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A Canadian Perspective on Addiction TreatmentNady el-Guebaly MDa

a Addiction Division, University of Calgary, Calgary, Alberta, CanadaAccepted author version posted online: 23 May 2014.Published online: 08 Aug 2014.

To cite this article: Nady el-Guebaly MD (2014) A Canadian Perspective on Addiction Treatment, Substance Abuse, 35:3,298-303, DOI: 10.1080/08897077.2014.923362

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A Canadian Perspective on Addiction Treatment

Nady el-Guebaly, MD

ABSTRACT. This paper presents a synopsis of addiction treatment in Canada, along with

some available comparative figures with other North American countries. Within the

framework of Canada’s Medicare, a largely single-payer system, addiction and psychiatric

disorders are insured on par with other medical disorders. Canada’s strategy recognizes the

four pillars of prevention, treatment, harm reduction, and enforcement. The Canadian

Alcohol and Drug Use Monitoring Survey is the yearly main source of data on alcohol and

illicit drug use. The main features of the Canadian addiction treatment network are identified

as a “top 10” list, outlining early identification and intervention, assessment, and referral;

detoxification; ambulatory care/day treatment programs; residential care; hospitals;

concurrent disorders networks and regionalization; drug specific strategies; mutual help;

behavioral addictions; and training, qualification, and research.

Keywords: Addiction treatment, Canada, drug strategy

INTRODUCTION

Canada is the second largest country in the world, and its geo-

graphic footprint is larger than Europe. The general principles

concerning the delivery of health care in the country’s 10 provin-

ces and 3 territories are remarkably congruent overall.

Canada’s Medicare

Since 1967, the country has enjoyed a national Medicare insur-

ance. The principles underpinning Medicare are a single-payer

system and public administration provided by the federal and pro-

vincial governments through taxation. Other principles involve

universal coverage for all citizens and insurance portability across

the country. The last principle is a promise of accessibility to all

medically necessary services.1,2 The report “More for the Mind”

is credited for ensuring a parity of coverage by Medicare to addic-

tion and psychiatric disorders equivalent to other medical disor-

ders.3 Although these principles still largely apply, Canada is

possibly the western country where a promise of universal cover-

age for all medically necessary services has been kept the longest,

for 45 years.

These principles face a mix of challenges, including rising

costs, successful medical advances in the management of an ever-

expanding range of disorders, a plethora of new medications, an

aging population, and rising consumer expectations. The health

indicators in Table 1 show that, although the proportion of health

expenditures as a percentage of the gross domestic product (GDP)

remains one third lower than in the United States (US), the public

expenditures cover only 70% of the costs.1 The rest, such as outpa-

tient medication, is from private insurance or out-of-pocket. The

lower expenditures in Canada are due mainly to the lower admin-

istrative costs resulting from the single-payer system. Increasing

waitlists for a range of nonacute services are now prompting a

reconsideration of the tenets of Medicare, including its long-term

sustainability. Repeated population surveys support Medicare as a

critical ingredient of the national fabric.

Canada’s Drug Strategy

The federal government’s key initiative to address the harmful

effects of substance use and abuse on individuals, families, and

communities in coordination with the provinces is described in its

drug strategy, with the four pillars of prevention, treatment, harm

reduction, and enforcement.2 The Canadian Centre on Substance

Abuse (CCSA) is the body mandated to spearhead the activities

emanating from such a strategy and, with the federal government,

plays largely a standard-setting role.

Prevention

The most visible federal activities include mass media aware-

ness campaigns, such as anti-smoking advertisements and regular

health warnings. The federal government, through its National

Native Alcohol and Drug Abuse Program (NNDAP), aims specifi-

cally at preventing alcohol and other drug abuse among First

Nations people and Inuit.4 Recently, programs to manage posttrau-

matic stress disorder and its sequelae, such as substance use disor-

ders, have been prioritized by the Armed Forces.5

Provincially, a range of approaches are implemented, such as

school programs; community-based programs for high-risk

Addiction Division, University of Calgary, Calgary, Alberta, Canada

Correspondence should be addressed to Nady el-Guebaly, MD, Foot-

hills Hospital, Addiction Centre, 1403 29th Street NW, Calgary, Alberta,

T2N 2T9, Canada. E-mail: nady.el-guebaly@albertahealthservices.ca

SUBSTANCE ABUSE, 35: 298–303, 2014

Copyright� Taylor & Francis Group, LLC

ISSN: 0889-7077 print / 1547-0164 online

DOI: 10.1080/08897077.2014.923362

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populations; recreational activities for youth groups; family-based

approaches; and policies against drug use and possession in the

school as well as the workplace, particularly for safety-sensitive

positions.

Treatment and rehabilitation

The Canadian Centre on Substance Abuse database on addic-

tion organizations (including gambling) lists more than 2500 such

organizations.6 Provinces, territories, and local communities fund

more than 1000 drug and alcohol treatment and rehabilitation pro-

grams, varying in their approach, philosophy, principles, and

goals. Canada supports opioid agonist therapy. A registry of physi-

cians able to prescribe methadone was instituted federally and

only recently delegated to provincial licensing boards. The restric-

tions on prescribing vary between provinces but all potential pre-

scribers are required to undergo an initiation course. The

prescription of buprenorphine is limited to those physicians on the

methadone registry.7

Harm reduction

The third pillar of the drug strategy, harm reduction, aims at

reducing the health and social harms related to substance use and

abuse and grew in the 1980s from the goal of reducing the risks of

blood-borne diseases (i.e., human immunodeficiency virus/

acquired immunodeficiency virus [HIV/AIDS], hepatitis) among

intravenous drug users (IDUs). Harm reduction accepts the fact

that some users cannot or will not stop using psychoactive sub-

stances, particularly at the early steps of their treatment engage-

ment. The panoply of harm reduction measures include

community-based outreach programs targeted at marginalized

populations and providing them with low-threshold services, such

as needle exchange programs and, more recently, clean pipes for

crack users; methadone maintenance programs; and a clinic for

supervised use for heroin.8 Although these expanding measures

regularly test the population’s tolerance and values, overall, they

are remarkably well accepted.

Enforcement and control

From the need to reduce both the supply and demand for drugs,

the Controlled Drugs and Substances Act (CDSA) “provides the

framework for the control, import, production, export, distribution,

and possession of psychoactive substances.”2 The Royal Canadian

Mounted Police (RCMP) is responsible for enforcing the CDSA in

collaboration with provincial and municipal police forces. Argu-

ments for a less costly strategy of drug decriminalization are regu-

larly made and face challenges ranging from potential public

safety issues to Canada’s obligations under international treaties.

Harm reduction measures, such as the availability of methadone,

are being progressively adopted in correctional institutions.

FEATURES OF CANADIAN ADDICTIONTREATMENT

Although Canadian addiction treatment is national and provincial,

10 selected aspects are considered critical to promote reduction of

the harms of illicit and unhealthy alcohol and drug use.

Early Identification and Intervention, Assessment,and Referral

Like in the US, concerted effort is ongoing to reach out to family

physicians and other primary care providers beyond a few pilot

projects and establish sustainable parameters for early identifica-

tion of substance use and intervention.9 Canada’s population has

traditionally benefited from ready access to a family physician.

Recent challenges in the recruitment of these physicians has pro-

moted a paradigm shift from solo to group primary care practices,

with the added incentive of funded multidisciplinary support for

TABLE 1

Snapshot of Indicators in Health Across North America

Indicator Year Canada USA Mexico

Health expenditure

Total as% of GDP 2010 11.4 17.6 6.2

Public as% total 2010 71.1 48.2 47.3

Resource

Physicians/1000 population 2010 2.4 2.4 2.0

Hospital beds/1000 population 2009 3.2 3.1 1.7

Life expectancy at birth—Female 2010 83.1 (2008) 81.1 77.8

Life expectancy at birth—Male 2010 78.5 (2008) 76.2 73.1

Infant mortality/1000 live births 2010 5.1 (2008) 6.1 14.1

Suicide rates/100,000 population 2009 11.1 12.0 (2008) 5.0

% Adults reporting good health—Male 2007 89 89 67

% Adults reporting good health—Female 2007 88 87 64

AIDS incidence rates (new cases/million population) 2006 9.5 127.0 45.3 (2003)

% Females with obesity 2008 23.3 35.5 34.5 (2006)

% Males with obesity 2008 25.2 32.2 24.2 (2006)

Daily smokers as% population 2010 16.3 15.1 13.3 (2006)

Alcohol consumption (L/capita): Age 15C 2009 8.2 8.7 5.9 (2008)

Note. Adapted from OECD Health, 2013.

N. EL-GUEBALY 299

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the groups. These Practice Community Networks (PCNs), as they

have been called in Alberta, have their counterparts in an expand-

ing number of provinces. Start-up initiatives have targeted the

reduction of use of tobacco and are credited for a significant reduc-

tion in national prevalence to the current 17.5%. The early identifi-

cation efforts to address other substances, such as alcohol and

marijuana, are more limited, despite the fact that they are also

common among the population above age 15, i.e., past 12 months’

use of alcohol is 76.5%, whereas cannabis is 10.6%.10,11

Detoxification

A national network of so-called “nonmedical” detoxification cen-

ters is available in most urban centers. In these centers, physicians

are part-time consultants. The Canadian Alcohol and Drug Use

Monitoring Survey (CADUMS) 2009 reports that 5.1% of Cana-

dians were heavy frequent drinkers in the past year (consumption

of 5C drinks 1 or more times per week).11 An internationally

known scale to assess the severity of alcohol withdrawal has been

the Clinical Institute Withdrawal Assessment—Alcohol (CIWA),

created by the Addiction Research Foundation in Canada and

monitored by nursing staff.12 Sensitive detoxifications, including

in pregnancies as well as polysubstance abuse, would be referred

to a neighboring hospital.

Ambulatory Care/Day Treatment Programs

A focus on ambulatory, rather than residential or hospital, care has

been an early feature of the Canadian Medicare System. Screening

and brief intervention are mostly delivered through primary care,

with specialized addiction treatment clinics of various sizes and

range of services, as back-up, available in most urban centers.

Patients discharged from these specialized treatment settings are

referred back to their primary physician for follow-up and medical

monitoring of their recovery.

Residential Care

Various levels of residential care for both genders are available in

urban centers as well as rural areas, and they mostly receive local

referrals. A formalized grid of level of care is not available in Can-

ada. Contrary to the US, the emergence of major interstate referral

centers, such as Hazelden or Betty Ford Center, has been limited

in Canada. A network of “interventionists” providing intervention

services and referring to these centers is practically nonexistent. A

select number of residential programs, such as Homewood Hospi-

tal and Bellwood Treatment Centre in Ontario and Edgewood

Centre in British Columbia, receive referrals from Worker’s Com-

pensation, Armed Forces, and the Police forces, who have supple-

mentary benefits to Medicare. Residential programs are not

funded by Medicare, except for related physicians’ services and

charge a variable admission fee. Residential programs are partly

funded by sources other than Medicare. A limited number of rela-

tively wealthy Canadians travel to residential programs in the US

for their care.

Hospitals

General hospitals have very few departments of addiction medi-

cine or addiction psychiatry and rarely identify designated beds

for the care of addicted patients. Access to beds most frequently is

through a range of admitting physicians, with consultations pro-

vided by specialists in addiction medicine or psychiatry. Desig-

nated beds, mostly for concurrent disorders are, however,

available in provincial Mental Health Centres.

Concurrent Disorders Networks and Regionalization

Over the last few years, a major national effort has been to inte-

grate administratively both addiction and mental health services.

Based on a best-practices document from Health Canada, the inte-

gration of the two cultures has been challenging, while prioritizing

a continuum of care through case management.13 In Alberta, for

example, the parameters of a concurrent disorders system

approach involve a welcoming and engaging consumer strategy, a

working knowledge of addiction and mental health disorders, a

standard approach to screening, a comprehensive assessment, inte-

grated treatment planning, comprehensive interventions, case

management and service coordination, and continuous care recog-

nizing the chronic nature of the disorders involved.14

Another major development, at the same time, has been a pol-

icy to regionalize the delivery of health care. With a single-payer

system, the planning of services on a regional basis enhances the

coordination and continuum of care. Models of comprehensive

delivery of services have been drafted in most provinces. An

example would be the Progressive and Integrated Recovery

(PaIR) model, originating in southern Alberta (see Figure 1).15

This model recognizes that at any one time, most residents suffer-

ing from substance use disorders would not be ready to change. Of

those ready to do so, a stepped care model is proposed, matching

the level of intervention to patient needs and preference. The plan-

ning of a recovery process is also included.

Drug-Specific Strategies

Aside from a tobacco strategy, focused on primary care, other

drug-specific strategies include the following.

The options of opioid management

According to the United Nations Office on Drugs and Crime

(UNODC), Canada’s prevalence for opiates in the population age

range of 15–64 is 0.68% for opioids, 0.36% for opiates, and 0.5%

for prescriptions (see Table 2). Opioids are the primary drug of

abuse for 22% of persons treated with drug problems (see

Table 3).

Canada has been an early adopter of methadone as far back as

the early 1960s (Dr. Robert Halliwell in Vancouver). More than

1000 physicians are now registered with their provincial licensing

colleges to prescribe methadone, mostly in specialized clinics.7

The prescription of buprenorphine has been mostly limited to

physicians on the methadone registry, with the result that the

incorporation of its prescription into primary care practices has

been limited.

Over the last 6 years, the North American Opiate Medication

Initiative (NAOMI) project in Vancouver, a controlled clinical

trial of heroin maintenance funded by the Canadian Institute of

Health Research (CIHR), has made headlines in the media.16 A

successful outcome has been reported in top medical publica-

tions.17 Insite, the clinic where the supervision occurred, was

threatened with closure by the federal government as contravening

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the CDSA but won a landmark ruling by Canada’s Supreme Court

that upheld its right to exist through an exemption.

Codeine is currently a source of public concern. In 2009,

CADUMS reported that 25% of respondents used a psychoactive

pharmaceutical in the past year, but only 2.3% of these users used

such drug to get high. Among the youth, 15 to 24 years of age,

9.5% of current users reported such use to get high (1.7% of

population). Opioid pain relievers were the most common cate-

gory of pharmaceuticals used (19.2%), and of these, 2.3% used

them to get high. Among the youth, this percentage was much

higher, 8.5%. The Canadian Society of Addiction Medicine has

developed a position paper outlining opioid prescription guide-

lines.18 Among users of stimulants, 9.4% used them to get high in

the past 12 months, and among users of sedatives or tranquilizers,

1.7% used them to get high.

Cannabis and medical marihuana

CADUMS reports in 2009 that the prevalence of past-year can-

nabis use among Canadians 15 years and older was 10.6%, statis-

tically significantly lower than the rate of 14.1% reported in 2001.

Despite the decline, the prevalence of use by youth was 26.3%. In

general, male’s use was twice as high as females.11

Two oral medications, a chemically synthesized tetrahydrocan-

nabinol (THC; Marinol) and nabilone (Cesamet), a synthetic can-

nabinoid, are readily available. In 2001, public pressure prompted

the federal government to introduce a medical access regulation

under the CDSA. Since then, persistent consumer advocacy, con-

sistent with other countries, has occurred to increase the availabil-

ity of smoked marihuana for an ever-expanding range of disorders

despite limited scientific evidence of the benefits of its

FIGURE 1. The Progressive and Integrated Recovery model.

TABLE 2

Annual Prevalence as a Percentage of the Population Aged 15–64

Across North America

Drug Canada USA Mexico

Opiates

Opioids 0.68 5.90 0.08

Opiates 0.36 0.57 0.04

Prescription opioids 0.5 5.60 0.06

Cocaine 1.4 2.40 0.4

Cannabis 12.6 13.7 1.0

Amphetamines 0.7 1.5 0.2

Ecstasy 1.1 1.4 <0.1

Source: UNODC World Drug Report 2011 Statistical Annex (http://

www.unodc.org/documents/data-and-analysis/WDR2011/World_Drug_

Report_2011_ebook.pdf).

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administration through smoking and larger evidence of side effects

akin to tobacco use.19 There is growing popular consensus in Can-

ada on the need to decriminalize the possession of marihuana as

well as differentiate the therapeutic promises of cannabinoids

from the mode of administration through smoke inhalation.20 The

Canadian Medical Protective Association has successfully warned

physicians of potential compromise in their practice insurance

resulting from the prescription of smoked marihuana. The federal

government will now allow physicians to write prescriptions that

would be filled by licensed suppliers.21

Options for nicotine and alcohol

The use of nicotine replacement therapies and other medica-

tions to control tobacco use has been widespread. Recent attempts

to promote the use of anti-craving medication, including naltrex-

one or acamprosate, have been met with skepticism due to their

low effect size. Unfortunately, this has led to some reluctance by

insurers to adopt newer promising pharmaceutical products in the

field.

Mutual Help

Mutual help originated in Canada in 1902, with the Ontario Soci-

ety for the Reformation of Inebriates. Currently, Alcoholics Anon-

ymous and other 12-Step mutual help groups are available in

every urban or rural center. Other groups, including SMART

Recovery (Self Management and Recovery Training), Women for

Sobriety, and Gamblers Anonymous are also available but on a

more limited basis. The concept of recovery and its requirements

promoted by mutual help groups is now receiving widespread

attention from planners and decision makers as a potential new

paradigm for the delivery of addiction and mental health

services.22

Behavioral Addictions

In Canada, provincial governments are both the regulators and

major recipients of gambling revenue. Compared with the US,

governments have funded an extensive research network aimed at

studying the risks of problem gambling as well as creating a num-

ber of specialized treatment programs. Other behavioral addic-

tions, such as Internet and sex addictions, are addressed much

more sporadically and, to our knowledge, struggle to establish a

treatment network as yet.23

Training, Qualification, and Research

The training of medical students in substance use disorders in the

18 medical schools remains marginal.10 National training require-

ments have been established for psychiatric residents and are

developing in family practice.24

The qualification of physicians is the jurisdiction of the College

of Family Physicians and the Royal College of Physicians and

Surgeons. Traditionally, both colleges, worried about fragmenta-

tion of the practice of medicine, have promoted the training of

generalists in the traditional specialties. Recently, the College of

Family Physicians has recognized special interest or focused prac-

tices and the Royal College may offer a diploma recognition

requiring an extra year of training.25 Recognizing the complemen-

tary roles of family physicians and specialists, a model of collabo-

rative care is being proposed to modify the training requirements

of addiction medicine leading to potential certification by either

the International or the American Medical Society of Addiction

Medicine.26 In addition, a major effort to flesh out the required

competencies for a multidisciplinary workforce is ongoing.27 Fel-

lowships in addiction medicine/psychiatry in training centers such

as Calgary, Toronto, and Vancouver are emerging, funded through

the reallocation from existing residency training spots or through

philanthropic donations.

Under the aegis of the Institute for Neurosciences, Mental

Health, and Addiction (INMHA), one of the institutes of CIHR,

the field of addiction is added to the neurological and mental

health portfolios, creating some discrepancy in visibility. Access

by Canadian researchers to the support of the National Institute of

Drug Abuse (NIDA) and the National Institute of Alcohol Abuse

and Alcoholism (NIAAA) in the US is welcomed. Leading

research efforts include studies on tobacco, psychiatric comorbid-

ities, opiates and the NAOMI project, cannabis, and gambling

research.

SUMMARY

This snapshot of Canadian addiction treatment highlights assets

such as the presence of parity in insurance coverage for both

addiction and mental health as well as 10 selected features of our

TABLE 3

Primary Drugs of Abuse Among Persons Treated for Drug Problems Across North America

Drug Canada (Ontario) % USA % Mexico %

Opioids 22.0 34.1 18.2

Cocaine group 33.4 19.5 26.9

Cannabis 32.5 29.3 21.2

Amphetamine-type stimulants 3.1 10.9 17.9

Ecstasy 2.4 — —

Solvents and inhabitants 0.6 0.1 11.4

Sedatives and tranquilizers 3.9 1.5 2.3

Drug-related deaths (rate per million aged 15–64) 93.3 182.4 63.9

Hepatitis C among IDUs 69 Unknown 96

Source: UNODC World Drug Report 2011 Statistical Annex (http://www.unodc.org/documents/data-and-analysis/WDR2011/World_Drug_Report

_2011_ebook.pdf).

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delivery of care. In a climate of economic constraints and the con-

cern of policy makers about the rising costs of health care, one

must address the additional challenge of stigma while advocating

for our patients. Compared with other visible health consumer

groups, the anonymity of our major mutual help groups may pres-

ent an additional advocacy hurdle. A vocal group of opiate users

recently were instrumental in gaining the support of Canada’s

Supreme Court. The struggle continues for meeting the needs of

our patients, providing the highest possible standard of empirically

based care, and ensuring a competent workplace to staff our

resources.

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