Substance Use and Mental Health: Integrating care to improve outcomes Kim Corace, PhD, CPsych Substance Use and Concurrent Disorders Program The Royal Ottawa Mental Health Centre Associate Professor, University of Ottawa Clinical Investigator, Institute of Mental Health Research Ottawa, Canada

Substance Use among Youth Youth (aged 15-24) have the highest self-reported past-year use of illicit substances compared to any other age group in Canada Youth are 5 times more likely than adults (>25 years) to report harm due to drug use Alcohol, cannabis, and opioids are most common Polysubstance use is the norm among youth Average age of initiation is 14 years Gender gap is narrowing

Past Year Drug Use (%) for the Total Sample, and by Sex and Grade, 2017 OSDUHS (CAMH) Male Female G7 G8 G9 G10 G11 G12 Alcohol 42.5 42.7 42.2 10.5 11.8 31.8 49.9 60.6 68.3 Cannabis 19.0 19.6 18.3 2.0 9.3 19.9 30.4 36.9 Binge Drinking 16.9 17.6 16.1 9.2 17.2 27.7 32.3 Opioid Pain Relievers (NM) 10.6 10.2 11.1 8.4 8.1 13.1 11.9 Cigarettes 7.0 5.8 2.8 6.4 15.2

At Risk Drinking in Canada (2015) 1 Canadian Tobacco Alcohol and Drugs (CTADS), 2015

Past year Cannabis Use in Canada Females: ↑7% to 10% 1 Canadian Tobacco Alcohol and Drugs (CTADS), 2015

CIHI, 2017

Opioid Related Morbidity and Mortality Among Youth (15-24) in Ontario PHO, Interactive Opioid Tool

What kinds of opioids are our youth (16-25) using? Corace, Willows, et al (2016)

Concurrent Disorders are the Norm People with substance use problems have higher rates of mental health problems than the general population People with mental health problems have higher rates of substance use problems than the general population Young people age 15-24 are more likely to report mental health and/or substance use problems than other age groups Substance Use Concurrent Disorder Mental Health

Substance Use and Mental Health Disorders MH D/O Individuals With SUD SUD (lifetime) SUD (past 12 months) % % Adults % Youth Any Mental Health Disorders 30% 18% 29% Severe Mental Health Disorders 40-60% 23-35% 35% National Comorbidity Survey, 1997; NSDUH, 2015; Rush 2008; Epidemiological Catchment Area study

Concurrent Disorders Increase Self-Harm Grade 7-12 Students in BC that reported ever self-harmed CCSA, 2013; BC Adolescent Health Survey

Youth with Concurrent Disorders More severe symptoms More likely to attempt suicide Poorer treatment outcomes More significant and chronic functional impairment: academic/employment difficulties legal problems family/peer relationship problems Substantial societal costs: criminal justice system, homelessness, family disruption, disability, school/unemployment….

MENTAL HEALTH PROBLEMS SUBSTANCE USE PROBLEMS Complex Connections Poverty Disability Racial discrimination Systemic discrimination Punishment/ Incarceration Age Lack of access to health care Sexual orientation Physical illness MENTAL HEALTH PROBLEMS SUBSTANCE USE PROBLEMS Gender TRAUMA Stigma

Adverse Childhood Experiences (ACEs) 7 x’s more likely to have an alcohol use disorder 10 x’s more likely to have injected illicit drugs 12 x’s more likely to have attempted suicide From Boivin et al., 2012

Substance Use and Suicide are Linked Adults: Alcohol Use Disorder: ~ 10 fold increase Opioid Use Disorder: ~ 14 fold increase Polysubstance Use: ~17 fold increase Youth: 27-50% of adolescents who died by suicide met criteria for a substance use disorder Problematic alcohol use = ~ 8 times higher Problematic illicit drug use = 9 times higher Rates of alcohol and other substance use disorders are high amongst those who attempt suicide (can be 50%) Among youth, the link between alcohol and suicide ideation and attempts is more established than the link with other substances CCSA, Substance Use and Suicide among Youth, 2016

At risk youth: Priority populations Early onset of substance use Concurrent disorders Gender: females may be at increased risk Indigenous youth LGBTQ CCSA, Substance Use and Suicide among Youth, 2016

A young person’s story…. 18 year old female with long history of: Depression Suicidal ideation; attempts Polysubstance use disorder Trauma Diabetes Left high school, “couch surfing” Family is very supportive but hopeless

How well can our system serve this young person?

A young person’s story…. Involved in mental health system over 5+ years Never “fit” in any program Conditions have become life threatening due to complex interplay of co-morbidities ER and acute care admission, but gets discharged due to substance use….

Most youth in need of treatment for substance use problems do not get treatment Those with concurrent substance use and mental health problems are even less likely to get treatment

Our Health Care System

What can we do?

What can an integrated treatment system look like?

Addressing Gaps in Care: Alcohol and mental health problems Our region required innovative solutions to reduce 30 day emergency department (ED) re-visit rates Alcohol intoxication/withdrawal is a common reason for presentation to the ED, many have co-occurring mental health problems (depression, anxiety) High proportion of 30 day re-visit rates Long wait times, limited services, fragmented approach to care Collaborative effort: developed a pilot rapid access service direct from the ED for people where alcohol is a major concern

What does the AMIC clinic provide? Rapid Access: “Walk-in” model; present as soon as possible post ED visit or inpatient admit Our multidisciplinary team: Assesses and treats: substance use and mental health Triages: to appropriate level of care Navigates: to other services in partnership with community organizations and primary care Connect with those who do not show for the walk-in appointment Integrated research and evaluation

Title Month Year Results Mental Health AMIC Clients Depression symptoms Moderate to Mod Severe 41% Severe 36% Anxiety symptoms Moderate 22% 48% In addition to serious alcohol use problems, 32% struggled with intermediate-severe problems with other substances Corace, Willows, et al (2018) 26

Results: Outcomes For clients served by AMIC: 82% reduction in 30-day ED revisits (p < .001) Decreased alcohol use and alcohol use severity (p < .001) Decreased symptoms of depression (p < .001) Decreased symptoms of anxiety (p < .001) 61% connected to additional community services Corace, Willows, et al (2018)

Results: Client Experience Title Month Year Results: Client Experience “Being part of this pilot project has been very helpful, and although I am not completely well yet, it has eased my mind knowing how much support there is at The Royal and in the community. Being followed by doctors and nurses who specialize in alcohol related mental health issues has given me the experience of feeling understood and hopeful. Thanks.” Corace, Willows, et al (2018) 28

Regional Opioid Intervention Service (ROIS) A novel, regional integrative, multidisciplinary model of concurrent disorders care targeted at youth and young adults with opioid use and mental health problems The ROIS has 4 pillars: Client care and family support Training, education, and capacity building (primary care) Integration and coordination of services: system-wide partnerships to bring care to where people live Program and outcome evaluation

Results: Youth have unique needs Title Month Year Results: Youth have unique needs Youth n= 44 Adults n= 76 Total N= 120 Drug use Severity** Low/Intermediate** 10% 41% 29% Substantial 43% Severe** 46% 16% 28% Number of illicit substance used not including opioids (M, SD)* 1.6 (1.3) 1.0 (1.1) 1.3 (1.2) Years of opioid use (M, SD)** 1.6 (1.1) 3.9 (4.2) 3.0 (3.6) Opioid use by injection* 45% 25% 32% Harmful/Hazardous drinking** 18% Note: * p < .05; ** p < .01 Corace, Willows, et al (2017) 30

Results: Youth have unique needs Title Month Year Results: Youth have unique needs Co-occurring Disorders Youth n= 44 Adults n= 76 Total N= 120 Depression* 100% 74% 86% Moderate/Severe Anxiety 77% 75% Externalizing Disorder* 38% 16% 25% Crime and Violence** 13% 5% Note. *p < .05, ** p < .01 Youth with opioid and mental health problems can access and engage in services tailored to their needs We need to create tailored treatment programs for youth, with a focus on integrated concurrent disorders treatment and harm reduction Corace, Willows, et al (2017) 31

All call to action Promote awareness about the link between substance use, concurrent disorders, trauma, and suicide Ensure substance use is taken into account when developing prevention strategies Bridge the silos between the addiction and mental health sectors and providers Key is system integration: development of collaborative, cross-sectoral, inter-agency partnerships Build capacity for providers, supporters, youth, families, and community

Meaningful engagement of young people is key to meaningful system change

Questions