During last fall’s provincial election, Premier David Eby promised voters his government would implement mandatory care for British Columbians unable to care for themselves due to brain injury, mental health and addiction issues. This week, the man Eby tasked with figuring out how to implement that care clarified the clinical guidance for involuntary treatment under the Mental Health Act, explaining the dos and don’ts around how it will apply.
Northern Beat sat down with Dr. Daniel Vigo, B.C.’s first chief scientific adviser for psychiatry, to find out more.
Q: You were asked by the premier to look into mandatory care. Can you explain the analysis done to understand the situation with mandatory care?
A: I’m an academic and a clinical psychiatrist. I produced a report for the government [in 2018]… to understand to what extent involuntary care was being provided to people with substance use disorders. What we saw is that the use of involuntary care for people with very prominent substance use disorders tended to be very short until the acute episode was resolved.
If the person was determined to have been using crystal meth, for example, maybe the physician in the Emergency Department would say, ‘Well, then we cannot keep you [after the high wore off] under the Mental Health Act.’ Whereas, if the person had a manic episode without the involvement of substance use, then they would feel more comfortable keeping them, assessing more thoroughly what the problem was, and providing longer-term care.
What we did today was say, it doesn’t really matter for the Mental Health Act what… is producing the mental impairment. What’s important is that that mental impairment is making that person unable to engage with care, despite needing it for the protection of self, protection of others, etc.
We know that there’s a group of people with overlapping severe mental illness, substance use disorders and acquired brain injury, very severe acquired brain injury, that you can already detect through administrative records, and that is a minimum of 2500 people. A fraction of those will require involuntary care. How many, we’re still studying. We’re still defining what is the level… of acquired brain injury that will generate that kind of chronic impairment.
“What’s important is that that mental impairment is making that person unable to engage with care, despite needing it for the protection of self, protection of others.”
In the meantime, what we’re doing is putting in the hands of clinicians a tool where, when they have a patient in front of them, they can say, ‘Okay, this patient has neuro-cognitive disorder due to the repeated overdoses,’ for example, in addition to their poly-substance use disorder that meets the threshold for involuntary care under the act.
So instead of just letting them out of the Emergency Department the minute that their acute agitation is resolved, I’m going to keep them. I’m going to assess them. I’m going to try a psychopharmacological regime that can keep them as stable as possible to prevent a new episode of agitation.
Q: Do you not think that another primary reason people were being released quickly was the lack of resources to keep them …[ particularly] in communities outside of Vancouver?
Well, that is a challenge for the system, and we are creating the beds that are needed. We are creating the first beds in Surrey pre-trial and in Maple Ridge.
But we have explored all the other health authorities. We have preliminarily identified sites that we’re studying and that I hope to confirm as soon as possible, as the sites of the expanded long-term psychiatric rehabilitation centres.
Q: Is this the Red Fish expansion [an unfulfilled promise from Budget 2023]?
A: Part of it will be Red Rish expansion. Part of it will be general tertiary care for psychiatry.
When Riverview [psychiatric hospital in Coquitlam] was closed, the idea was that we were going to create decentralized psychiatric rehabilitation units. Of course, we didn’t know how hard the impact of synthetic drugs would be. But still. Now we have seen that we need to ramp up the creation of those beds and of the community teams that can provide care for those folks … because what we need is a seamless approach, the continuum of care.
The Mental Health Act allows us to, let’s say, keep the person in the ED, treat them, transition them to an acute bed. Once a person is involuntarily admitted and treated, we now will be able to exercise our full clinical judgment as to the combination of pharmaceutical drugs that we use to stabilize that person.
“We don’t need to physically keep them in [hospital] a minute longer than they need.”
Then we can release them on extended leave. We don’t need to physically keep them in an inpatient bed one minute longer than they need. And we can provide depot [injectable] antipsychotics, depot [injectable] buprenorphine that will significantly improve our ability to manage these patients in the community.
Q: Wasn’t that already available? Are you talking about Opiate Agonist Therapy [OAT]?
A: [Nods] But many colleagues wrongly would have said… you cannot use buprenorphine under the Mental Health Act. And what I’m clarifying is that, you can. There’s no restriction as to the psychiatric care that you can provide under Section 31 of the Act, you just need to provide the rationale of why you are using, let’s say, depot antipsychotic and depot buprenorphine.
Q: Okay, since OAT was already available to clinicians, is this more of a clarification, so that there’s an understanding of it across the system?
A: It was available, but… it was mistakenly thought… that you couldn’t [involuntarily prescribe OAT]. And so now we’re making it crystal clear how and when you can use your judgment as a psychiatrist to involuntarily admit and involuntarily treat.
Q: So OAT was always available, but now, now clinicians… can [administer] it involuntarily?
A: Exactly. Now it should be said, all of these patients that we’re talking about are very difficult patients. There’s no manual to treat them. And so whoever is managing these medications needs to be comfortable doing that, needs to be a specialist… psychiatrists, addiction docs, psychiatric nurses, etc,
In general, the main thing to take away is now it’s crystal clear what you can do and the things that you cannot do, [so] in time, people will feel more comfortable and will treat these [patients] better.
Q: One of the things I heard, certainly in the rural areas… early in the pandemic especially, was the challenge of finding clinicians who were comfortable prescribing OAT. That seemed to be the limitation.
A: There’s an interesting wrinkle there. So the BC Mental Health Act does not allow for the treatment of any disorder involuntarily. If there’s no state of mental impairment that is serious enough in someone who only has an addiction and who is outside of episodes of intoxication, [and they] refuse care, you cannot treat them involuntarily.
There are several drugs that can be used as OAT, buprenorphine is one, methadone, morphine, and then others, but let’s say those are the three. Methadone and morphine have some side effects [and]… a number of requirements to prescribe them that make it very cumbersome for a regular, either GP [General Practitioner] or psychiatrist, to feel comfortable.
Buprenorphine is not that case. Buprenorphine is very benign in terms of side effects, much more benign than many of the other drugs we use routinely. So any doctor should feel comfortable prescribing buprenorphine. Remember, we’re talking involuntary care for people with a mental impairment… someone who you’re trying to keep in a situation where they’re safe and others are safe.
“Buprenorphine is… much more benign than many of the other drugs we use routinely.”
In the future, they may decide themselves to treat their addiction, but for now, we’re using an anti-psychotic, augmenting it with buprenorphine to avoid the behaviour and… repercussions of the psychosis. [A regime]… any doctor can feel comfortable with it, any doctor that reads the evidence and decides to try it. Because it’s not that more complex daily regulation of morphine or methadone or oral buprenorphine every day several times. It is an injection once a month, in addition to the injection once a month that they get for the anti-psychotic medication, or Clozapine let’s say, if you have a treatment-resistant psychosis.
Q: What’s the process after that? You get someone stabilized, and then they’re released to potentially go and acquire more brain injury?
A: Let’s say you admit a patient who has a concurrent disorder – psychosis and poly-substance use disorder – which is unfortunately very frequent here, because any drug that they take has all sorts of combinations of stimuli, crystal meth and fentanyl and benzodiazepine, etc.
You give them antipsychotics, and you don’t reach stability because the disorganization is so severe that they continue going out, getting in trouble, going out with weapons, all sorts of things that put them and others at risk. So you may say, ‘Okay, I’m going to try this augmentation strategy’ [involuntary buprenorphine injection].
Let’s say you got them in through the Emergency Department. You need to find an acute bed, which may happen or not happen that day or the next one. And if the ED is saturated, then… you may need to follow them up in the community – that’s what community teams are for – until the bed frees up.
Then you bring them back. This is the bread and butter of our community care for these patients. That’s what we do.
When you get the acute bed, you stabilize the patient with let’s say clozapine and depot buprenorphine. Now that patient, at that point, if things work, is stable.
The patient can go out; the patient can use drugs.
While receiving involuntary treatment, a person can continue to use illicit drugs.
The patient as a secondary, positive externality of your regime, will not die of an overdose, because the buprenorphine will put a ceiling to the toxic effects of fentanyl, for example. The behaviour is more manageable. The psychosis doesn’t affect their mood and their actions in the same way. That’s a patient that doesn’t show up in the Emergenty Department for months. Or anymore.
Q: But their substance use disorder is not treated?
A: Correct.
Under involuntary care, substance use disorder is not treated.
Q: You mentioned [in an earlier press conference] 18,000 people were involuntarily treated last year and the most severely affected 150 people will go into the system first. Can you … give us some data here?
A: If we look at… health utilization data where physicians write up a diagnosis… with a fairly stringent definition of brain injury and of severe mental illness and of substance use disorders, there are around 2500 people that have [those] three [concurrent conditions].
If you use a higher threshold, meaning you include lesser forms of acquired brain injury, you can go up to 4,500 people.
At least 4,500 British Columbians have serious overlapping mental illness, addictions and brain injury, with 2,500 of those “very severe.”
That doesn’t mean that 2500 people will require involuntary care. Even at that level of severity, many of these folks don’t require voluntary care. They engage with care. They are going to their addiction doc. They’re seeing their psychiatrists. They engage with a community mental health team, or with a… community treatment team.
Now, a subgroup of those… in the hundreds, but we are homing in on that, will have a level of behavioural disturbance that is not manageable with the usual things that we have. So that group is the one we’re focusing on most urgently, because they are the most at risk themselves.
Q: Just for clarification, this is the group that the public is most aware of in terms of repeat offending and concurrent disorders?
A: That’s exactly right.
So basically… the 150 most disruptive – from a behavioural perspective – patients in need. The ones that are less able to seek care themselves because they are interfered by psychosis, they have brain damage and so on and so forth.
Some of the most disruptive patients may be treated ‘involuntarily’ in the community.
So we want to be able to create teams that can do outreach for them, seek them out, because the police know them. The police interact with them day-in and day-out, and so we can ensure that they are connected with the mental healthcare team, that the right psychopharmacological approach was tried, that despite the prominence of the substance use disorder, they are treated under the Act and a proper regime is designed for them by a specialist.
Q: So they’ll be treated in community?
A: They will be treated in community if possible, in inpatient settings if not possible, in an approved home, if impossible. In correctional settings, if that’s where they are.
We are able, thanks to the Mental Health Act, to discharge someone from an inpatient bed the moment they’re stable enough to be in the community, but still in involuntary care on what’s called ‘extended leave.’
When we talk about 1000s of people under the Mental Health Act, that doesn’t mean, of course, that they are in an inpatient-bed. Many of them are in the community. They have to adhere to their treatment because they have proven, time and again that when they stop it, they go back to the hospital.
So our tools are there to treat them, voluntarily or involuntarily, in an inpatient setting, in the community and [soon] in an approved home or in a mental [health unit], if living in Corrections.
Q: Okay, so the ability is there legally, but are the resources there?
A: We’re creating some beds this month, some more beds in May, some more beds throughout the year. That’s my commitment to keep advocating within government and to the community, because this will be a whole-of-society effort to fund these services.
“This will be a whole-of-society effort to fund these services.”
Q: Particularly a government effort.
A: The whole-of-society. This is a health system that people fund through taxes.
Q: But the money actually has to be [budget by government] to start.
A: Yes, the government has funds that they allocate to different things. And this is a priority for the government.
Q: What really matters to people is, when will they see a difference on the street, and with six beds here and six beds there–
A: It will ramp up. It’s 10 beds now that will go to 20. It’s six beds that will go to 18, and it’s dozens of other beds that are being created.
Q: One of the things the BC government promised in budget 2023 within three years – which is next year – is three regional centres [based on Red Fish] for people with concurrent issues.
A: Well, I joined the effort in June of last year. The Office of the Chief Scientific Advisor is an independent office tasked with making evidence-based recommendations, which is what I’ve been doing.
What I requested was access to the data, which I got. What I requested was the ability to have an office that actually analyzed that data, which I got. A commitment from the premier that the recommendations were going to be followed. And they are being followed.
So, I’m very optimistic, and I think we are going to see the changes gradually.
Note: This transcript was edited for clarity and brevity.