The housing crisis is increasing wait times for publicly funded voluntary treatment
More people were being removed from the waitlists than were being accepted into treatment beds, according to BC government documents
As BC’s two leading political parties pose competing bids for involuntary treatment in the province, the BC government has had a hard time clearing waitlists for a voluntary program because there isn’t enough housing for people to be discharged into, according to internal government documents.
It’s a challenge that wouldn’t be resolved under an involuntary treatment regime, and which suggests substance use disorders can’t be meaningfully addressed without resolving the housing crisis.
Starting in early 2021, the Canadian Mental Health Association’s BC division took charge of administering a $13-million grant from the provincial government to fund recovery beds at a variety of private treatment centres.
In all, the grant funds 105 beds — including 46 new beds and the remainder converted from privately paid beds — at 14 facilities across the province, according to quarterly reports on the program filed by the CMHA BC with the Ministry of Mental Health and Addictions.
The reports, obtained through a freedom-of-information request, contain a wide array of data ranging from referrals to the program, data around the waitlist, discharges from beds funded by the grant, and the use of opioid agonist therapy in the programs.
The reports captured by the FOI request span 27 months of monitoring, starting with the second quarter of the program from July-September 2021 to, most recently, the 10th quarter in July-September 2023.
Throughout that time period, the reports point to troubles clearing waitlists around the province.
Until summer 2022, the waitlists are measured in terms of average days on the waitlist. Starting in October that year, CMHA BC began breaking down the number of people on the waitlist by how long they have been waiting. They included those who waited fewer than seven days, one to four weeks, five to 12 weeks, 13 to 20 weeks and 21 weeks or more. In July-September 2023, that changed again to those who waited one week, two to six weeks, seven to 11 weeks, 12 to 16 weeks and 16+ weeks.
Throughout the more than two years of monitoring, the reports see the distribution of wait times shift, but typically the largest number of people were waiting five to 12 weeks.
Leaving the waitlist
As the waitlist grew over time, it was being reduced more often by people being removed from the list than by people entering treatment.
Between April 2022 and September 2023, the reports count 1,111 individuals who were removed from the waitlist, while 837 entered treatment, a ratio of about three people removed for every two entering treatment.
This is a problem that only got worse with time, as the two quarters covering April to September 2023 saw 608 people removed from the waitlist, while 312 entered treatment, a ratio of nearly two to one.
This includes clients who died while waiting to access treatment, though it’s not clear how many. Not every quarterly report listed reasons for clients being removed from the list, but of the five reports that did, three of them listed client death as one of the reasons.
The reasons also include losing contact with clients, recurrence of drug use or being arrested, as well as individuals who accessed treatment elsewhere.
CMHA BC did not answer a question about how many people were removed from the waitlist because they died or were unreachable.
“Clients that are unreachable are unreachable by the treatment centre. Outreach from CMHA BC to a client that has been on the waitlist is not something that occurs and is out of the scope of CMHA BC’s involvement,” CMHA BC said.
Leslie McBain, co-founder of Moms Stop the Harm, said long waitlists for people looking to access treatment pose a lot of potential risks.
“If they aren’t on safe supply, which they probably aren’t because so few people are, they are going to go to the toxic drug market. … They’re at great risk of injury or death from those drugs,” she said.
“People won’t wait that long, can’t wait that long. I keep saying that the system is completely broken, and it’s not attending to the reality of people who are addicted.”
Why the long waits?
Housing appears to be a major contributing factor to clearing the waitlist.
The first annual report, looking at April 2021 to March 2022, notes that clients are “drawn to the CMHA beds for varied reasons,” but the fact that these treatment beds are publicly funded is “a key factor.”
“Upon discharge, they are no wealthier than they were at intake, and the rising cost of market housing is becoming an inhibiting factor in the service provider’s ability to safely discharge them,” the report notes.
The report adds that supportive housing is often an untenable option for those exiting treatment.
“In many cases supportive housing will house people that have active and ongoing mental health and substance use challenges that put the long-term success of a client coming out of treatment at risk of relapse,” the report says.
The reports similarly note a “significant barrier” to beginning treatment is that clients are afraid they would lose their housing if they attend a recovery centre.
It also points to a lack of adequate access to opioid agonist therapy in many communities for the client to continue that treatment as they graduate out into the community.
“In some cases, a client may not be able to get an appointment with a practitioner for months, which delays discharge and further intake,” the report notes.
And it notes to a lack of staffing, with the pandemic, chronic stress and illness and economic factors having “driven people away from the treatment and recovery field and into other industries.”
Dangers exiting treatment
Allowing patients to stay until they have access to adequate living space post-treatment may add challenges with clearing waitlists, but McBain said the alternative is potentially even riskier.
Supports available for people leaving treatment are sparse, she said, and often inadequate.
Even if a person has been on methadone or suboxone throughout their treatment, leaving after a few months into a position where a person is likely to return to substances leaves them “tremendously vulnerable to injury and death from the ever-increasing toxicity of the street drugs,” McBain said.
Studies show that individuals leaving treatment, prison and hospitals are at a higher risk of injury and death from overdose because they have reduced tolerance to opioids. The risk may be higher for those who complete detox than for those who drop out early.
Critics of involuntary treatment argue this is particularly true for those who are confined against their will, as those programs, by definition, target those who may not be ready to discontinue their substance use and who are therefore more likely to resume afterwards.
Housing vs. recovery
That housing is a factor in challenges with the treatment program is not surprising to those who closely watch drug policy, including Nicole Luongo, systems change analyst with the Canadian Drug Policy Coalition.
“There is such a strong correlation between material deprivation and high-intensity drug use. … When people are experiencing homelessness, there is so much incentive to stay intoxicated,” Luongo said.
“From a purely psychological perspective, when you are homeless, you are so grotesquely stigmatized and dehumanized. So that unto itself is, I think, a key component driving high-intensity drug use — the need to, in the simplest of terms, escape that, or mute that feeling.”
For the sake of safety, she added, it’s common to use stimulants to stay awake at night. Medications that help keep people off of street drugs can be stolen or taken in street sweeps.
And a person on disability assistance has their housing allowance — which is already widely considered to be legislated poverty — revoked while in treatment, Luongo said.
“That has just always struck me as such a form of state violence, to put it bluntly,” she said.
“People are being admitted to these spaces. They have no opportunity, obviously, to generate income. And because they are housed temporarily, it could, in theory, at least be a bit of time to cobble together a few dollars.”
Even having $500 coming out of treatment, she said, “can feel really significant” to finding stability and maintaining abstinence or medication-assisted treatments like methadone.
Punished for their economic status
The depth of the housing crisis may be new, but Luongo described a trajectory that she said is far from new, starting with social and economic inequality and the compounding factors within that inequality that drive high-intensity drug use.
For decades, those severely marginalized people have accessed treatment, which Luongo said too often can be “effectively a flop house” before being discharged after a month or two “back into the same circumstances.”
“And when they are not able to maintain abstinence, then that just provides fodder for blaming them as individuals,” she said.
Blaming the individuals, then, becomes ammunition for policies like involuntary treatment.
“It created this policy milieu that really produces addiction en masse. It produces the conditions that people need to escape from, and that drive high-intensity drug use,” she said.
“And rather than address those conditions, what the government now is doing is promoting the idea that … the biggest victims of our policy environment ought to be and deserve to be now doubly victimized through involuntary treatment for conditions that they did not create.”
Asked about the implications of these challenges with voluntary treatment on the province’s plan to expand involuntary treatment, CMHA BC referred to its statement of Sept. 18, in which the organization noted a “dramatic increase in reliance on involuntary services, while voluntary services have not kept up with demand.”
People with substance use disorder are “the fastest growing population being detained” under the existing involuntary framework, CMHA BC wrote.
“This fact, along with the recent announcement, is concerning to CMHA BC, knowing that there is a lack of evidence to support the effectiveness of involuntary treatment for people with substance use disorder, and that existing evidence actually suggests that involuntary treatment leads to an increased risk of death due to drug poisoning upon release,” CMHA BC wrote.
“There remains very little oversight or accountability of the mental health system. CMHA BC is concerned that a movement to detain more people under these current conditions and culture, without addressing significant gaps in the quality and effectiveness of care, will not lead to positive or dignified outcomes for people.”