How Addiction Psychiatrists Add Value to (Mental) Health Care in Canada

CONCURRENT DISORDERS ARE INADEQUATELY ADDRESSED IN CANADA Substance use disorders (SUDs) and their negative impacts on the health and well-being of Canadians are substantial, and these have significantly increased since the COVID-19 pandemic.1 Alcohol, opioids, cannabis, stimulants [such as prescription psychostimulants (eg, methylphenidate), cocaine and methamphetamine], nicotine and tobacco (including nicotine vaping), and behavioural addictions (eg, gambling and online betting) are the primary substances/addictive behaviours of concern in Canadian society. These SUDs contribute ~$50 billion CAD annually in direct economic costs and lost productivity in Canadian society (www.ccsa.ca; accessed April 7, 2025). In fact, the economic costs of alcohol alone in 2020 were estimated at $20 billion.2 Complex biopsychosocial factors are involved in the initiation and maintenance of SUDs.3,4 Concurrent psychiatric disorders are frequently present in people living with SUDs,3 which often necessitates the involvement of psychiatrists with combined training in addiction medicine and psychiatry in the care of these patients.4–6 For example, the lifetime prevalence of SUDs in people with mood and anxiety disorders is significantly higher (odds ratios range from 2.0 to 5.1) compared with the general population.3 Unfortunately, there are often significant gaps in the care of people with concurrent disorders.4 In many instances, the presence of concurrent disorders may impede access to timely psychiatric evaluation and care.4,6 Importantly, there are few psychiatrists in Canada who focus on SUDs. Such addiction psychiatrists are located mostly in teaching hospitals in major urban centres such as Toronto, Montreal, Calgary and Vancouver. Similarly, there are estimated to be only 1100 subspecialty-certified (American Board of Psychiatry and Neurology) addiction psychiatrists in the United States5; this number of addiction psychiatrists does not meet the current needs of Americans as well.4,5 The Canadian College of Family Physician (CCFP) has “Plus One” funded training programs which are of one year’s duration in addiction medicine.7 These programs do offer some training in psychiatric assessment, psychotherapy, and psychopharmacology, but this is less training than is offered in a 5-year Canadian psychiatry residency training program. Moreover, there are only five formal postgraduate addiction medicine fellowship programs for which psychiatry trainees are eligible in Canada (eg, University of British Columbia, University of Calgary, University of Toronto, McGill University, and Université de Montreal); however, there is no Royal College Specialty Certification in Addictions. In a positive development, there is a Royal College Area of Focused Competence (AFC) in Addiction Medicine credential (Diplomate status), which is earned through successful completion of an accredited AFC training program or through practice eligibility. However, the creation of such training programs is a major undertaking, similar to a Royal College-approved residency program. Nonetheless, it is important to note that the care of most concurrent disorders patients is done primarily by family physicians and general psychiatrists. These physicians may seek the support of psychiatrists with specific training and expertise in addiction psychiatry (if available) to provide integrative mental health and addictions care to concurrent disorders patients, especially those who present with high complexity. Canadian psychiatry residents receive training in addictions within the Competency By Design (CBD) framework. However, this is often evaluated by supervisors without formal training in SUDs. Recently, a Canadian working group on addiction psychiatry endorsed by the Canadian Psychiatry Association (CPA) provided a comprehensive framework for SUD training in psychiatry for both residents8 and practicing psychiatrists.9 However, there is high variability across Canadian psychiatry residency programs in the quality of SUD training, and psychiatry residents identify such training as a significant skills gap when they graduate from residency training programs.8 Given these challenges, we present several recommendations to address these issues, emphasizing the importance of improving care for people with concurrent disorders, the valuable contribution of addiction psychiatrists, and how they can play a key role, alongside other clinicians and stakeholders in a collaborative model of care, in achieving this goal. Recommendations: There needs to be an improvement in the perception that excellent psychiatric care can be done without the management of concurrent SUDs. Importantly, the care of patients with substance use (whether or not they meet criteria for an SUD) should be considered as an intrinsic role of psychiatrists in all settings. Consideration of how substance use may impact the presentation and trajectory of other mental disorders should be routine, rather than viewed as separate and distinct. There should be the availability of consulting addiction psychiatrists (eg, addictions consultation-liaison psychiatrists) in general and mental health subspecialty hospitals, not only to provide care for complex cases, but also to support other practitioners in managing concurrent disorders in less specialized settings. Support should be available through diverse modalities, including direct consultation and care to patients, and by telemedicine and mentoring (ie, ECHO program) initiatives. This has been shown to be highly effective in increasing evidence-based addictions care in general hospital settings.10 Addiction psychiatrists should work collaboratively with addiction (family) medicine specialists, other physicians and allied health professionals, such as nursing, psychology and social work, to address the current demands of concurrent disorders assessment and treatment in our (mental) health care system. Leaders in the field of psychiatry (eg, the CPA and psychiatry department chairs and hospital chiefs) should acknowledge that addiction psychiatrists have unique training, combining expertise in psychotherapy, psychopharmacology, complex psychodiagnostics skills, and the ability to address SUDs in the context of the high prevalence of co-occurring psychiatric disorders.4 Importantly, the biopsychosocial model in psychiatry is well-suited to address the complexities that are associated with the care of people with concurrent disorders,4 which are significant challenges to the mental health and well-being of Canadians. Mechanisms to enhance SUD training for residents and staff psychiatrists are critical. Within the CBD training framework, there should be clear and consistent national standards for SUD assessment and treatment using entrustable professional activities (EPAs). The development and implementation of national EPAs for SUD training should have the involvement of addiction psychiatrists. This will create more positive impressions for psychiatry residents (and their supervising staff psychiatrists) with the message that inclusion of SUD assessment and treatment is the expectation for the standard of mental health care across inpatient, outpatient and consultation-liaison practice settings. There should be an increase in the number of addiction psychiatry fellowship training programs nationwide, in addition to those in Toronto, Montreal, Vancouver and Calgary. Identifying, mentoring and supporting leaders in addiction psychiatry in other centres (eg, in Edmonton, Saskatoon, Winnipeg, Thunder Bay, London, Hamilton, Ottawa, Quebec City, Halifax, St. John’s, and elsewhere across Canada) should be prioritized. The Royal College should consider subspecialty certification in Addiction Psychiatry, similar to that in geriatric, forensic, child and adolescent psychiatry subspecialties. However, since many residents (often for financial reasons) are reluctant to pursue additional years of postgraduate training beyond five-year residency training programs, such addictions subspecialty training is better integrated into the existing psychiatry residency programs in the PG-5 year. This is already occurring in residency programs at the University of Toronto, University of Calgary, and University of Alberta, and should be expanded to all residency programs. Moreover, training in addictions should provide additional financial incentives (eg, higher billing rates for addiction psychiatry service provision) upon graduation from residency. Federal funding (eg, CIHR) for research on patients with co-occurring mental health and addictive disorders should be prioritized, as should be the development of clinician-scientists in addiction psychiatry, which has the potential to improve the quality of (mental) health care for concurrent disorders patients in Canada. A CALL TO ACTION FOR ENHANCING THE ROLE OF ADDICTION PSYCHIATRY Given the high rates of SUD co-morbidity in psychiatric patients, we believe that addiction psychiatrists are well-positioned to foster an integrated approach to the care of people with concurrent disorders.4 The present drug toxicity crisis in Canada is an important example of how such a nuanced biopsychosocial approach may improve the care of people with SUDs, complicated by concurrent mental health, trauma and medical problems.6 Accordingly, we believe that the (mental) health and well-being of Canadians will be better served if these recommendations are implemented.

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