Chapter 5 of 13 · ~1,313 words
5. Addiction, Rehabilitation and Life After Discharge
Substances that changed clinical work
The unregulated drug crisis has become one of the defining conditions of contemporary psychiatry in British Columbia. Preliminary BC Coroners Service figures for 2025 recorded 1,826 deaths, approximately 21% fewer than the 2,315 in 2024. People aged 30 to 59 accounted for 69% of deaths, and men for 77%. 48% died in a private residence, and 20% outdoors. A substantial share of crises therefore unfolds in the lives of people with housing, families and employment histories. [78]
Among those who underwent expedited toxicology testing, fentanyl was detected in 69%, fluorofentanyl in 54%, cocaine in 53% and methamphetamine in 52%; substances were frequently combined. Smoking was the most common route of use, at 65%, followed by intranasal use at 11% and injection at 9%. Clinically, this means frequent combinations of opioid dependence, stimulant use, psychotic symptoms, sleep disturbance and physical complications. [78]
Treatment of opioid and alcohol use disorders
The BC Centre on Substance Use, or BCCSU, guideline for opioid use disorder combines agonist treatment, psychosocial support, harm reduction and long-term follow-up. The choice of buprenorphine, methadone or slow-release oral morphine considers previous experience, tolerability, clinical condition and the feasibility of regular dispensing. Different buprenorphine formulations permit daily or long-acting treatment. After acute withdrawal, the next stage is retention in care, with repeated assessment of craving, continued use, sedation and comorbid illness. [79]
The range of prescribing professionals has expanded. Since September 2024, specially certified registered nurses and registered psychiatric nurses, RN/RPN CP-OUD, can prescribe buprenorphine/naloxone, extended-release buprenorphine, methadone and slow-release oral morphine after the required training. This allows addiction treatment to be incorporated into nursing and community services. [80]
For alcohol use disorder, the Canadian guideline calls for assessment of severity, withdrawal risk and treatment goals. Naltrexone and acamprosate are first-line options for ongoing treatment; acute withdrawal management follows its own algorithm. Opioid use history and hepatic and renal function influence medication selection. A screening update in May 2026 proposed a simplified approach for primary care, where a short consultation often begins with a physical complaint. [81]
Prescribed alternatives to unregulated substances have separate dispensing requirements. A December 2025 BCCSU bulletin describes the transition to witnessed dosing and the permitted exceptions. For the patient, this changes the daily schedule: travel to the dispensing location, timing that can fit around work, and the ability to maintain treatment. [82]
Decriminalization: a three-year pilot
From 31 January 2023, a federal exemption allowed adults in BC to possess a combined total of up to 2.5 g of specified substances for personal use: opioids, cocaine, methamphetamine and MDMA. In May 2024, the conditions were narrowed, restricting the permitted locations. The pilot ended on 31 January 2026; the province retained funding for navigation and outreach workers engaged during it. [83]
OAT, naloxone, drug checking, overdose prevention sites and treatment of concurrent disorders continue in clinical practice. Their everyday tasks remain specific: reducing the risk of a toxic dose, maintaining contact, selecting treatment and helping a person continue it after a crisis. The legal framework for possession changed within this broader system of care. [79, 83]
Addiction in the general hospital
During an infection, after an injury or following surgery, pain and withdrawal require treatment alongside the physical reason for admission. BCCSU describes inadequate control of these symptoms, stigmatization and difficulties remaining in hospital as circumstances that may lead a person to leave before necessary care is complete. Medication reconciliation, continuation of appropriate agonist treatment, analgesia and a discharge plan also support treatment of the infection or injury. [84]
Road to Recovery at St. Paul's Hospital has been developing since 2023. In autumn 2026, it operates 25 withdrawal management places, 20 transitional care places, and an outreach follow-up team launched in autumn 2024. Entry is possible through Access Central, the rapid access addiction clinic, the emergency department and other Providence services. A nurse clarifies goals, substance use history and physical health; a physician joins when needed. While admission is pending, the team arranges outpatient support and, for eligible patients, same-day virtual care. [85]
Transitional places are for people awaiting a treatment program or long-term housing. After a return to the community, the outreach team maintains contact. If relapse occurs, the intensity of care increases again according to the person's condition. [85]
Persistent concurrent disorders and rehabilitation
Red Fish Healing Centre has 105 beds for people with severe concurrent mental health and substance use disorders. The usual program duration is six to nine months; care includes voluntary and involuntary admissions. Planning for community return begins early, identifying housing, medication, regional team contacts and the support required. [8]
A 40-place Rehabilitation and Recovery Program provides a subsequent stage. Medically stable people from Red Fish and Heartwood are referred in conjunction with their regional team; participation is voluntary. The program includes medical and psychiatric treatment, daily-living and social skills, employment and education support, addiction work and housing assistance. Its team includes physicians, nursing and social work professionals, vocational rehabilitation counsellors and recreation workers. [86]
Several levels of support lie between ordinary outpatient care and intensive outreach. A community team provides psychiatric treatment, psychological work and case coordination. Intensive Case Management, or ICM, in Fraser primarily serves people with severe substance use problems, often alongside homelessness and mental health concerns. The team helps them reach treatment, maintains contact and addresses housing and daily needs. Where a severe, enduring mental disorder requiring intensive psychiatric follow-up is the predominant problem, ACT may be the more appropriate pathway. [10]
Community Assertive Community Treatment, or ACT, teams support adults with severe, persistent needs where they live. Fraser Health describes outreach treatment and assistance with medication, physical health care, housing, daily-living skills and activities. The team's work may begin with a visit at home and continue by accompanying the person to a pharmacy or health facility. [87]
Housing and Housing First outcomes
In the Vancouver randomized trial by Somers and colleagues, 297 people with longstanding homelessness, mental disorder and high support needs entered one of three pathways. An ACT team supported scattered-site apartments; a congregate housing complex provided round-the-clock support. Rent in both programs was capped at 30% of income. [88]
Accessible chart data and 95% confidence intervals
Horizontal bar chart showing proportion of time in stable housing over 24 months in the Vancouver Housing First trial (n = 297): Congregate housing with support (n = 107) 74.3% (95% CI 69.3–79.3%); Scattered apartments with support (n = 90) 74.5% (95% CI 69.2–79.7%); Services as usual (n = 100) 26.3% (95% CI 20.5–32.0%).
| Pathway | Participants | Proportion of time in stable housing over 24 months |
|---|---|---|
| Scattered-site apartments with ACT | 90 | 74.5% (95% CI 69.2–79.7%) |
| Congregate housing with round-the-clock support | 107 | 74.3% (95% CI 69.3–79.3%) |
| Services as usual | 100 | 26.3% (95% CI 20.5–32.0%) |
In the complex with round-the-clock support, MCAS functioning, psychological community integration and subjective recovery on RAS-22 also improved compared with usual services. Between-group differences in change were 5.81, 2.53 and 5.58 points, respectively. For scattered-site housing, the study found no significant advantage on its secondary outcomes. There were also no significant between-group advantages in psychiatric symptom severity, substance use problems or quality of life. The strongest result shared by both models was therefore housing stability; some functional advantages accompanied the more intensive support within one complex. [88]
Family and everyday work after discharge
Relatives often first notice changes in sleep, spending, communication or self-care. Fraser Health describes how they can share these observations with the team; disclosure of the patient's confidential information occurs with consent or another applicable legal basis. Families can also receive general information about the illness, ways of providing support and resources for their own needs. [89]
The Red Fish handbook connects discharge with concrete agreements about accommodation, medication, upcoming consultations, financial and legal matters, and a safety plan. The person, relatives, hospital and regional team take part. For the family, the most tangible elements are the next appointment date, a reachable telephone number and a clear division of daily tasks. [90]
The hospital has a case coordinator. At home, the job often goes to whoever finds the missing prescription first. 