Polished shoes; a collared shirt peeking out from under his pea coat; a professional degree listed on his chart. When the patient walked into my exam room, I was surprised when he told me he was struggling with drinking too much, but far more surprised he felt comfortable enough to open up to me, a family medicine resident, about it.
Substance use disorders are prevalent in Canada – a 2012 report noted about 21.6 per cent of Canadians met the criteria – and often go hand-in-hand with mental health disorders, trauma and life stressors, and are under-detected. Although deaths and overdoses related to opioids have decreased in the past decade across Canada, the rates of other substances like stimulants, cannabis or nervous system depressants have increased.
Substance use has major impacts on a person’s functioning, relationships and sense of self and can be devastating. Costs associated with obtaining substances and risky situations can put individuals at risk for more blood-borne infections, accidental injuries like heart disease and overall health outcomes. It can also affect society on a larger scale. Data shows that the overall economic cost of substance use in Canada in 2020 was $49.1 billion – almost $1,300 for everyone across the country. Nearly 75 per cent of these costs were related to lost productivity and, more specifically, people dying at a young age from opioid use. The impact of premature deaths or disability amounted to about $22.4 billion in 2020. Health-care costs like hospitalizations, emergency department visits and paramedic services have increased in the past decade, mainly caused by stimulants, cannabis, alcohol and opioids.
However, stereotypes and stigma often result in health-care providers overlooking risky substance use.
“Just because someone doesn’t look like they may be struggling with a substance doesn’t mean that they aren’t, and there is often shame about bringing it up,” says Mira Pavan, a family doctor at Recovery Care in Ottawa, a rapid-access clinic for patients to help improve their substance use health, adding that patients don’t always present in the way providers would expect.
Given her experience in a rural practice, where supports often are non-existent, Pavan knows family physicians are in the unique position of being the first to detect substance abuse. This is especially important given a patient’s comorbid conditions that family doctors may already be managing.
“Ideally,” says Pavan, “your family physician is the place, your go-to place – that is the person that should have a longitudinal relationship with you for your health. What is health if not addressing a substance use disorder which has huge implications on a person’s life?”
However, a randomized clinical trial of family physicians in Ontario showed they were three times less likely to accept new patients with opioid use disorder compared with other conditions like diabetes; 28 per cent of physicians reported they would not accept patients who require prescribed opioids into their practice.
But there are solutions to hesitation around opioid use disorder treatment. “(The University of British Columbia) offers a free course that you can finish over a weekend,” says Pavan. “You just have to spend two half-days with someone that does opioid agonist therapy treatment. That’s it. That is the only thing you need to do to be able to prescribe Suboxone or methadone.”
She acknowledges that “family doctors don’t really get much training about starting or titrating lithium or methotrexate or tacrolimus, but we still do it anyway. Same with many antipsychotics. So, to say ‘I’m not comfortable with this,’ I think that is something that many family physicians put up as an excuse. A legitimate-sounding excuse to say I don’t want to treat, and I’m othering these patients.”
In a different study, Ontarian physicians listed insufficient training and discomfort with practicing addictions medicine as the greatest barriers; only 32 per cent of surveyed family physicians said they had adequate knowledge of pharmacotherapies to prescribe for nicotine, alcohol or opioid use disorders.
“You don’t see everything in a two-year residency anyway,” says Pavan. “Are you going to say you don’t feel comfortable doing all of family medicine? Or are you going to use the problem-solving skills you learned to figure it out for your patient?
“Not trying is really not an excuse for a family physician – we’re able to do the basic treatment for any health issue, including substance use disorders. That’s well within a family doctor’s wheelhouse.”
In the clinical trial, physicians said patients with substance use disorder were too complex, potentially disruptive to practice workflows and too time consuming to manage, something Pavan acknowledges. “The biggest limiting factor, to be honest, is time. Patients with substance use disorders take a lot of time and appointment spots. That is a systemic thing, but it’s a big limiting factor.”
However, she adds there are practical tips to ease physicians’ time constraints long-term with new patients, starting with the first visit. “Whenever you meet a new patient, take their social history. Have a standard intake. Do you smoke cigarettes or vape? Do you drink alcohol – how many times a week, how much, what’s your drink of choice? Any recreational drugs, including marijuana?” Another place to start is sleep. “If someone comes in saying they’re not sleeping well – substances affect sleep. There’s a pretty natural segue: What’s keeping you up? What do you use to try to sleep? How do you cope with stress? Here are some things that might interfere – caffeine, alcohol, recreational drugs.”
She says where she sees the most benefit is approaching with natural curiosity, as opposed to a tactic of “tell me what you might be taking.”
Primary care clinics can be the best place for detection because of the stigma patients feel when walking into a specialized clinic. “When you walk into a substance use disorder clinic, people see you walking into a substance use disorder clinic. (When) you walk into a family doctor’s office, no one knows why you’re there,” says Pavan, adding that asking about substance use takes as much effort as sending a patient for diabetes or cholesterol screening.
“Just because someone’s presenting well, you just don’t know. People mask well. Sometimes it’s a brewing substance use disorder, and you might be able to bring some light on it before it develops into a full-blown moderate or severe disorder.”
As for family medicine physicians making time to detect substance use disorders, she emphasizes the main tenet of the specialty: “That’s preventative health right there.”
