As a Vancouver physician specializing in inner-city medicine, I’m regularly asked by friends and colleagues about what can be done to improve the situation in the city’s notorious Downtown Eastside. As the poorest urban neighbourhood in Canada, the area suffers from a range of poverty-associated conditions, including a serious HIV epidemic that emerged among drug addicts in the 1990s.
A fundamental issue is the high rate of untreated drug and alcohol addiction. While complaints about underfunding of the addiction-treatment system have been regularly voiced, one of the basic reasons for the problem will come as a shock to many.
Unlike virtually all other medical disciplines, which graduate an annual wave of specialist physicians from fellowship programs based within Vancouver’s university-affiliated hospitals, there is no fellowship training program in addiction medicine in the province.
The problem is typical of all Canadian provinces. In fact, although Ontario’s leading Centre for Addiction and Mental Health does place some emphasis on physician education, a patient with an addiction who walks into Ottawa Hospital, for example, cannot be treated by an addiction medicine specialist because there is none on staff. As a result, despite the fact that recent advances in addiction research have helped identify effective new treatments, there are few skilled physicians to prescribe them. Dedicated and caring as they usually are, most Canadian physicians who consider themselves addiction medicine specialists assembled their knowledge about addiction treatment after completing their medical training.
From a patient’s perspective, imagine being rushed to the hospital emergency room clutching your chest in the throes of a heart attack and being seen by an extremely well-meaning physician – who has not actually been through a standardized cardiology training program.
A recent report from the U.S. National Center on Substance Abuse highlights the fact that most people with addictions in the United States do not get treatment from a physician at all. Rather, much as in Canada, U.S. addiction care is usually provided by unskilled laypersons. The report’s harshest criticism is saved for the medical community, stating that “most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat it.”
There are, however, centres of excellence in addiction, and few rival the Boston Medical Center’s Clinical Addiction Research and Education (CARE) Unit. What was really eye-opening from my visit to this program was the impact that a skilled addiction medicine work force can have in turning patients’ lives around. In some instances, they are using medications not even available in Canada.
While Canada has benefited from the work of the Canadian Society of Addiction Medicine and its efforts to certify physicians who have received on-the-job experience treating drug and alcohol addiction, a potentially ground-shifting opportunity has emerged with the recent establishment of the American Board of Addiction Medicine. The board has created guidelines for the development of addiction medicine fellowship programs enabling Canadian medical schools to create programs that are eligible for full accreditation.
This development cannot go unnoticed, especially given that, according to the Canadian Centre on Substance Abuse, untreated substance abuse costs Canadians about $40-billion a year.
When Stephen Harper released his government’s five-year National Anti-Drug Strategy in 2007, the Prime Minister stated: “If you’re addicted to drugs, we’ll help you, but if you deal drugs, we’ll punish you.” Since that time, a lot of attention has been placed on expensive criminal justice measures while helping addicts and their families has been given short shrift. The results have been predictable.
Last week, a study published in the American Journal on Addictions demonstrated how, despite the expensive policing measures enacted as part of the anti-drug strategy, illegal drugs remain free and easily available in Vancouver. In fact, evidence globally has demonstrated that funding police and prisons instead of addiction treatment has resulted in avoidable human misery and a large and growing criminal enterprise that exists because of this steady stream of untreated drug consumers.
The Downtown Eastside has received a lot of notoriety, but every community in Canada has been harmed by the problems of untreated addiction. With Canada’s drug strategy currently set to be renewed for another five years, all Canadians would benefit if the new strategy placed some emphasis on the creation of addiction medicine training programs.
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