those living with addiction.

How was this technology developed?

CAMH’s education department is continually researching and evaluating new ways of learning – like virtual reality – to understand how innovative technologies can support the next generation of health care professionals. This virtual reality training was co-developed with clinical experts and lived experience advisors. The goal was to deliver a training that is informed by best practices and community expertise, and to ensure that training is patient-centred and trauma-informed.
 

Buzz-worthy News

• While CAMH received the first Canadian grant to study the anti-depressant effects of psilocybin, not all experiences are the same. Our own Dr. Ishrat Husain joined CBC Fresh Air to discuss why people should avoid self-medicating with psilocybin.
  https://twitter.com/CAMHnews/status/1718998693930770598
• Congrats to Dr. Peter Selby who has received the 2023 Lifetime Achievement Award for his contributions to the field of addiction medicine in Canada as a leader, researcher, clinician + educator. The Lifetime Achievement Award is the highest honour bestowed by the Canadian Society of Addiction Medicine.
  https://twitter.com/CAMHnews/status/1719030201932472341
• A new Nature Human Behaviour review by CAMH researcher Dr. Meng Chuan-Lai reiterates the importance of a neurodivergence-informed understanding of autistic people’s mental health + provides a framework for clinicians to understand their unique experiences.
  https://twitter.com/CAMHResearch/status/1715432379588768014