A man is called into a room where his family and friends are waiting. One by one, they explain how his substance-use problem has affected them. At the end, he’s given the option to go to treatment.
You’ve probably seen a television show just like this — Intervention Canada, for example. It can make for powerful viewing, but, experts warn, such programs can perpetuate false beliefs about substance use and treatment. “The media supports the idea that you go somewhere for treatment,” says Brian Rush, a scientist emeritus at CAMH and professor in the departments of psychiatry and public-health sciences at the University of Toronto. “I’m going for treatment, and I’ll be better when I come home — a lot of movies are created around that theme.”
But entering treatment isn’t the end of the story — and not everyone finds the support they need in residential facilities.
Many who seek addiction treatment have a long history of trauma, says Rush. “The field is getting much more sensitized and recognizing the importance of trauma and working with trauma,” he says. “It’s institutional, and it’s kind of like a system-wide change. People are on board, but not everybody interprets it so broadly.”
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In order to help people with trauma and addiction, experts say, residential centres need to be trauma-informed, which includes using appropriate trauma-related assessment tools and undertaking in-depth training of addiction workers. Facilities can also incorporate different therapies, including cognitive-behavioural therapy, into their programs.
But training levels vary: some residential-treatment programs employ social workers, psychologists, and psychiatrists, Rush says, while other programs have few staff with those types of professional degrees.
There are currently no official provincial requirements to work in the addictions field, although some organizations, such as Addictions and Mental Health Ontario and the Canadian Centre on Substance Use and Addiction, list guidelines for treatment standards. “If you want to call yourself an addictions counsellor, you can just do that,” Rush says. “I don’t think anybody is going to hire you without some training or certification, but there’s nothing stopping you from just being a private practitioner.”
Rush says that we need to get a better sense of what is happening now in inpatient treatment settings. “We really need to review the programs to see exactly what they are doing,” he says. “Nobody really knows what they are doing — even the government doesn’t know.”
According to David Jensen, a media relations co-ordinator at Ontario’s Ministry of Health and Long-Term Care, the ministry does not conduct inspections of government-funded or privately owned residential treatment facilities — although the Ontario Healthcare Reporting Standards requires that residential addiction treatment centres file financial reports, which are collected by the ministry and include information about the types of programs and medical resources funded.
(The Ontario government has announced that it will invest $3.8 billion in mental health and addictions over the next 10 years. It’s also announced the establishment of Ontario Health, which “will consolidate oversight and reporting requirements under the mandate of a single entity which will improve system accountability,” Jensen wrote in an email to TVO.org.)
“Ministry-funded agencies providing addictions treatment are independent corporations governed by their boards of directors,” Jensen wrote. “It is the responsibility of each agency’s board to ensure that staff competencies and/or qualifications are appropriate for the service being delivered.”
Rush believes that there should be specific requirements governing who provides treatment for publicly funded addiction services. “For professions like physiotherapy, dietician, etc., they are kind of self-regulated. They’re referred to as the regulated health professions,” he says. “There is no equivalent in addictions.”
Medication policies can also constitute a major barrier to care. Most residential-treatment programs in Ontario involve self-help regimens, such as 12-step curricula, says Rush. Many of those programs prohibit participants from using certain medications considered to be mood- or mind-altering.
That was an issue for Alexandra Stuart, 47. Stuart, who is in recovery from opioid and crack-cocaine addiction, takes medications for sleep and mood stabilization. She says that a program she attended in around 2004 prohibited those medications. “They keep moods stable. So if you take it away, I don’t sleep, and I just get funky,” she says.
Some residential facilities won’t allow people to take opioid-replacement medications, although there is evidence proving their usefulness, says Karen Urbanoski, the Canada Research Chair in substance-use, addictions, and health-services research at the University of Victoria.
This can be problematic because many people don’t make it through the entire residential treatment program, says Chris Cavacuiti, an addiction-medicine doctor and founder of the TrueNorth Medical Centres. And when they leave, they’ve lost their tolerance to their drug, so the next time they take opiates, they overdose and die. “These programs that are refusing methadone and Suboxone patients, frankly, are killing people,” he says.
Deborah Gatenby is the CEO of Hope Place Centres, which runs two separate residential treatment programs for men and women, plus an outpatient facility. Neither residential centre admits people who take opioid-replacement medications, although if clients have a history of opioid use, they’ll give them naloxone when they leave the facility. “We’re always concerned that people may go back to opioid use or they may use opioids when they relapse, even if they didn’t use them initially,” Gatenby says.
She says there are several reasons that people on replacement medication aren’t integrated into the facility’s residential programs — for example, it’s not clear whether that population will benefit from Hope Place Centres’ inpatient treatment curriculum, which incorporates an abstinence-based model of care and serves only clients whose goals are compatible with that framework.
“Is there the potential for [people on opioid agonist therapy] to get worse because our model so strongly reinforces the sort of 12-step definition of abstinence?” Gatenby says. “When you have dissonance within the community based on people seeking two models of care, what are the implications for that? They’re largely unknown.” She adds that it’s also unclear whether mixing the client populations could undermine Hope Place Centres’ clinical results, as those it currently serves are looking to remain abstinent.
“That doesn’t mean there shouldn’t be inpatient treatment programs for people on OAT [opioid agonist therapy]. I think that those programs need to be just as specialized and competent and clinically validated and research-based,” she says. “I don’t think that one size does fit all.”
And, in many cases, residential treatment isn’t tailored to individual needs. There’s a lot of contested evidence in the area of addictions, Urbanoski says. Some studies explore whether a service is effective overall, but this hasn’t necessarily reflected people’s individual needs when it comes to recovery. “What works for who under what circumstances is a more fruitful avenue of research at this point in time versus studies that are just looking to see what works better overall,” she says.
David Gagne, a 38-year-old from Red Lake who’s recovering from cocaine addiction and has completed residential treatment four times, says that the formats of the programs he’s attended been relatively similar. “The structure for treatment centres — as sad as it is to say — being in a few over the years, it’s all basically the same,” he says, adding there are usually classes on preventive maintenance, anger, and emotions.
Certain groups may find it especially difficult to find and access appropriate services. For example, Urbanoski says, women may experience barriers when seeking help, especially if they’re pregnant and have young children. Income, education, immigration status, and other social determinants, she notes, also influence access to treatment.
Stuart was pregnant when she tried to get off drugs for the first time, at 20 years old, but she found it impossible to locate treatment for pregnant women. She wasn’t fully abstinent from substances during the pregnancy, but when her baby was born, she stopped using drugs completely — on her own.
After residential treatment is complete, many people will need outpatient services to help them heal, but that’s not always an option.
“It’s not like you go to residential [treatment] and that’s it,” Rush says. “You go to residential to remove yourself from that environment — that’s the main value.” Going home and thinking everything will be perfect again is not the reality, he says, adding that there need to be follow-ups and counselling.
“It’s very easy to not use and stay clean when you’re in a little bubble and everyone’s there to support you,” says Althea Blu, whose name has been changed to protect her privacy. A 42-year-old originally from Port Stanley, she’s in recovery from opioid addiction. “You get out, and all of that is gone.”
Although some residential treatment programs do follow up with clients once they return home, Rush says, there’s no official obligation for them to do so. “We invest literally tens of thousands of dollars in residential treatment, and then just kind of kick people to the curb and keep our fingers crossed,” Cavacuiti says. “That’s not an appropriate way to try and manage this illness.”
“There’s not enough women’s beds, there’s not the accessibility, there’s no aftercare, there’s no counselling, there’s nothing,” Stuart says. “To me, if you want to get clean, you do it at home, have your seizures, take your whatever and hope you’re strong enough to make it through it.”
Daina Goldfinger is a local online journalist for Global News, Barrie.