Substance Use Or Addictive Disorders

Introduction

Substance use and addictive disorders represent a significant public health concern in Canada, impacting individuals, families, and communities. As a future Canadian physician preparing for the MCCQE1, understanding these disorders is crucial for providing effective patient care within the Canadian healthcare system.

Epidemiology in Canada

Understanding the prevalence and patterns of substance use disorders in Canada is essential for MCCQE1 preparation:

• According to the Canadian Centre on Substance Use and Addiction (CCSA), approximately 21% of Canadians meet the criteria for a substance use disorder during their lifetime.
• Alcohol is the most commonly used substance, with about 78% of Canadians reporting alcohol use in the past year.
• Cannabis is the most widely used illicit drug, with about 16% of Canadians reporting use in the past year.
• Opioid use disorder has been declared a public health crisis in Canada, with significant regional variations in prevalence and impact.

Classification and Diagnostic Criteria

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) is used in Canada for diagnosing substance use disorders. Key points to remember for the MCCQE1:

1. Substance use disorders are classified based on the specific substance involved (e.g., alcohol use disorder, opioid use disorder).
2. The DSM-5 uses a dimensional approach, with severity specified as mild, moderate, or severe based on the number of criteria met.
3. The diagnosis requires meeting at least 2 out of 11 criteria within a 12-month period.

Canadian Guidelines for Substance Use Disorders

For MCCQE1 preparation, familiarize yourself with key Canadian guidelines:

1. Alcohol Use Disorder: The Canadian Centre on Substance Use and Addiction (CCSA) provides Low-Risk Alcohol Drinking Guidelines.
2. Opioid Use Disorder: The Canadian Research Initiative in Substance Misuse (CRISM) offers national guidelines for the clinical management of opioid use disorder.
3. Cannabis Use: Health Canada provides guidelines for cannabis use, including recommendations for reducing health risks.

Treatment Approaches in Canada

Canadian treatment approaches for substance use disorders emphasize a harm reduction model and evidence-based interventions. Key points for MCCQE1:

Canadian Healthcare System Considerations

Understanding how substance use disorders are managed within the Canadian healthcare system is crucial for the MCCQE1:

1. Universal Healthcare: Treatment for substance use disorders is covered under provincial health insurance plans, but coverage may vary by province.
2. Integrated Care: Many Canadian jurisdictions are moving towards integrated mental health and addiction services.
3. Indigenous Populations: Culturally appropriate treatment programs are available for Indigenous communities, recognizing their unique needs and historical context.
4. Telemedicine: Increasing use of telemedicine for addiction services, especially in rural and remote areas.

Key Points to Remember for MCCQE1

• 🍁 Understand Canadian epidemiology and how it differs from global data
• 🏥 Know the DSM-5 criteria and severity classification for substance use disorders
• 📊 Familiarize yourself with Canadian-specific screening tools and their interpretation
• 💊 Be aware of first-line pharmacological treatments approved in Canada
• 🤝 Understand the principles of harm reduction and their application in Canadian healthcare
• 🌿 Know the current legal status and medical use guidelines for cannabis in Canada
• 🩺 Recognize the role of primary care physicians in managing substance use disorders within the Canadian healthcare system

Sample MCCQE1-Style Question

# Sample Question

A 32-year-old woman presents to her family physician with concerns about her alcohol consumption. She reports drinking 5-6 drinks daily for the past year and has tried to cut down multiple times without success. She has missed several days of work due to hangovers and her partner has expressed concern about her drinking. Which of the following is the most appropriate next step in management?

- [ ] A. Advise her to attend Alcoholics Anonymous meetings
- [ ] B. Prescribe disulfiram to deter alcohol consumption
- [ ] C. Refer her to an addiction specialist
- [ ] D. Start naltrexone and provide brief counseling
- [ ] E. Recommend inpatient detoxification

Explanation

The correct answer is:

• D. Start naltrexone and provide brief counseling

Explanation: This patient meets the criteria for moderate to severe alcohol use disorder based on the DSM-5 criteria (inability to cut down, tolerance, social/occupational problems). In the Canadian healthcare context, primary care physicians play a crucial role in managing substance use disorders. The most appropriate first-line treatment for this patient would be pharmacotherapy combined with brief counseling.

Naltrexone is a first-line medication for alcohol use disorder in Canada, shown to reduce heavy drinking days and cravings. Brief counseling, such as motivational interviewing, can be effectively delivered by family physicians and has been shown to improve outcomes when combined with pharmacotherapy.

Options A and C (Alcoholics Anonymous and specialist referral) may be helpful adjuncts but are not the most appropriate first steps. Option B (disulfiram) is not first-line therapy and has significant side effects and compliance issues. Option E (inpatient detoxification) is not necessary for all patients and should be reserved for those with severe withdrawal risk or failed outpatient management.

This question tests your knowledge of:

1. Diagnostic criteria for alcohol use disorder
2. First-line treatments in the Canadian context
3. The role of primary care in managing substance use disorders
4. Evidence-based pharmacotherapy options

Canadian Guidelines

The Canadian Centre on Substance Use and Addiction (CCSA) provides guidelines for alcohol use:

• Low-risk drinking guidelines: No more than 10 standard drinks a week for women, with no more than 2 drinks most days
• For men, no more than 15 standard drinks a week, with no more than 3 drinks most days
• Plan non-drinking days every week to avoid developing a habit

References

1. Canadian Centre on Substance Use and Addiction. (2018). Canada's Low-Risk Alcohol Drinking Guidelines. Retrieved from https://www.ccsa.ca/canadas-low-risk-alcohol-drinking-guidelines-brochure (opens in a new tab)

2. Bruneau, J., Ahamad, K., Goyer, M. È., Poulin, G., Selby, P., Fischer, B., ... & Wood, E. (2018). Management of opioid use disorders: a national clinical practice guideline. CMAJ, 190(9), E247-E257.

3. Fischer, B., Russell, C., Sabioni, P., van den Brink, W., Le Foll, B., Hall, W., ... & Room, R. (2017). Lower-Risk Cannabis Use Guidelines: A Comprehensive Update of Evidence and Recommendations. American Journal of Public Health, 107(8), e1-e12.

4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

5. Centre for Addiction and Mental Health. (2019). Alcohol. Retrieved from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/alcohol (opens in a new tab)