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Training in Substance-Related and Addictive Disorders, Part 1: Overview of Clinical Practice and General Recommendations.

Substance-related and addictive disorders include the substance use disorders (SUDs) and the behavioural addiction of gambling disorder.1 Together, they represent some of the most prevalent mental disorders, where it is estimated that 11 to 14 per cent of North Americans will meet lifetime criteria for an SUD2–6 and a further 0.4 to 1.1 per cent will meet criteria for gambling disorder.7 The peak age of onset for SUD is in young adulthood (ages 18 to 20), apart from cannabis use disorder, which typically has its peak age of onset in later adolescence (ages 16 to 18), and comorbid mental disorders often being established early, then extending into adulthood.8–11 In addition to contributing to a wide range of social problems, including abuse, neglect, crime, unemployment, suicide, accidents, and family dysfunction, substance-related and addictive disorders are a major contributor to potentially preventable medical illnesses and premature death, where the estimated cost to Canadian society is $40 billion, annually.12,13 Psychiatric comorbidity in people with substance-related and addictive disorders are all too common, where between one-quarter and one-half of all patients seeking psychiatric treatment meet criteria for a lifetime SUD,14–17 and for those patients seeking addiction treatment, 40 to 60 per cent are identified to have an independent (nonsubstance-induced) mood disorder.15 
 
In the Canadian health care system, mental health and addiction treatment services have been traditionally compartmentalized and have functioned independently with different philosophies. While we have known for some time that people suffering from a serious and persistent mental disorder with a co-occurring addiction tend to respond less well to traditional abstinence-focused addiction services,18 current fragmented services have impeded the development of a specialized capacity to effectively treat this population. These patients can do well with what has been called integrated treatment, where the treatment of the mental disorder and the addiction illness is provided by the same team of professionals. In fact, more than 50 controlled studies have established the importance of integrating the treatment of patients with co-occurring disorders, which inherently solve the typical problems encountered in the separate systems of care for these individuals.19 For these reasons, Canadian clinical guidelines recommend that all people seeking help from mental health treatment services be screened for co-occurring SUDs.20 Health Canada Best Practices20 further recommend an integrated treatment approach at the program level for people suffering from serious and persistent mental disorders with co-occurring addiction. 
 
In 1997, a first position paper was published by the Canadian Psychiatric Association (CPA) in the form of Curriculum Guidelines for Residency Training of Psychiatrists in Substance-Related Disorders.21 Since then, the field of addiction psychiatry has continued to advance, with the emergence of new scientific data regarding neurobiology and psychosocial interventions. 
 
 
Importantly, clinical guidelines have been published for the treatment of SUDs by the American Psychiatric Association (APA)22 and the World Federation of Societies of Biological Psychiatry.23,24 Health Canada also published Best Practices recommendations on concurrent mental and SUDs.20 In addition, in 2007, the Royal College of Physicians and Surgeons of Canada (RCPSC) released the new Specialty Training Requirements (STR) in Psychiatry,25 outlining more specific expectations in addiction training for psychiatry residents. The Objectives of Training (OTR)–STR, as they apply to training in substance-related and addictive disorders, include the following: 
 
 
Supervised experience in the treatment of patients with substance-related and addictive disorders in various settings. A learning portfolio or log should be maintained and reviewed by the program director. This experience must be undertaken as a discrete rotation of no less than one month or incorporated as a longitudinal experience (at any time during postgraduate year [PGY] 2 to 5) of no less than the equivalent of one month. This must be documented and evaluated separately from other rotations. 
 
 
Availability of a selective rotation in substance-related and addictive disorders of no less than three months, but preferably six months, during senior psychiatric residency training (PGY 4 to 5) to develop advanced knowledge (definition in Table 1) in addiction psychiatry. 
 
 
 
Table 1 
 
RCPSC knowledge and skills definitions81 
 
 
 
 
Proficient (definition in Table 1) clinical knowledge, skills and attitudes appropriate to their practice in substance-related and addictive disorders. 
 
 
Function effectively as consultants, integrating all of the CanMEDS roles to provide optimal, ethical, and patient-centred medical care, by identifying and appropriately responding to patients with addiction comorbidity. 
 
 
Demonstrate introductory knowledge (definition in Table 1) in assessing suitability for prescribing and delivery of motivational interviewing (MI). 
 
 
 
 
To address the changes offered in the RCPSC OTR– STR and to update the previously published CPA curriculum guidelines21 with current recommendations, a working group with national representation and expertise in addiction psychiatry was sought to prepare a position paper and offer recommendations for training in residency. The objectives of the first part of this position paper are to highlight key concepts relevant to substance-related and addictive disorders in the clinical practice of psychiatry and to offer general recommendations regarding education and training for our profession. More specifically, we aim to discuss important issues relevant to addiction, such as attitudinal skills, the process of screening and diagnosis, its integration within general psychiatry clinical settings, psychosocial interventions and pharmacotherapy. Issues related to special population are also briefly discussed. The second part of this paper26 will offer updated curriculum guidelines for psychiatric residency training in substance-related and addictive disorders, which review, in detail, what we consider an appropriate preparation for the future psychiatrist in training to work with people suffering from addictive disorders.