The coexistence of psychiatric disorders, drug addiction and medical problems associated with substance abuse requires flexible clinical programming, reconciling different therapeutic modalities. First of all, a psychiatrist from the Unit must carry out close follow-up with the help of a key worker from the interdisciplinary team (social worker, nurse or occupational therapist). Together, they oversee the entire delivery of care, from the initial assessment to the end of the intervention, the primary objective being to ensure that changing priorities are respected at all times in terms of patient needs. Psychiatric monitoring includes the prudent and rational use of pharmacotherapy (molecules used for withdrawal or treatment of drug addiction, and molecules traditionally used in the treatment of psychiatric disorders).
This may be supplemented by additional individual interventions including motivational interviewing, supportive psychotherapy or, if available, targeted cognitive behavioral therapy. These interventions aim to personalize the care protocol required by each individual. They also make it possible to modulate the external follow-up and the intensity of the treatment according to the willingness to change of the patient;
Given the notorious rate of absenteeism among this type of clientele, this organization of care promotes rational use of human resources; moreover, it makes it possible to take advantage of the therapeutic group model, which is to strengthen solidarity and the feeling of belonging among the participants, and to increase their social and relational skills, which are often intertwined with the problem as a whole. At the UPT inpatient unit, group psychotherapeutic programming includes two weekly sessions, one focused on personal motivation, the other focused on managing anxiety and sleep difficulties through techniques yoga. At the UPT outpatient clinic, a reception group called “Accès-Cible” uses interactive psychoeducation combined with other strategies to increase the level of patient engagement (telephone reminders, liaison with the navigator, etc.). Another group, called Rehabilitation, Addiction and Impulsivity or RDI, employs proactive cognitive and behavioral strategies to reduce substance use and prevent relapse. A weekly group focusing on the development of social skills and autonomy in daily activities is also offered to people who experience difficulties or who have functional deficits. This formula has been shown to be effective in the treatment of alcohol dependence (Miller et al., 2003) and in the treatment of various psychiatric pathologies. For its part, the social reintegration group “Return to Productive Activities” or RAP uses a cognitive and behavioral approach to provide active support to patients who have achieved stability in their substance use and their psychiatric condition for a few months.
Wishing to help a socially vulnerable and often neglected population and in agreement with the hospital management, the Addiction Medicine Service had been committed for some time to providing care to patients with no evidence residency or health insurance card. The UPT’s approach is part of this position statement. On the other hand, eligible patients must agree to take the necessary steps to obtain a valid card from the Régie de l’assurance- maladie du Québec (RAMQ) with the help of the team’s social workers during their episode of care. This administrative concession constitutes a relaxation of the eligibility criteria in favor of the itinerant population,
Challenges for UPT
The challenges are considerable when it comes to effectively aligning the multiple services for the treatment of drug addiction and mental health problems in urban areas, and in Montreal in particular. Of course, unnecessary and costly duplication of services must be avoided; it is also necessary to promote an uninterrupted sequence of episodes of care to prevent the instability of a particularly vulnerable clientele. Unfortunately, each organization operates according to its reference models, its access criteria and its waiting lists. Each of these factors is likely to delay or even jeopardize the continuity of the recovery and rehabilitation process once the stabilization phase has been reached in the UPT. Another major obstacle, the notorious scarcity of low-cost or sheltered housing and systemic discrimination against this clientele with a history of drug addiction or psychiatric disorder. Indeed, without better living conditions and a healthy environment, efforts to help these people recover could easily end in failure, despite intensive therapeutic follow-up. To finally succeed in working together to manage this clientele, it will also be necessary to overcome the years of mutual ignorance and mistrust maintained by the various institutions, both in hospital and community settings. In this regard, the increased recognition and appreciation of innovative approaches in the treatment of concurrent disorders provides a glimmer of hope. Thanks to small gestures in this direction on the part of all the partners involved, we can collectively hope to see this particularly vulnerable population soon benefit from appropriate treatment delivered in a timely manner.
The authors would like to thank Madame Camille Brochu for the linguistic revision of this article. The writing of the manuscript was made possible thanks to the support of the CHUM Research Center, the CHUM Department of Psychiatry and the Department of Psychiatry of the University of Montreal (DJA).