1. 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

2. 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

3. 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

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

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

6. CIHI, 2017

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

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

9. 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 are more likely to report mental health and/or substance use problems than other age groups
Substance
Use
Concurrent Disorder
Mental
Health

10. 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

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

12. 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….

13. 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

14. 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

15. 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

16. 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

17. 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

18. How well can our system serve this young person?

19. 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….

20. 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

21. Our Health Care System

22. What can we do?

23. What can an integrated treatment system look like?

24. 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

25. 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

26. 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

27. 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)

28. 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

29. 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

30. 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

31. 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

32. 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

33. Meaningful engagement of young people is key to meaningful system change

34. Questions