S04 – Controversies in Addiction Psychiatry

S04 – Controversies in Addiction Psychiatry

Friday, Oct. 28
10:45 – 11:45 (1 hr)
Meeting Room: Sheraton Hall E (Lower Concourse)
David Crockford*, MD, FRCPC; Anees Bahji, MD, FRCPC; Christian Schütz, MD, PhD, MPH, FRCP; Emily Cooley, MD
Supported by the Addiction Psychiatry Section

CanMEDS Roles:

  1. Health Advocate
  2. Medical Expert
  3. Collaborator

At the end of this session, participants will be able to: 1) Know the impact of the legalization of cannabis on psychiatry and addiction treatment; 2) Understand the pros and cons of decriminalization and legalization of illicit drugs, based on historical examples; and 3) Review the evidence for and against involuntary treatment for addiction and its associated ethical issues.

The opioid crisis and cannabis legalization have put substance-related and addictive disorders at the forefront. There is a need to rapidly adapt to the impact of the opioid crisis and cannabis legalization. Still, opinion and the need to do something often dictate the dialogue around policy and approaches, where quick fixes are often sought to address complex problems. An objective examination of the evidence for and against policy and approaches is required to create a nuanced understanding. There has been advocacy for the legalization of all substances, safer supply, and even involuntary commitment to try and help. Although the evidence for the benefit of addiction treatment remains clear, how to best reduce harm for those in an earlier stage of change around their substance use is less certain. Attempting to engage people with substance use disorders better and facilitate change in substance use behaviour is critical for this group as part of harm reduction. This symposium will discuss the objective evidence from extant literature as it pertains to substances and substance use disorders, addressing potential roles of decriminalization, legalization, and involuntary treatment. The outcomes of cannabis legalization and its impact on Canadian psychiatric practice and society will be discussed by Dr. Bahji; then, Dr. Schutz will speak on the history of legalization of illicit drugs and how this may inform current policy; finally, Dr. Cooley will review the current evidence on involuntary addiction treatment and the associated ethical issues.

S04a – Clearing the Smoke on Cannabis Use Disorder and Cannabis Legalization in Canada
Anees Bahji, MD, FRCPC

At the end of this session, participants will be able to: 1) Review the diagnostic criteria, epidemiology, and evidence-based treatments for cannabis use disorder; 2) Quantify how cannabis legalization impacts cannabis use and other substance use disorders; and 3) Review Canadian Psychiatric Association position statements on cannabis that discuss the current evidence base for cannabis use related to psychiatry.

Cannabis is the most used illicit substance in the world. With more than 200 million users of cannabis worldwide, the harmful mental health effects associated with cannabis have become a serious global problem. With more regions legalizing cannabis and amidst changing public perception of cannabis, there is considerable confusion around its safety and uses related to psychiatry. Further, psychiatrists are unsure how to assess for cannabis use, how to differentiate use from cannabis use disorder, what information to give their patients, and what the clinical implications of cannabis use are. There is also limited understanding of cannabis and the risks of addiction, where between 25% and 33% of people using cannabis are at risk for developing a cannabis use disorder. As many as 47% of people who consume cannabinoids will develop cannabis withdrawal. Recent conflicting evidence has shown whether cannabis legalization affects opioid use and overdose. This symposium will briefly present on these topics and follow the presentations. We also hope to provide the audience with resources, such as Canadian Psychiatric Association position statements and documents that can be used in practice.


  1. Brooks E, Gundersen DC, Flynn E, et al. The clinical implications of legalizing marijuana: are physician and non-physician providers prepared? Addict Behav 2017;72:1-7.
  2. Hasin DS, Saha TD, Kerridge BT, et al. Prevalence of marijuana use disorders in the United States between 2001–2002 and 2012–2013. JAMA Psychiatry 2015;72:1235-42.

S04b – Clinical Implications of Legalizing Drugs: What Can We Learn from History
Christian Schütz, MD, PhD, MPH, FRCP

At the end of this session, participants will be able to: 1) Understand the history of substance legalization; 2) Understand the relative pros and cons of legalizing substances, based on historical examples; and 3) Recognize the different roles of substance use, intoxication, addiction, and substance-induced deaths in arguments around legalization.

Legalization of drugs is argued to improve public health and provide economic advantages. This presentation will focus on the public health aspect and discuss available historic examples. Alcohol, currently a legal substance of abuse, was illegal during prohibition, with Canadian alcohol prohibition predating the US prohibition. The evaluation of the impact of prohibition on public health has been discussed incongruently. The presenter will focus on the available data and the reason for the inconsistent evaluation. Cannabis was decriminalized in Canada in 2018. Implications of decriminalization and the emerging public health impact will be discussed. Finally, opioid decriminalization and legalization has recently become a topic, often within the context of discussing “toxic supply” versus “safe supply”. Historic evidence, such as the “legalization” of opium in China in the 19th century and the “decriminalization” of heroin use in Portugal about 20 years ago, will be analyzed, including the context of legal change and the consequences of legal changes on public health.

History is sometimes used to strengthen arguments for or against legal changes. The presentation will, within the limitations of available data, point towards consistent findings and some of the potential shortcomings in the currently used arguments.

In trying to focus on the public mental health impact, the presenter will differentiate between substance use, intoxication (a short-term consequence), addiction (a long-term consequence), and mortality (drug-induced deaths) and their roles in the ongoing discussion of legalization and decriminalization.


  1. Schütz CG, Ramírez-Vizcaya S, Froese T. The clinical concept of opioid addiction since 1877: still wanting after all these years. Front Psychiatry 2018;9:508.
  2. Crépault JF, Rehm J, Room R. Legalization as more effective control? Parallels between the end of alcohol prohibition (1927) and the legalization of cannabis (2018) in Ontario, Canada. Int J Drug Policy 2021;97:103367.

S04c – Is There a Role for Compulsory Treatment of Substance Use Disorders?
Emily Cooley, MD

At the end of this session, participants will be able to: 1) Review the evidence for and against involuntary addiction treatment in adults; 2) Consider the applicability of international data to the Canadian context for involuntary addiction treatment; and 3) Explore relevant ethical and medicolegal issues related to involuntary addiction treatment.

Innovative clinical approaches are needed to mitigate the high mortality and morbidity of the opioid epidemic. While voluntary engagement and enhancing readiness for change are cornerstones of addiction treatment in Canada, a conversation is emerging about involuntary medical detention and treatment as a potentially life-saving measure of last resort. The Mental Health Act legislation allows for involuntary treatment in acute states of intoxication and withdrawal if there is a modifiable risk to the safety of the patient or others, but it is a grey area if a person’s risk due to substance use is more chronic, especially if another psychiatric disorder is not present. Although there has been advocacy in favour of this approach by some clinicians and family members of people with substance use disorders, evidence of efficacy is limited. The literature to date on involuntary treatment of substance use disorders will be reviewed from the international literature and attempted to be applied to the Canadian context. A prior review suggested no benefit, but more recent data from Norway, where there is legislature to support involuntary treatment, suggests some benefit, albeit less than voluntary treatment. In Switzerland, involuntary treatment has been less successful, but issues with treatment planning and continuity may contribute. The potential pros and cons of involuntary treatment will then be discussed, addressing ethical and medicolegal contexts. Gaps that need to be addressed in treatment settings and in current legal frameworks to allow potential involuntary treatment will be reviewed.


  1. Benedikt H, Lea W, Patrik R, et al. Coercion in substance use disorders: clinical course of compulsory admissions in a Swiss psychiatric hospital. Swiss Med Wkly 2018;148:w14644.
  2. Pasareanu AR, Vederhus JK, Opsal A, et al. Improved drug-use patterns at 6 months post-discharge from inpatient substance use disorder treatment: results from compulsorily and voluntarily admitted patients. BMC Health Serv Res 2016;16:291.