Profile - Substance Abuse Treatment and Rehabilitation in Canada

Treatment philosophies and practices

Most respondents indicate that service providers in their regions increasingly view addiction as a complex bio-psycho-social phenomenon, often recognizing a "spiritual" component. However, support for the various modifications of the disease model continues in some service sectors. Harm reduction is viewed as a valid philosophy in five jurisdictions. The program survey would seem to support this, with just over half (51%) of treatment providers in Canada indicating an openness to treatment goals other than abstinence for alcohol problems, while somewhat fewer (47%) report the same openness for clients being treated for problems with other drugs.

Figure 2

The practice of client assessment is well accepted in Canada; however, there is little uniformity in this practice across the country. Thirty-three percent of programs use a structured test for assessment (set of questions on substance abuse that has been psychometrically tested, such as MAST, AUI), while 55% use a structured interview (interview format for asking set questions, possibly including other life areas). Specific tools mentioned were: Addiction Severity Index (ASI), A Semi-Structured Interview for Selecting Treatment (ASSIST), Substance Abuse Subtle Screening Inventory (SASSI), Alcohol Dependence Scale (ADS), Michigan Alcoholism Screening Test (MAST), Substance Use Disorder Diagnostic Schedule (SUDDS), Substance Abuse/Life Circumstance Evaluation (SALCE) and Medical Triggers Screening Tool. In Quebec, most rehabilitation centres are using the ASI or Indice de gravité de la toxicomanie (IGT) which is promoted by the government. Thirty-one percent of programs report use of unstructured assessments. A computerized lifestyle assessment is used by the CSC. In summary, clear consistencies did not emerge in assessment practices across the country.

Reflecting an understanding of the co-occurrence between mental health problems and substance abuse, 47% of substance abuse treatment programs screen clients for mental health problems. With the recent proliferation of gambling opportunities available to Canadians, an emerging concern in most jurisdictions is problem gambling. At least 30% of programs in Canada screen their clients for gambling problems.

Figure 3

Understanding the difficulty in "separating out" treatment activities which are often multi-modal, key informants were asked to rate the prevalence of specific types of interventions in their province. Across the country, confrontation is used least in government agencies. The program survey suggests that these interventions may be more prevalent in agencies not funded by government, with 31% of programs indicating use of confrontation, while 10% use anti-alcohol drug therapy and 6% use some other form of drug therapy. A total of 38 programs in the survey provide methadone maintenance treatment. Half of these programs use a higher dose regimen (60-100 mg/d), which has been evaluated more favourably in the research literature. In British Columbia, particularly, pharmacological treatment is reportedly quite prevalent, no doubt because of the use of methadone in the treatment of heroin addiction. British Columbia has the highest proportion of heroin addicts using methadone in the country.

Close to 40% of programs surveyed report the use of psychotherapy. The use of this approach varies across the country and appears to be most common in Newfoundland, Nova Scotia and British Columbia, while it is hardly ever used in Alberta or the Northwest Territories. The most prevalent treatment activities, with approximately 7 in 10 programs reporting use, are alcohol-drug education, problem-solving counselling, and skills training, with stress management, assertiveness and behavioural self-control training emerging as the most common forms of skills training used. Over half (54%) of the treatment programs report using activities based on a 12-step, modified disease model approach within their program.

In general, governments do not promote any specific types of treatment. However, Saskatchewan promotes a form of motivational interviewing and a developmental model of recovery. The B.C. government has a policy promoting holistic, gender-relevant treatment. The CSC views substance abuse as learned behaviour and uses treatment strategies based largely on cognitive-behavioural and social learning theory, as well as on the trans-theoretical model of change.