Imagine this: Every day, you can feel people looking at you warily. They want to hurt you. Even the police are out to get you. You try to rid your mind of all the ill-intentioned people, but you can't ignore the other thing that is gnawing at you. Those bugs on your arm won't leave you alone, no matter how often you gouge at them.
Such are the hallucinations and paranoia felt by those with a stimulant drug addiction. Sometimes the substance abuse is so severe it causes neurological damage and psychosis becomes a chronic condition.
Combine untreated addiction with homelessness and physical health problems, and you get a health emergency. Vancouver police and the region's health authorities are desperately trying to figure out how to help the most vulnerable of mentally ill drug addicts.
The province estimates that roughly 130,000 people in British Columbia suffer from a severe addiction and/or mental health illness. But police and emergency workers are increasingly dealing with a much smaller group of people whose brains have been damaged by their stimulant addiction and who appear to be responsible for random violent acts on Vancouver's streets.
Dr. Nader Sharifi, addiction medicine lead with the Fraser Health Authority, said there are few good treatment options for those people.
"It's a bit of a challenging question, because what we have available isn't necessarily structured for this patient sub-type. It's either structured for addiction, or structured for mental health illness, but not necessarily the two together."
Drugs such as cocaine and crystal meth can both damage the brain, but Sharifi says the effects of crystal meth can be irreversible.
"In chronic crystal meth users, somewhere between three to six per cent will have persistent psychosis that won't go away even after they stop using."
Earlier this year, Vancouver's police chief and the mayor pleaded for help from the B.C. government to deal with what they call a mental-health crisis comparable in scope to the HIV/AIDS epidemic which swept Vancouver's impoverished Downtown Eastside 20 years ago.
It was the third time in five years that the police asked for help, even though the province pours millions of dollars into mental health and addiction services and supportive housing every year.
Police chief Jim Chu said officers are taking more people into custody than ever under the provincial Mental Health Act. St. Paul's Hospital in downtown Vancouver has also seen an alarming spike in mentally ill patients in its emergency department.
It's often uncertain which came first, the mental illness or the substance abuse, or whether one caused the other, said Michael Krausz, professor of psychiatry at the University of B.C.
"It's a level of complexity where the cognitive impairment, the substance use, the psychological trauma are just so entangled that you can't say this is causing that," he said.
"It's all contributing to a very complicated situation for those clients."
Many people with severe mental illnesses and drug addictions are socially marginalized and homeless, making it harder for them to get treatment, Krausz said. Delivering continuous care remains the toughest task.
For example, said Sharifi, those with neurological damage caused by crystal meth may well have to take anti-psychosis medication for the rest of their lives. They will need help with housing and will need more thorough follow-up in the community.
Such services are intensive, said Sharifi, and a treatment team will generally include a psychiatrist, family physician, social worker, case manager, nurse, occupational therapist and psychologist.
"It really requires a team-based approach and will take months."
The public plea from the police and the city prompted B.C.'s Health Minister Terry Lake to announce a series of measures last month.
They include adding a nine-to-12 bed psychiatric assessment and stabilization unit at St. Paul's. There will also be two more Assertive Community Treatment teams — or ACT teams — which include social workers, psychiatrists, nurses, addiction counsellors, police and outreach workers to help people discharged from emergency.
"So they would have experienced their crisis, they would have ended up in (emergency rooms) for whatever reason they had been brought in, sometimes substance abuse, sometimes mental illness," said Andrew MacFarlane, mental health and addictions director for Vancouver Coastal Health.
"If they are not known to our system, or they're waiting for a more intensive service, we have a new team that we're developing which would go out and see those clients post-discharge."
There are currently 14 ACT teams across the province. Police say the three in Vancouver have led to a 50 per cent reduction in difficult encounters with police and a 70 per cent decrease in non-urgent emergency department visits.
Krausz said the two more ACT teams announced by Lake are a significant step. However, the last piece of the puzzle remains long-term care beds.
"We can only effectively work in the community if you have ... a specialized institution that is stepping in to help you if there is a crisis, if people are really getting sick."
Only one facility in the province serves mentally ill drug addicts. The Burnaby Centre for Mental Health and Addiction has 100 beds, but an estimated 300 people are in need.
Even the Health Ministry acknowledged the centre is not "optimally equipped" to meet the needs of "the small subset of aggressive clients with severe addiction and/or mental illness."
"The ... centre ... is designed, and is effective, for most mental health and addictions issues that we see in British Columbia," said Health Ministry spokesman Ryan Jabs in an email to The Canadian Press.
But he added a small number of patients require a higher level of care — closer observation, additional security and care targeted to their needs.
Lake is reluctant to add many more beds immediately, but he did say a new facility linked to the Burnaby centre will provide stabilization, assessment and individual case planning services. It will boast six beds, but eight overflow beds will be available.
It's not the 300 beds that Vancouver Mayor Gregor Robertson and Chu have asked for, but Krausz said the new measures are a start while the province figures out — yet again — what more it must do for its most vulnerable citizens.
Krausz said the equation is simple: "If you have less community treatment, you need more beds."