Embracing complexity: Challenges and opportunities of treating those with substance misuse and mental illness

Why don’t those of us in the medical field not readily embrace complex patients? There are many potential reasons we might consider in defense of this question. First, we have limited time, so complicated patients tax our scheduled time and limited bandwidth, given all we need to accomplish in our busy days. Second, we aren’t paid for complexity: with fee-for-service funding, it’s more cost-effective NOT to treat very complex patients. Third, there’s considerable “unfunded” time spent with complex patients: repeated phone calls with family members and case managers and case conferences with other care providers— and the frustration that comes dealing with a healthcare system ill-equipped to handle the challenges associated with complex care, including multiple referrals, complicated electronic health records and care coordination. Finally, even if a complex patient becomes motivated to seek treatment, many public and privately funded facilities often don’t accept some of the evidence-based interventions, such as long-acting injectable anti-psychotics or the extended-release formulation of buprenorphine, which results in their exclusion from admission. In the last two years since the beginning of the COVID-19 pandemic, we’ve not only observed increasing volumes of people seeking medical and psychiatric care, but also observed that these patients appear to be presenting with more complex medical, psychiatric and substance use disorders that tax patients, caregivers and the intricacies of the healthcare system. The fragmentation of the system is becoming increasingly apparent, as community clinicians struggle in heroic efforts to engage complex, unwell patients, often with precarious psychosocial circumstances. In addition, physicians who are skilled to collaborate on assessing and treating these patients are not often working collaboratively, despite being similarly well-intentioned. Burnout is the rule, not the exception now, in our profession. The example of people with concurrent mental-health and substance-use problems is illustrative of these challenges, and may be a source of opportunity, and will be discussed in this blog. The complexity of care of people with mental health and addictions is illustrated with the following case: Mr. AM is a 25-year-old man who was born in Eastern Europe and migrated to Canada with his parents and sister when he was seven years old. At the age of 13, his father died from malignant melanoma. Mr. AM finished high school and attended community college where he took courses in criminal justice with hopes of becoming a police officer. He also worked part-time at the post office to help pay for college and help his mother at home. When he was 20 years old, he was involved in a serious motor vehicle accident. Another driver ran a red light and T-boned his car on the driver’s side. He sustained significant neck, shoulder and back injuries, but refused treatment since he needed to return to work. His pain continued to be a problem, and he took over-the-counter pain medications (ibuprofen) to manage the pain. He tried physiotherapy and was even referred to a pain specialist but did not find either helpful. Eventually, he became very depressed and anxious, had to quit working as the heavy lifting made it impossible to do his job and went on short-term disability. A consulting psychologist diagnosed posttraumatic stress disorder (PTSD). He started smoking crystal methamphetamine (“meth”) to give him “energy”and relieve his depression. Unfortunately, his depression and anxiety worsened, and he went to many local emergency rooms seeking help; “I want to go to drug rehab,” he said. He eventually went to a residential drug program for five weeks and achieved abstinence from crystal meth. He then went to a local mental health centre where he received group therapy for his stimulant-use disorder for six months. He was referred for follow-up in the community, but quickly relapsed to heavy crystal meth use. He became increasingly aggressive, paranoid, disorganized and experienced auditory (i.e., voices telling him that people were going to kill him) and tactile (e.g., bugs crawling under his skin) hallucinations. His mother asked him to leave her house, so he moved between various local shelters. On the subway, he assaulted two women, and was arrested, brought to a local emergency department, and released two days later when his psychiatric symptoms remitted. This scenario recurred two days later after he relapsed to crystal meth when he seriously assaulted an older man who then required hospitalization; “He looked at me and I knew he was the devil,” he said. Mr. AM was arrested and incarcerated. He was evaluated by a forensic psychiatrist in jail and declared capable of standing trial. He has remained in jail for the past year, awaiting disposition by the local forensic review board. This unfortunate case exemplifies complex clinical presentations and care, in which most of us as individual (medical, mental health and addictions) caregivers, as well as our healthcare system, are not well-positioned to intervene, in a definitive, strategic manner. While numerous treatment guidelines for people with concurrent pain, mental-health and addictive disorders exist, any one practitioner or health program does not have the skills, time and system knowledge to manage such a complex patient. Moreover, such patients often elicit substantial negative “countertransference,” that is, we don’t often feel the urge to help such patients who are often difficult to care for at an interpersonal level (e.g., demanding, the presence of personality disorders) and who often sabotage their own treatment plans. Yet, caring for a patient like this is a reminder that if we strive for integration of complex medical, psychiatric and addictions care—given that such presentations are increasingly common in acute and longitudinal care settings (and not just in tertiary care centers anymore!)—it behooves us as individual physicians within organizations and systems to be able to appropriately manage such people when they present to us in crisis, or for on-going care. Fortunately, there are excellent treatment guidelines for the care of patients with concurrent (co-occurring) disorders in Canada, the U.S., the U.K., Australia and elsewhere around the world. However, these are rarely followed because of the intensive resources and training required to diagnose and treat these patients (Bahji et al., 2021), especially given that the long-term treatment required doesn’t often have the scientific evidence to support these cost-intensive treatments (e.g. dialectical behavioural therapies, intensive case management). Nonetheless, the irony here is that with our simplified, standard approach to these patients, clinical and system outcomes are poor, costs are typically very high, and these patients are considered a burden to the health system. As well, caregivers, patients and families grow increasingly frustrated with the outcomes, as these patients “fall through the cracks.” But imagine a healthcare model that embraced the care of these complex patients, emphasized inter-professional training, collaboration, integrated care delivery and incentives for caring for such patients—financial and otherwise? We think it’s imperative for our system to better invest in such coordinated and integrative care of complex patients, as well as a health system better suited to the realities of caring for these people in a wholesome manner, which takes a bona fide approach to the biopsychosocial perspective and social determinants of health. Such an approach has been suggested for the opioid toxicity crisis in Canada (George et al., 2022), and emphasizes nuanced clinical skills development (Muuvala et al., 2019). We have a long way to go before we (and our system) can achieve such an integrated care delivery system. But we believe that it would produce better outcomes for such complicated patients, their families, and towards our own self-efficacy and satisfaction with the care we give, which might even lead to reduced burnout and improved well-being for ourselves as medical practitioners. All that is required is a vision that challenges us to do what is right for these patients, as well as the advocacy, training and resources to make this happen. Dr. Tony George is professor of Psychiatry at University of Toronto and senior clinician-scientist at CAMH. Darby Lowe is a research consultant at CAMH. Dr. Nitin Chopra is assistant professor of psychiatry at the University of Toronto, and staff addiction psychiatrist at CAMH. References: Bahji, A., Danilewitz, M., Lamba, W., Chopra, N., George, T.P. (2021). Concurrent Disorders Management in Psychiatric Care: Opportunities and Challenges (Invited Commentary). Can. J. Addict. 12: 7-9. George, T.P., Welsh, L., Franchuk, S.L., Vaccarino, F.J. (2022). Why integrating medications and psychosocial interventions is important to successfully address the opioid crisis in Canada. Can. J. Psychiatry. 67: 176-178. Muvvala, S.B., Edens, E.L., Petrakis, I.L. (2019). What role should psychiatrists have in responding to the opioid epidemic? JAMA Psychiatry. 76: 107-108.

Embracing complexity: Challenges and opportunities of treating those with substance misuse and mental illness

Register for free access or login.

Related Topics