Decriminalization. Rising rates of experimentation. Misuse and abuse coupled with the ‘double pandemic’ which includes the longstanding opioid crisis. As Ismaili Healthcare Professionals it behooves us to reflect on our own competency and comfort in considering if/how substance use plays a role in the wellness of those whom we strive to serve. 

The statistics can be surprising – and unsettling. One in five Canadians aged 12 or older drinks in excess of the daily or weekly limit (1). Of those 15 years or older who do drink, 18% of them will have a diagnosis of “alcohol use disorder” (AUD) during their lifetime. Interestingly, twin studies indicate that the propensity to develop AUD is 50% genetically influenced; this new insight can inform care plans tailored to individuals, but may also be a consideration as a life choice with the potential to impact future generations. In terms of cost, alcohol contributes to 8% of Canadian deaths. Furthermore, the economic implications of substance use in Canada is approximately $40 billion dollars per year ($14.6 billion from alcohol, $12 billion due to smoking and $11.8 billion from others) (2, 3, 4).   

Research estimates that up to half of current users will die of a tobacco-related disease (6, 7). With the advent of alternative options, there is a mounting “gateway concern”. That is, young people who would not otherwise try cigarettes, start using e-cigarettes (the ‘gateway’ [substance]), thereafter, becoming smokers. The literature showed a 900% increase in Canada, from 1.5% in 2011 to 16% in 2015 among high schoolers who began using e-cigarettes. While media and mates may minimize the sequalae of e-cigarettes, firm evidence on the types and concentrations of potentially harmful chemicals within e-cigarettes remains lacking, as does data on long-term safety. Some associations however, continue to be verified. A recent review concluded that “the early initiation of cannabis use was associated with an increased risk of early onset psychotic disorder, especially for those with a pre-existing vulnerability and those who use cannabis daily” (9). 

Sometimes, a person’s drug of choice could be a stimulant (cocaine, ecstasy, amphetamines, etc.) or an opioid (morphine, heroin, fentanyl/carfentanyl etc.). According to a survey by Health Canada, 22% of Canadians 15 years or older had used a psychoactive agent (10). Often, substances are used together. Given the multifactorial impact, coupled with the rise in accidental injury and fatalities, public health, inner city and primary care responses – particularly in regions such as Vancouver’s downtown eastside (DTES) – are augmenting efforts to mitigate the current opioid crisis. Opioids have surpassed motor vehicle accidents, and are now the leading cause of injury in North America. Ancillary impact also occurs with high risk behaviours, such as sharing of needles, which leads to increase risk of transmitting and acquiring blood-borne viruses including hepatitis and HIV. 

The impact of substance use can compound easily. For example, anxiety frequently co-occurs with substance use disorders (11). Compared to the general population in which 16% are affected, 30% of those with substance use disorders have an anxiety disorder (12). Furthermore, the presence of a substance use disorder increases the risk for anxiety disorders by 1.7-2.8 times. Other critical factors, such as social determinants of health (poverty, housing, access to food, resiliency … a global pandemic) can add other barriers. Layered upon this is taboo, tradition, today’s times, Tariqah, and ultimately, our openness to open the conversation. 

What’s out there?  

The longstanding advocacy for primary care and improved access to it, seems to be garnering local and national support, albeit in varying degrees. In some areas of the country, creative models aim to accelerate improvement, both on a person/family level but also on a systems level. Examples include rapid access to opioid agonist therapy such as the Rapid Access Addiction Clinic (RAAC) in BC, Rapid Access Addiction Medicine (RAAM) in Hamilton, Addiction Recovery and Community Health Clinic (ARCH) in Edmonton. Other models include offering team-based care which can provide much needed allied health supports (for example, in social work and trauma informed counselling), and may include ‘wrap around care’ and case management. Still others may ‘outreach’ – physically going to the person, whether they are living at home, or on the streets. In tandem, public-private partnerships often enable community resources which aspire to be nimble to the needs of those requiring additional supports. 

What can we do? 

References 
1. Canada's Low-Risk Alcohol Drinking Guidelines – Recommendations are: no more than two drinks a day, 10 per week for women, and three drinks a day, 15 per week for men, with an extra drink allowed on special occasions. Website. 
2. UBC CPD elearning Alcohol Use Disorder Module. Addiction Care and Treatment Online Certificate Program 
3. Canadian Centre on Substance Use and Addiction. Canadian Substance Use Costs and Harms in Provinces and Territories (2007-2014). 
4. Litten, R. Z., Ryan, M. L., Falk, D. E., Reilly, M., Fertig, J. B. and Koob, G.F. (2015) Herterogeneity of Alcohol Use Disoder: Understanding Mechanisms to Advance Personalized Treatment. Alcohol Clin Exp Res, 39: 579-584. 
5. Statistics Canada. Health Fact Sheets: Smoking (cat. no.82-625-X). Website. Published 2017. Accessed August 27, 2018. 
6. Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 Countries, 1980-2012. JAMA. 2014: 311(2). 
7. World Health Organization. WHO Report on Global Tobacco Epidemic, 2013. Enforcing bans on tobacco advertising, promotion and sponsorship. Website. Published 2013. Accessed. Accessed January 11 2019. 
8. Glantz SA, Bareham DW. E-Cigarettes: Use, Effects on Smoking, Risks, and Policy Implications. Annu Rev Public Health. 2018;39(1):215-235. 
9. Bagot KS, Milin R, Kaminer Y. Adolescent initiation of cannabis use and early-onset psychosis. Subst Abuse. 2015; 36: 524-33. 
10. Canadian Tobacco Alcohol and Drugs (CTADS): 2015 summary. Government of Canada. Website. Updated June, 2017. Accessed Janar 24, 2019. 
11. Ries R, Miller SC, Saitz R, Fiellin DA, Ebooks Corporation. The ASAM Principles of Addiction Medicine. Fifth ed. Philadelphia: Wolters Kluwer Health; 2014. 
12. Wolitzky-Taylor K, Operskalski JT, Ries R, Craske MG, Roy-Byrne P. Understanding and treating comorbid anxiety disorders in substance users: review and future directions. J Addict Med. 2011;5(4):233-247