Thank you for allowing me to come here to speak. I'd like to provide a disclaimer that the views and opinions I express are my own and are not attributable to any organization.
I'm an addictions and forensic psychiatrist, and I'd like to talk about the connection between substance use, psychiatric illness, overdose and violence. I want to take a case from forensic psychiatry.
So, this is John Doe. His father left the household when he was young. He experienced racism in school due to his skin colour. He found a sense of belonging in a group of friends who used cannabis. He started using cannabis in elementary school and started to skip school to use with his friends. In high school, he was transferred to an alternative school, but he dropped out shortly after. He started using opioids with hydromorphone that he bought from the street. Due to his drug use and theft at home, he was asked to leave, and he moved to the Downtown Eastside. To stay awake on the streets, he began to use crystal meth. Roughly one year prior to his index offence, he began to experience psychosis with paranoia and visual hallucinations, and he heard voices with auditory hallucinations.
On the day of the index offence, John Doe was using fentanyl and crystal meth. John Doe heard voices that the victim was going to rob him. As a result, John Doe punched the victim. The victim grabbed John Doe, who is now afraid for his life. John Doe then pulled out his knife and stabbed the victim in the neck. John Doe felt remorse after the event when he was no longer intoxicated and psychotic. John Doe did not know the victim before the event.
So, when we look between 2017 and 2022, we see that unregulated drug toxicity has become the number one cause of death among British Columbia youth, and 73% of the youth who died had received services from the Ministry of Children and Family Development. A study called the "Hotel Study" looked at the population of the Downtown Eastside and found that 95% had a substance-use disorder and 84% had a mental illness, with 74% having a current mental illness at the time of their substance-use disorder. There was also a 45% prevalence of a diagnosable neurological disorder on MRI, so there are a lot of folks out there with these disorders who are brain damaged.
Also, with the coroner's report in 2017, what they found was that 52% had a mental disorder. Concurrent disorders—a mental illness and a substance-use disorder—are the rule, not the exception.
There was a study by Kristen Morin out of Ontario, and it looked at adding psychiatric treatment for folks with opioid agonist therapy—so methadone clinics. It looked at northern Ontario and southern Ontario, and what it found was that adding psychiatric treatment decreased ER visits and hospitalizations in both northern and southern Ontario, and all-cause mortality in southern Ontario.
There's a lot of amphetamine use among these folks who overdose in British Columbia. Between 67% and 79% of the people who passed away also had amphetamines in their systems. Now why should we worry about amphetamines? There's been a rise of phenyl-2-propanone in meth, which is more potent and more likely to cause psychosis.
When you look at the folks with an amphetamine-use disorder, you will see that 40% will have experienced psychosis. As an amphetamine-use disorder increases in severity, 100% will have experienced psychosis. Psychosis is a neurotoxic event. Initially, these users won't be psychotic. Then they'll be psychotic when they're intoxicated. Then it will be when they're in withdrawal and then in times of sobriety. There's a kindling effect, and this psychosis is more difficult to treat and more severe as use continues.
What would be the recommendations?
Treating addictions is complicated. The way the opioid crisis has been approached is as if there's an opioid deficiency—so like iron-deficiency anemia, where if you add iron, you'll cure the illness. Almost the entire focus has been on giving people enough and different kinds of opioids, assuming that this will solve the crisis.
Opioid-use disorder is not an opioid deficiency. Any place on earth that has treated an opioid crisis has used multiple approaches where medication was just a small part. We need to look at a wide range of evidence and solutions. It is unlikely that we will find a home-run intervention. With the varied populations, we will need input from public health, from addictions medicine and from addictions psychiatry, among other things. We will need to have clearly defined metrics of failure for interventions and be willing to re-evaluate those interventions if they do not pass the bar.
There is recent Canadian evidence that treating patients' mental health and addictions issues concurrently will keep the population alive. Psychosis increases the risk of violence threefold to fourfold, so treating psychosis is important in treating violence. Early access to treatment for concurrent disorders can help change the trajectory of the illness and the associated risk. Clients, especially high-risk clients, need timely access to treatments.
Along with treatment, there needs to be stable housing with appropriate supports. There needs to be vocational and rehabilitation opportunities. Psychological therapies are not covered. The intervention with the most evidence for amphetamine-use disorders is contingency management, which is psychosocial treatment. There are significant gaps in the criminal justice system, especially on release, and those gaps need to be filled.
Providing concurrent psychiatric care to patients with addictions can reduce violence and save lives.
Thank you.