Response to Canadian Psychiatric Association Opioid Use Disorder Position Statement: More than Just Collaborators in Care

The recently published Canadian Psychiatric Association position statement (“Psychiatry and the Opioid Crisis in Canada”) provides a background on the Canadian opioid crisis and makes recommendations for psychiatric practice relevant to opioids. ¹ In it, Neilson and colleagues defined an interprofessional and multidisciplinary model of care for individuals with opioid use disorder (OUD) that Canadian psychiatrists should adopt. ¹ To that end, the position statement describes the main role of psychiatrists as collaborators in the management of patients with OUD, specifically highlighting our expertise with concurrent psychiatric disorders, and also in the management of chronic pain. ¹ Throughout, the authors of the position statement highlight a variety of CanMEDS roles, namely, the role of advocate, collaborator, and communicator. ²

While the publication of this position statement represents a positive step forward in increasing the visibility of psychiatrists as addiction experts, there are opportunities to boost the impact of this position statement further.

First, training psychiatry residents and psychiatrists in the pharmacotherapy of OUD needs to be emphasized. Opioid agonist therapies (OAT), including methadone and buprenorphine, are lifesaving medicines that can greatly reduce morbidity and mortality for individuals with OUD and no longer carry any additional federal requirements to be able to be prescribed. Unfortunately, too few physicians currently prescribe OAT. ³ Current training guidelines in substance-related and addictive disorders for psychiatry likely need to be updated to encourage proficient or advanced knowledge and skills in addiction pharmacology, particularly OAT, from the current working knowledge expectation. ^4,5 In addition, explicit training in harm reduction strategies and how to reduce risks of OAT being diverted or used with other substances should also occur.

Second, while the position statement encouraged trainees to pursue pain fellowships, trainees should also be encouraged to pursue addiction fellowships. In Canada, there are currently seven 1-year addiction fellowships, which provide trainees a structured opportunity to gain practical skills in addiction pharmacotherapy, psychotherapy, and approaches to treatment. Although the addiction fellowships are not yet certified as formal Royal College subspecialty training programs, this landscape is rapidly changing with the shift to competency-based training and the establishment of an area of focused competence in addiction medicine. Moreover, trainees can still obtain certification by writing the International Society of Addiction Medicine.

Third, psychiatrists should take a more active role in the management of individuals with OUD and other substance use disorders. Substance use and addictive disorders are ubiquitous in psychiatric practice, with comorbidity being the norm rather than the exception. Many Canadian psychiatrists report discomfort in working with individuals with addictive disorders, often citing stigma, bureaucracy, the absence of an organized Canadian institution dedicated to addiction psychiatry, beliefs about addiction, and inadequate training. Psychiatry programs are the only postgraduate programs to date that mandate addiction training, involving either an intensive 4-week rotation or the equivalent as a longitudinal experience. Expanding beyond 4 weeks to ensure competence and translation to practice is likely required. Ultimately it will be through improved training, active treatment, and leadership that psychiatry will better address the opioid crisis.