Exploring Ontario’s lack of mental health, addiction services

On this episode, we hear from mental health, and addictions specialists Dr. Chris Cavacuiti, Dr. Renata Villela and Dr. Michael Paré who discuss how the pandemic has affected patient treatment, and the impact the increasing demand for services is having on them as physicians.

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Spotlight on Health  – Exploring Ontario’s lack of mental health, addiction services

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Georgia Balogiannis: In this podcast the Ontario Medical Association looks at current issues of interest in health care. Spotlight on Health gives you all the straight talk. We’re Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association.

On this podcast doctors address the lack of mental health and addiction services in Ontario. Dr. Chris Cavacuiti is chair of the OMA Section on Addiction Medicine. Dr. Renata Villela is chair of the OMA Section on Psychiatry. Dr. Michael Paré is a medical psychotherapist in Toronto.

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Dr. Chris Cavacuiti: During my training, I had a lot of exposure to addiction medicine care, and it really served to highlight for me that there was very much an unmet need. For folks who had opioid use disorder, access to treatment was, was almost non-existent. 

And there was all sorts of very sad stories about people, for example, deliberately infecting themselves with HIV simply to get on opioid-agonist treatment because that brought you to the top of the list. I was seeing, there was definitely a huge need for more physicians doing this care. 

So, I started my own addiction medicine program. I started out with just me, a month or two later, had one other doctor join me. Now, we have a program with about 100 locations across Ontario, with about 15 to 20 doctors who provide clinical care with our program.

Almost every day I'm still having conversations with other providers and with patients about the stigma that exists towards this patient population and the kind of subtle ways that that manifests itself. And there's also a big treatment gap as well. So, to put it in perspective, the OMA has about 50,000 members in total. Our section, the Section on Addiction, has 200. So less than 0.5 per cent of all of the physicians in Ontario sort of self-identify as being addiction medicine physicians. 

I think a lot of people are finding the pandemic a very stressful time. They're lonely. They've lost their social network that helps with maintaining sobriety and maintaining good mental health. So, all sorts of things have been lost as a result of that. And then there's also the fact that when you're taking a look at the harms associated with alcohol and drug use, a lot of them are from using alone. 

If you're using opioids and you experience respiratory depression and there's nobody else there to help try and rouse you, or to give you a Naloxone injection if you need it, that's not going to be a pretty situation. 

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It's rare that a week would go by that we don't receive an email from one of our doctors saying, “Just to let everybody know, this patient has, has died this week”. We haven't been given additional supports in terms of counselling staff or anything else to help with trying to help patients get through this pandemic. 

So, we've sort of been left to our own devices with significantly less funding than we had pre-pandemic and trying to, sort of, do our best job with what we've got available.  

And I think it really has served to unmask just how tenuous our ability to look after these patients is because one of the other things we saw is that pre-pandemic there was over 50,000 patients on opioid agonist treatment in Ontario, and that number dropped in the matter of a month or two down to about 42,000. So, we lost about 8,000 patients across Ontario to opioid agonist treatment in the early days of the pandemic. 

This is challenging work at the best of times, and this is certainly not the best of times. You know, we're dealing with a very ill patient population, who often have had less than wonderful experiences with the healthcare system in the past. They often have a lot of baggage. A lot of our patients suffer from PTSD and have a lot of challenges in terms of homelessness, other social determinants of health challenges, and often their main, if not only point of contact with the healthcare system tends to be their addiction medicine team. And so, to be trying to do that, during the pandemic, where so many other services are closed is just incredibly challenging.

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If we're going to really start reversing the trend in terms of what's happening with opioids and other substances, investing in Ontario's pre-existing network of addiction medicine programs is the single best way of doing that. So, setting standards for what these programs have to be delivering, that would make sense. 

Doctors have invested their livelihoods trying to bring these programs to their community. And these programs have been there for years, the doctors have a long-standing relationship with that community. And what we're seeing happen, more often than not, is when there's additional services put in, rather than trying to partner with the physicians who have already demonstrated a long-standing commitment to these communities, the programs that are coming in are trying to operate completely separately from these existing services. 

And that does two things. One, it doesn't serve patients very well, but it actually almost serves to dismantle the work that has already been done for 20 years, sometimes, in the community. So rather than trying to support that existing network, it seems like there's either an intentional or an unintentional effort to dismantle that without necessarily giving a lot of thought to what's going to replace that if they do and not recognizing the fact that, you know what, physicians in Ontario have invested decades and their livelihoods in finding these locations and building them up and putting in the resources out of their own pockets to develop these programs and in the middle of a pandemic rather than saying, ‘You know what, we're going to support that,’ instead, what's happening is, ‘No, you know what, we're going to go in a completely different direction’. 

The pandemic has really served to unmask the challenges that we have faced as front-line clinicians. We have our fingers crossed that this is going to be the wake-up call that we need to look at a more integrated system. Because right now, it definitely is not an integrated system.

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Dr. Renata Villela: There's the societal idea oftentimes that somehow the brain and the body aren't connected. So, the mind exists in a separate box. But really, the mind and body are interwoven. You can't actually separate the two. And this is, in terms of the training that we receive as psychiatrists, is so core to what we can offer our patients in terms of that understanding. 

Really looking at full bio-psychosocial profile of the situations and experiences that people have undergone that have been part of where they are at today with their problems, and therefore using that knowledge to help them unstick themselves from problematic patterns and start to move forward in a healthier manner. 

So, when we have this idea that people need to stay quiet and shouldn't be seeking help, that is so fundamentally destructive because it tends to just build the pressure up in the system. And then, by the time people are in a situation where they're seeking help, things could have really escalated; there could be safety issues for themselves or others for example. And then, the cost burden is so much higher. And I don't even just mean in terms of money. I'm talking about the emotional toll. And not just for the person involved. 

This is bigger than just an individual. Families, job implications, school — again, depending on what the person's particular situation is, all of that then gets interconnected.

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It's just this tsunami of need that has come about. We're dealing with the people who were already struggling and were getting help. We're dealing with people who are struggling and were still trying to get help. And now there is just this extra layer of, for those groups, what the pandemic has done in terms of stressors in their day-to-day lives. And then, people who may have been doing well beforehand, but the pandemic was such a poor precipitant, and now are seeking mental health services as well. 

So, it's been incredibly tough for people, particularly in terms of issues such as isolation. We as, as humans, so much of our day-to-day structures have to do with interactions, and so there's been this massive paradigm shift in terms of how we are still operating within society. What does it mean to stay connected in different ways and when those ways are different, what's better? What's missing? And then just understanding that.

So, managing feelings of loneliness, which are huge and have detrimental effects. Even in terms of long-term consequences, for example with dementia, there's been increase in terms of those people who are first time seeking out mental health services as well as even people currently in the system needing more support. 

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I think there's an element of wanting to try to do everything one can in terms of seeing the distress and responding to it in terms of different channels that people can stay connected in. So, I think there's an element of burnout for everyone in terms of just being fried by the constant uncertainty, the evolving nature of everything that we're trying to deal with. And even just understanding things now as, not necessarily a post-pandemic world, perhaps more of a co-existing with COVID world and all that that entails. 

At the end of the day, it's important to remember that physicians are only human. It's hard for you to be the best version of offering health care to others if you're not taking care of yourself. 

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The virtual care options that are now on the menu, so to speak, have been really transformative. It used to be that patients, for example, would want treatment, but there were all these logistical barriers that would prevent them from being able to connect. 

So, for example, they didn't have the funds to be able to take public transit to get somewhere. Their job didn't give them the flexibility to take time off. They were managing childcare and couldn’t figure out a way to get connected with services. Or people with physical disabilities, not necessarily able to easily get from point A to point B, for all sorts of reasons. 

So, virtual care has been so important in helping to reduce, if not eliminate, a lot of these issues. These are all the ways in which virtual care has allowed us to connect with people in ways that we couldn’t before. 

I think that virtual care, in, in all of its forms is here to stay. So, I think the standards will be around helping people to feel like there can be good clinical decision-making around deciding what is the format again that works best for the patient, given their needs, so that we’re recognizing there's still a time and place for in-person services, there can be a time place for video visits and there can be a time and a place for telephone contact points. 

And patients have been incredibly grateful to have access to that, so we should continue to make that an ongoing experience for them while also ensuring that we're meeting the quality standard. 

I hope that we aren't going to be in a position where services are being taken away. 

This pandemic has shown that it's not going to be a time-limited event. There are long-standing consequences, either from people who have long-haul symptoms, for example, or even people just still processing what it has been to be a collective nightmare. 

The goal, I think, is to understand where the inefficiencies in the system. How can we coordinate around that? Can the team-based health-care facilitate? How can we continue to have access to services? Instead of cutting them, how can we continue to offer high-quality care?

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Dr. Michael Paré: I'm a medical psychotherapist and have lots of training in terms of other credentials in psychotherapy, but maybe my best training was being a patient with a number of very good therapists. That really helped me, and also taught me that psychotherapy works because it helped me tremendously. It kept me able to work and connect and do what I had to do, plus feel better about myself just generally. 

Stigma and discrimination about mental illness — it's discrimination that not only affects the patient, but affects the practitioners that are treating people with mental illness, including psychiatrists and primary-care psychotherapists as well. Even in the way we refer to mental illness services we often call them mental health and that's partly because we don't want to say “mental illness”. Somebody said, ‘Well the brain can be sick, too. It's only fair’. 

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The whole area of counselling, psychotherapy, mental illness, is so broad. There's a bunch of different professions that do psychotherapy, provide psychotherapy, and of course psychologists, medicine, and of course psychiatrist and other family doctors, and then nurses, social workers, and then occupational therapists.

And there's a whole bunch of different kinds of psychotherapy, it's about 1,000. And it's hard to really define exactly but it's many, many kinds of therapy. And so, it's a complicated field, but we do know that it has been underserviced within medicine. 

There's the connection between physical health and mental health. And so, somebody with a mental illness often will utilize services way beyond what they really need, because they have mental illness, that they wouldn't need to if they were better. And a perfect example would be panic attacks or panic disorder, where they're going to the emerge three times a month, when in fact they have panic disorder. If they got the treatment that would decrease that. 

There's lots of evidence that treatment of mental illness actually saves money. And it saves money not only in decreased utilization of other health-care services, but also it helps the society because people go back to work, and they don't do other things that can cause problems.

We had many, many, many times too many patients before the pandemic. So, even if it was doubled, it wouldn't really change much because we were overwhelmed before and we were just doing what we could. So, we also have to protect our own mental health as well so you can't overdo it, and so we need to be mindful of our own mental health and work life balance, et cetera, et cetera.

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Zoom is not the same, of course. For some people, it's fundamentally different and not positive and they don't want to do it. So, I had quite a few patients drop out, maybe a little less than 20 per cent. But then other people, the ones that stayed, many of them like Zoom better. They may like it for lots of reasons that are quite reasonable. They don't have to get on a bus and a subway to come to me, exposing themselves to people who, who potentially have COVID. It's more convenient. And then they do have that connection. 

So, the thing is, some people find it really not good and other people find it better. Now, is it as effective? That would be up to the researchers that would have to do that. I can't tell. I would say that a lot of my patients say, you know, “Thank you so much Dr. Paré." I think I've gotten more compliments since COVID started than in all the years before that. 

I mean, we represent the continuity from before. We haven't stopped services. A lot of our patients will say “Well, it's good to see other people. You know I haven't seen anybody since last group session last week”. And we have many doctors in our clinic and they're basically not taking on that many patients and so we have a huge clinic. The numbers of patients that we can take on are so limited, it's shocking.

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Georgia Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit OMA.org.