PORTRAIT OF THE ENVIRONMENT IN QUEBEC. Concerning the use and abuse of drugs and alcohol. November 2011

Transcription

1 PORTRAIT OF THE ENVIRONMENT IN QUEBEC Concerning the use and abuse of drugs and alcohol November 2011

2 All rights of reproduction, translation and adaptation reserved Centre québécois de lutte aux dépendances PORTRAIT OF THE ENVIRONMENT IN QUEBEC Concerning the use and abuse of drugs and alcohol For information Funding for this publication was provided by Health Canada. Research: Editor: Review: Caroline Dion, bibl. Prof. Information Specialist Eve Paquette, Research Professional, CQLD Robert Faulkner, Outside Consultant Renée Latulippe, M.A., Executive Director, CQLD Eve Paquette, Research Professional, CQLD Rodrigue Paré, Executive Director, Maison Jean Lapointe Sophie Bellefeuille, Program Consultant, Health Canada Françoise Lavoie, Regional Manager, Health Canada Linguistic review (French) : Monic Bleau, administrative assistant, CQLD Translation : Health Canada Page 2

3 Table of Contents Note to the reader Key Findings Introduction Part I Portrait of Drug and Alcohol Use in Quebec 1. Alcohol use Drug use Cannabis Other illicit drugs Use of psychoactive drugs Other substances Steroid use Use of energy drinks Portrait of use by young people Alcohol use Drug use DEP-ADO and use by young people At-risk populations Pregnant women Youth in crisis Young people in youth centres Street youth Persons with mental health problems Young homosexuals First nations Homeless people IV drug users Incarcerated persons Members of street gangs The elderly Public opinion about consumption The principal approaches used in Quebec The harm reduction approach Programs involving alcohol Programs involving drugs Methadone support treatment The therapeutic communities approach The approach connected to the self-help group philosophy Page 3

4 Part II Governments, Health and Dependencies 9. Government agencies Bureau des projets Centre hospitalier de l Université de Montréal, (CHUM), McGill University Health Centre (MUHC) and Centre hospitalier (CHU) Sainte-Justine The provincial Committee for the provision of health and social services to persons from ethnocultural communities The Provincial Committee for the delivery of health and social services in the English language The Health and Welfare Commissioner Institut national de santé publique du Québec Institut national d excellence en santé et en services sociaux Office des personnes handicapées du Québec Régie de l'assurance maladie du Québec Urgences-santé Plan d action interministériel en itinérance Plan d action interministériel en toxicomanie Ministère de l Éducation, du Loisir et du Sport Ministère de la Justice and Ministère de la Sécurité publique Prevention of criminality Reduction of criminality through enforcement Ministère de l Emploi et de la Solidarité sociale The other ministries Ministère des Transports Ministère de la Famille et des Ainés Ministère du Conseil exécutif Ministère de l Immigration et des Communautés culturelles Clientele targeted Four lines of action Preferred settings for action Programme-services Dépendances (MSSS) Clientele targeted Definition Principal observations and challenges Orientations of the Programme-services Dépendances Organization of services At the local level At the regional level Service Trajectory of the Programme services Dépendances Services connected to dependencies Detection of cases (screening) and orientation to appropriate services (referral) Early intervention Psychosocial follow-up after a specialized treatment Psychosocial and medical follow-up with methadone support Inpatient and outpatient detoxification with psychosocial support Specialized regional assessment program Inpatient and outpatient rehabilitation Page 4

5 Social reintegration Support to families The Federal Government Other activity sectors Health promotion Prevention Prevention activities and programs Education College level University level Research Part III The Private and Community Network 15. Organization of services Table of provincial groups of community and volunteer organizations Support for community agencies Services connected to dependencies Certification of agencies offering residential addiction services Inpatient and outpatient residential rehabilitation Homelessness Social reintegration Other activity sectors Prevention Self-help groups Part IV Telephone and Internet Resources 18. Telephone assistance services Websites Page 5

6 List of figures Figure 1. Change in per capita use (age 15 and above), in litres of pure alcohol, in Quebec and in Canada, from to Figure 2. Change in per capita use (age 15 and above), in litres of pure alcohol, by type of alcoholic beverage, in Quebec from to Figure 3. Drug use by Quebeckers Figure 4. Type of drug use by the population (age 15 and above) by age in Quebec in Figure 5. Number of different drugs tried during life by age, in Quebec in Figure 6. Biennial change from 2000 to 2008 in alcohol use among Quebec adolescents Figure 7. Biennial change from 2000 to 2008 in type of alcohol users among Quebec adolescents.28 Figure 8. Biennial change from 2000 to 2008 in drug use among Quebec adolescents Figure 9. Biennial change from 2000 to 2008 in use of cannabis, hallucinogens, amphetamines and cocaine among Quebec adolescents Figure 10. Biennial change from 2000 to 2008 in binge drinking and repetitive binge drinking among Quebec adolescents who have used alcohol Figure 11. Geographic distribution of the 18 health and social services agencies of Quebec Figure 12. Organization of the Quebec Health and Social Services Network Figure 13. Service Trajectory of the Programme services Dépendances (MSSS) Page 6

7 List of tables Table 1. Percentage of Canadians who have used alcohol during their life and during the preceding 12 months, by province Table 2. Consumption habits of Canadians, by province Table 3. Cannabis use by Canadians, comparison between 2004 and Table 4. Cannabis use, comparison between Quebeckers and Canadians in Table 5. Cocaine/crack use among Quebeckers and Canadians in Table 6. Hallucinogen use by Quebeckers and Canadians in Table 7. Amphetamine and methamphetamine use among Quebeckers and Canadians in Table 8. Ecstasy use by Quebeckers and Canadians in Table 9. Change in use among Canadians Table 10. Use of psychoactive drugs among Canadians during the last twelve months (according to the survey) Table 11. Index of alcohol and drug problems (DEP-ADO) in 2006 and 2008 in Quebec Table 12. Actions of the Plan d action interministériel en toxicomanie Page 7

8 Note to the reader The following document is intended to present a portrait of drug and alcohol use in Quebec, concerning both the scope of the problem and the means implemented by the government and the private network to address it. To ensure proper understanding and thoroughness of the information, certain sections of the document are taken from ministry web sites without revision. Complete references are in the footnotes. Page 8

9 Key Findings In 2010, 92.6% of Quebeckers age 15 and over have already used alcohol in their life, and 82.5% have used it during the 12 months preceding the survey. Alcohol Quebec is the province with the highest percentage of persons age 15 and over who have used alcohol in their life and during the preceding 12 months. Quebec is not the province which consumes the most and the most often. It is ranked next to the bottom among Canadian provinces for frequent excessive use. The use habits of Quebeckers tend toward frequent consumption of alcohol in lesser quantities. In Quebec, it is noted that Quebeckers ages 15 to 24 are the largest current users of drugs, compared to other age groups. The prevalence of cannabis use during the 12 months preceding the CADUMS survey among Canadians age 15 and over is 10.7%; this prevalence has remained unchanged from 2009 (10.6%), but it is significantly lower than the 14.1% reported in Comparing the cannabis use rates (2004 versus 2010), we note that the rate has fallen significantly among men (18.2% versus 14.6%), women (10.2% versus 7.1%) and among young people ages 15 to 24 (37.0% versus 25.1%). Only 36.6% of Canadians agree with the legalization of marihuana. Among those who approve of this legalization, 37.9% are in favour because they believe that marihuana is not a dangerous drug. We note a significant drop in the prevalence of cocaine use for the Canadian population, falling from 1.9% in 2004 to 0.7% in Drugs We note that in 2004, 3.7% of Quebeckers age 15 and over have consumed ecstasy at least once in their life, versus 4.4% in Out of the possible measures of stemming drug-related problems, the Canadian population prefers prevention. In fact, the public prefers prevention and treatment (78.0%) to law enforcement and incarceration (18.7%) as means of fighting drug use. 82.8% of Canadians believe that the government should give preference to treatment programs over criminalization of drug use. 10% of cases of poisoning caused by use of energy drinks involved youth age 11 and under. Page 9

10 According to the results collected using the DEP-ADO questionnaire (2008), 88% of secondary school students do not have an obvious problem with drug or alcohol use, while 12% show signs of a developing or established use problem, for which professional intervention is suggested. Young people These results are very different for young people from youth centres in Quebec. The majority of young people entering a youth centre (58.4% of girls; 63.1% of boys) receive a red light score on the DEP-ADO, i.e., they have an obvious problem with drug or alcohol use. Among young homosexual Montréalers (under age 30), 79.8% have used alcohol, 47.6% cannabis, 25.2% cocaine, 26.4% ecstasy, 26.2% amphetamines, 16.9% GHB, 15.7% ketamine, 6.3% magic mushrooms, 5.1% heroin, 3.5% other opioids and 3.5% LSD, two hours before sexual relations at least one time in the last six months. It s not dependency on alcohol that causes problems for First Nations peoples, but rather the way it is used. In fact, those who use it do so until they are intoxicated, resulting in serious social consequences. The situation is also problematic among young First Nations people living in an urban setting. In fact, they appear to be two to six times more susceptible to alcohol problems than their peers in urban communities. More of them also use marihuana or solvents. At-risk population s According to a survey conducted in the Québec City and downtown Montréal regions, close to one half (46%) of homeless people present a current or recent problem with drug or alcohol use. Page 10

11 There are several approaches in the field of drug addiction in Quebec. These include harm reduction, therapeutic communities as well as the approach connected to the philosophy of self-help groups. The Plan d action interministériel en itinérance is a result of the wish of many government ministries and agencies to work together in their commitment to prevent and fight homelessness in Quebec. The Plan d action interministériel en toxicomanie was developed in cooperation with eight ministries and will have the objective of implementing actions at the provincial, regional and local level. This plan targets the general population and pays special attention to certain groups with special needs (young people; youth in crisis; pregnant women; the elderly; members of cultural communities and First Nations; delinquents; people with mental health problems; IV drug users and the homeless). The Programme-services Dépendances brings together services intended for people with at-risk behaviours involving the use of psychotropic drugs or people with abuse or dependency problems. This program also includes services for families and loved ones of dependent people. Organization of services The purpose of this program is to prevent, reduce and treat dependency problems by deploying and consolidating a range of services throughout Quebec. In Quebec, there are more than 4,116 community and private agencies in the Quebec health and social services network. In the field of addiction, community and private agencies are able to determine their own mission and practices. As a result, their field of activities may be very diverse. Some of them will offer prevention activities, assistance services, support, treatment programs and social reintegration services. The MSSS is responsible for the Programme de soutien aux organismes communautaires and has made a series of commitments to help community environments consolidate their actions and outreach (while respecting the organizations autonomy), determine their missions, their orientations, their interventional approaches and their management methods. Finally, in Quebec, there are a great many private or community resources which offer an extended range of addiction services. These services may be dispensed on an inpatient or outpatient basis, in the short or long term, according to their specific philosophy and structure. These resources may require a greater or lesser financial contribution from the people who use the services. Page 11

12 Introduction Quebec in brief Covering a territory of 1,667,441 km 2, Quebec is the largest of the ten Canadian provinces. In Canada, only the territory of Nunavut is larger. Quebec is bounded by more than 10,000 km of land, river and maritime borders, by Ontario, Newfoundland, New Brunswick and four American states (Maine, New Hampshire, Vermont and New York). The population of Quebec is estimated at 7.83 million persons as of July 1, and is a majority Francophone society. Based on current trends, the population of Quebec should reach eight million by A majority of Francophone Quebeckers are the descendants of the first colonies who came from France in the 17 th and 18 th centuries. In addition to this central group, there are many immigrants whose native language is not necessarily French and who, over the years, have adopted the language of the Quebec majority. The Anglophones of Quebec are the descendants of immigrants who were primarily British, but also come from other strains who sought a better life in North America or left the United States after the American Revolution out of loyalty to the mother country. Quebec laws grant them various rights, such as the right to attend English-speaking public schools from kindergarten to university and the right to receive treatment in their language. They also have a vast network of cultural institutions. In addition, two thirds of Anglophones in Quebec know French. The Quebec territory is divided into 104 regional county municipalities (RCM) divided into 17 administrative regions. These RCMs bring together 1,135 local municipalities, 96 unorganized territories and 57 First Nation territories. The population density in Quebec varies from 0.03 inhabitants/km 2 (Kativik) to 3,808.5 inhabitants/km 2 in Montréal. In , nearly six million people, or just over three out of four Quebeckers, lived in a municipality of 10,000 inhabitants or more. The ten most populous municipalities in Quebec (100,000 inhabitants or more) have 3.7 million inhabitants, or 48% of the Quebec population. As in most industrialized countries, Quebec is experiencing an aging of its population, characterized by the rapid rate of the change. In , one Quebecker out of two were 41 years or older. In 1971, the median age of Quebeckers was 25.6 years. This median age has been climbing constantly, exceeding 30 years in 1982 and 40 years in It should reach 45 years about the year However, in 2009, 15% of the Quebec population was 65 or older (this proportion should exceed 25% in 2031), 69% were 15 to 64, while those ages 0 to 14 were stable at 16%. 1 Institut de la statistique du Québec. (2010). Available online: 2 Ibid 3 Ibid Page 12

13 Also in , 39,400 more persons entered Quebec than left. From 1991 to 2010, Quebec took in 787,256 immigrants. The highest average (47,711 admissions) was observed during the period In 2010, with a 19.2% share of Canadian immigration, Quebec is number two among Canadian provinces, after Ontario (42.1%). The number of admissions to Quebec is divided almost equally between women and men. The immigrant population is young. Immigrants under 35 years old represent about 71% of the total immigrant population. More than one half (61.7%) of immigrants admitted from know French. About one third (32.7%) of admissions from the last five years come from Africa, followed by Asia with 27.0%, South America (21.3%) and Europe (18.9%) 5. Quebec has some 81,864 First Nations people, the descendants of the first inhabitants on North American soil. 71,840 of them are Amerindians and 10,024 are Inuit, representing about 1% of the population of Quebec. 6 4 Institut de la statistique du Québec. (2010). Available online: 5 Ibid 6 Immigration et Communautés culturelles. (2007). Historic overview. Page 13

14 Part I Portrait of Drug and Alcohol Use in Quebec Page 14

15 In order to prepare a portrait of drug and alcohol use by Quebeckers, the results of several surveys were consulted, including: Canadian Addiction Survey (CAS), 2004, 2005, 2006 and 2007, conducted by Health Canada. Enquête québécoise sur la santé de la population (EQSP): pour en savoir plus sur la santé des Québecois, 2008, conducted by the Institut de la statistique du Québec. Canadian Alcohol and Drug Use Monitoring Survey (CADUMS), 2009, conducted by Health Canada. Quebec Population Health Survey (EQSP), 2009, conducted by the Institut de la statistique du Québec (ISQ). Report on the Illicit Drug Situation in Canada, 2009, conducted by the Royal Canadian Mounted Police (RCMP). Rapport sur la consommation d alcool et la santé publique, 2010, conducted by the Institut national de santé publique du Québec (INSPQ). Enquête sur la santé dans les collectivités canadiennes (ESCC), 2010, conducted by the Institut national de santé publique du Québec (INSPQ). Rapport sur les boissons énergisantes: risques liés à la consommation et perspectives de santé publique, 2010, conducted by the Institut national de santé publique du Québec (INSPQ). Rapport sur l usage de substances psychoactives chez les jeunes québécois, portrait épidémiologique, 2009, conducted by the Institut national de santé publique du Québec (INSPQ). Page 15

16 1. Alcohol use Quebec is the province with the highest percentage of persons age 15 and over who have used alcohol in their life and during the preceding 12 months. According to the Canadian Alcohol and Drug Use Monitoring Survey (CADUMS) 7 conducted by Health Canada in 2010, 92.6% of Quebeckers age 15 and older have already used alcohol during their life and 82.5% used it in the 12 months preceding the survey. Quebec is the province with the highest percentage of persons age 15 and over who have used alcohol in their life and during the preceding 12 months. As indicated in Table 1, these percentages are higher (statistically significant) than the Canadian average. Table 1. Percentage of Canadians who have used alcohol during their life and during the preceding 12 months, by province8. n Use during life (%) Use during the preceding 12 months (%) QC 1, * 82.5* ON 1, NB 1, * AB 1, * SK 1, NL 1, BC 1, MB 1, NS 1, * PEI 1, * Canada 13, *Statistically significant difference between the provincial estimate and the national estimate. Per capita alcohol use refers to the average consumption per person age 15 and older, established according to the volume of alcohol sales. In , Quebeckers age 15 and older used an average of 8.1 litres of alcohol per year. As presented in figure 1, per capita alcohol use by Quebeckers corresponds to that of the Canadian average for the same period, 8.2 litres 9. In , beer accounted for 56.8% of per capita alcohol use. While consumption of beer and spirits remained relatively stable, per capita consumption of wine by Quebeckers has grown since (see figure 2). 7 Canadian and Alcohol and Drug Use Monitoring Survey (CADUMS). (2010). Health Canada Available online: 8 Ibid 9 April, N., Bégin, C. and Morin, R. (2010). La consommation d alcool et la santé publique au Québec. Institut national de santé publique du Québec. Available online: 10 Ibid Page 16

17 Figure 1. Change in per capita use (age 15 and above), in litres of pure alcohol, in Quebec and in Canada, from to [vertical axis: Alcohol use per capita (in litres of pure alcohol) horizontal axis: All alcoholic beverages ] Figure 2. Change in per capita use (age 15 and above), in litres of pure alcohol, by type of alcoholic beverage, in Quebec from to [vertical axis: Alcohol use per capita (in litres of pure alcohol) top of chart: Spirits Wine - Beer ] 11 April, N., Bégin, C. and Morin, R. (2010). La consommation d alcool et la santé publique au Québec. Institut national de santé publique du Québec. Available online: 12 Ibid Page 17

18 According to the INSPQ, in 2005, 29.5% of men and 11.9% of women acknowledged that they had used alcohol to excess 13. That is, during the year preceding the survey, they had had at least five or more drinks in one sitting. This type of consumption (binge drinking) is especially prevalent among ages 15 to 24. In fact, 35% of respondents from this age group state that they have consumed excessively, at least once per month, during the 12 months preceding the survey. According to CADUMS 14, however, Quebeckers are not the ones who use the most and the most often. As presented in Table 2, Quebec is next to the bottom on the list of Canadian provinces for frequent excessive use (heavy frequent). The use habits of Quebeckers tend toward frequent consumption of alcohol in lesser quantities (light frequent). Table 2. Use habits of Canadians, by province 15. n Light infrequent (%) Light frequent (%) Heavy infrequent (%) Heavy frequent (%) NL 1, * 8.7* 8.4* NB 1, * 7.8* 7.0* NS 1, * 7.2* 6.5* MB 1, PEI 1, * 6.5* 5.7 SK 1, * 23.0* ON 1, * Q BC 1, Q 4.2 QC 1, * 42.7* AB 1, * 28.4* 3.0 Q * 2.6 Q * Canada 13, Light infrequent: Light frequent: Heavy infrequent: Heavy frequent: A person who drinks less than once per week on average in a year, and usually consumes less than five drinks on each drinking occasion. A person who drinks once or more per week on average in a year, and usually consumes less than five drinks on each drinking occasion. A person who drinks less frequently than once per week, and usually consumes five or more drinks on each drinking occasion. A person who drinks one or more times per week on average in a year, and usually consumes five or more drinks on each drinking occasion. ** Statistically significant difference between the provincial estimate and the national estimate. Q Estimate qualified due to high sampling variability; interpret with caution. 13 April, N., Bégin, C. and Morin, R. (2010). La consommation d alcool et la santé publique au Québec. Institut national de santé publique du Québec. Available online: 14 Canadian Alcohol and Drug Use Monitoring Survey (CADUMS). (2010). Health Canada Available online: 15 Ibid Page 18

19 According to the Enquête sur la santé dans les collectivités canadiennes (ESCC) 16, the prevalence of alcohol dependency was 1.8% in Note that the prevalence in Quebec is lower than that in Canada (2.6%) 17,18 and that more men than women present this diagnosis (2.7% versus 0.9%). Among people with alcohol dependency, 45% evaluate their mental health as good or excellent, while 48% indicate that they have a high level of psychological distress Drug use The Quebec Population Health Survey (EQSP) 20 conducted by ISQ indicates that 54% of Quebeckers age 15 and older have never used drugs during their lifetime, 33% have used them (former users) and 13% used them during the 12-month reference period (current users) (see figure 3). Quebeckers ages 15 to 24 are the largest current users of drugs. Figure 3. Drug use by Quebeckers 21. [ Never used Former users Current users ] Figure 4 presents the results obtained by dividing types of users by age group. We note that Quebeckers ages 15 to 24 are the largest current users of drugs, compared to other age groups. In addition, 92% of the elderly (age 65 and over) indicate that they have never used drugs. 16 Enquête sur la santé dans les collectivités canadiennes. (2010). Institut national de santé publique du Québec. Available online: 17 April, N., Bégin, C. and Morin, R. (2010). La consommation d alcool et la santé publique au Québec. Institut national de santé publique du Québec. Available online: 18 Enquête sur la santé dans les collectivités canadiennes. (2010). Institut national de santé publique du Québec. Available online: 19 Ibid 20 Enquête québécoise sur la santé de la population: pour en savoir plus sur la santé des Québécois. (2008). Institut de la statistique du Québec. Available online: 21 Ibid Page 19

20 Figure 4. Type of drug use by the population (age 15 and above) by age in Quebec in [Horizontal axis: Never used Former users Current users Legend: "All (age 15 and over), 15 to 24 years, years, years, 65 years and over ] Figure 5 presents the results obtained when people were asked how many different types of drugs have they tried in their life. Figure 5. Number of different drugs tried during life, by age, in Quebec in [Horizontal axis: None One drug Two drugs Three or more drugs Legend: "All (age 15 and over), 15 to 24 years, years, years, 65 years and over ] 22 Enquête québécoise sur la santé de la population: pour en savoir plus sur la santé des Québécois. (2008). Institut de la statistique du Québec. Available online: 23 Ibid Page 20

21 Drugs can be grouped into 5 major categories according to how they affect perceptions, mood, consciousness, behaviour and the various physical and psychological functions. Drugs are found in the following categories: Depressants: these slow the psychic functions, such as alcohol, anesthetics, anxiolytics, GHB, opioids and volatile substances; Stimulants: these stimulate the psychic functions, such as amphetamines and cocaine; Mind-altering drugs: these disturb the psychic functions, such as hallucinogens and cannabis; Psychoactive drugs: psychoactive substances prescribed to treat mental problems such as anxiolytics, sedatives, soporifics, antidepressants, antipsychotics and mood stabilizers; Androgens and anabolic steroids: these increase athletic performance, such as testosterone, danazol and nandolone. For the purposes of this report, the most popular substances will be discussed. 2.1 Cannabis Cannabis is the most widely used illegal product in Quebec. Cannabis is the most widely used illegal product in Quebec, in Canada and in the world 24. The marihuana produced in Canada is still the most seized illicit drug (number of seizures and quantity) in the country 25. It comes in three forms: 1) marihuana, 2) hashish and 3) oil, and its concentration varies greatly depending on the preparations and provenance of the product. In addition, although its pharmacological properties are well known, its regulation is the subject of much discussion. According to the Canadian Addiction Survey (CAS) conducted in , 44.5% of Canadians age 15 and older have used cannabis at least once in their lifetime. In the same survey, 14.1% of Canadians age 15 and older have used cannabis during the year preceding the survey. The results of CADUMS show that the prevalence of cannabis use during the 12 months preceding the survey among Canadians age 15 and over is 10.7%; this prevalence has remained unchanged from 2009 (10.6%), but it is significantly lower than the 14.1% reported in 2004 (see Table 3). Table 3. Cannabis use by Canadians, comparison between 2004 and 2010 Last 12 months Lifetime % 44.5% % 41.5% 24 Drugs: Know the facts, Cut your risks. (2006). CQLD, Montréal. 25 Report on the Illicit Drug Situation in Canada. (2009). Royal Canadian Mounted Police (RCMP). Available online: 26 Adlaf, E.M., Begin, P., and Sawka, E. (Eds.). (2005). Canadian Addiction Survey (CAS): A National Survey on Canadians Use of Alcohol and Other Drugs: Prevalence of use and related harms: Detailed report. Ottawa, Canadian Centre on Substance Abuse. Available online: 27 Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: Page 21

22 In Quebec, the prevalence of lifetime cannabis use is higher than in the rest of Canada (see Table 4). Table 4. Cannabis use, comparison between Quebeckers and Canadians in Last 12 months Lifetime Quebec 10.1% 44.5% Canada 10.7% 41.5% Comparing the cannabis use rates in 2004 versus 2010, it has fallen significantly among men (18.2% versus 14.6%), women (10.2% versus 7.1%) and among young people ages 15 to 24 (37.0% versus 25.1%). Cannabis use among adults age 25 and older has not changed significantly (10.0% compared to 7.6%). 2.2 Other illicit drugs The results of CADUMS show that the rate of use of the most frequently mentioned drugs, after cannabis, was estimated at under 1%. The following drugs are involved: 1) cocaine or crack; 2) hallucinogens; 3) amphetamines, methamphetamines, crystal meth, ecstasy, synthetic drugs and 4) heroin. Cocaine or crack Cocaine can come in the following three forms: paste, salt and base cocaine (also called crack or rock). Comparing the results of CAS to those of CADUMS , we note that 12.2% of Quebeckers age 15 and older in 2004, versus 7.8% in 2010, have used cocaine at least once in their lifetime. In 2010, 7,8% of Quebeckers have used cocaine at least once in their lifetime. According to these same surveys, 2.5% of Quebeckers age 15 and older had used cocaine in the year preceding the survey in 2004, versus 0.9% in A similar and significant drop is noted for the Canadian population, from 1.9% in 2004 to 0.7% in Table 5 presents the CADUMS results 32 on cocaine (crack) use for the Quebec population in comparison to the Canadian population. 28 Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: 29 Ibid 30 Adlaf, E.M., Begin, P., and Sawka, E. (Eds.). (2005). Canadian Addiction Survey (CAS): A National Survey on Canadians Use of Alcohol and Other Drugs: Prevalence of use and related harms: Detailed report. Ottawa, Canadian Centre on Substance Abuse. Available online: 31 Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: 32 Ibid Page 22

23 Table 5. Cocaine/crack use among Quebeckers and Canadians in 2010 Last 12 months Lifetime Quebec 0.9% 7.8% Canada 0.7% 7.0% Hallucinogens A hallucinogen causes hallucinations or alterations in perception, coherence of thought and regulation of mood, but without causing persistent mental confusion or memory problems. These include substances such as ketamine, LSD, magic mushrooms and mescaline. Table 6 presents CADUMS results 33 on hallucinogen use for the Quebec population in comparison to the Canadian population. Table 6. Hallucinogen use by Quebeckers and Canadians in 2010 Last 12 months Lifetime Quebec 0.8% 11.5% Canada 0.9% 11.9% Amphetamines, methamphetamine, crystal meth, ecstasy, synthetic drugs Amphetamines (Speed, Ice or Crystal) are major stimulants which come in tablet, crystal or powder form 34. Methamphetamine is a psychostimulant in the amphetamine family. It is two times more active than amphetamine 35. It is part of a group of substances called club drugs, which also include ecstasy, GHB, PCP and ketamine. These drugs are associated to a large degree with the phenomenon of raves and after hours clubs. In fact, according to a field study conducted in the Montréal party scene in 2004, amphetamines were the type of substance used the most (70.4% of cases) at raves 36. Crystal meth (Ice, Crystal or Glass) is methamphetamine in crystal form that can be smoked in the same way as cocaine or crack. It can also be injected (powder) or ingested (tablet). Comparing the results of CAS to those of CADUMS , we note that 8.9% of Quebeckers age 15 and older in 2004, versus 7.5% in 2010, have used amphetamine at least once in their lifetime. According to these same surveys, 2.3% of Quebeckers age 15 and older had used amphetamine in the year preceding the survey in 2004, versus 1.6% in A similar but insignificant drop is noted for the Canadian population, from 0.8% in 2004 to 0.5% in Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: 34 Ibid 35 Ibid 36 Ibid 37 Adlaf, E.M., Begin, P., and Sawka, E. (Eds.). (2005). Canadian Addiction Survey (CAS): A National Survey on Canadians Use of Alcohol and Other Drugs: Prevalence of use and related harms: Detailed report. Ottawa, Canadian Centre on Substance Abuse. Available online: 38 Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: Page 23

24 Table 7 presents the results of CADUMS on amphetamine and methamphetamine use for the Quebec and Canadian population. Table 7. Amphetamine and methamphetamine use among Quebeckers and Canadians in 2010 Amphetamines Methamphetamines Last 12 months Lifetime Last 12 months Lifetime Quebec 1.6% 7.5% S 1.2% Canada 0.5% 3.9% S 1.0% S: estimate deleted due to high sampling variability. The composition of a tablet presented as ecstasy is often uncertain. Ecstasy (tablet, capsule, powder) produces both stimulating and hallucinogenic effects. However, the composition of a tablet presented as ecstasy is often uncertain 40. Certain other substances may be present (amphetamines, hallucinogens, other stimulants, anabolic agents or analgesics). Synthetic or designer drugs, of which ecstasy is one, are manufactured by chemists in clandestine laboratories. To avoid falling under the provisions of the law, these traffickers create new products by modifying molecules, hence the arrival of these new drugs on the market. Comparing the results of CAS to those of CADUMS , we note that 3.7% of Quebeckers age 15 and older in 2004, versus 4.4% in 2010, have used ecstasy at least once in their lifetime. According to these same surveys, 1.1% of Quebeckers age 15 and older had used ecstasy in the year preceding the survey in 2004, just as in An insignificant drop is noted for the Canadian population, from 1.1% in 2004 to 0.7% in Table 8 presents the results of CADUMS on ecstasy use for the Quebec and Canadian population. 39 Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: 40 Drugs: Know the facts, Cut your risks. (2006). CQLD, Montréal. 41 Adlaf, E.M., Begin, P., and Sawka, E. (Eds.). (2005). Canadian Addiction Survey (CAS): A National Survey on Canadians Use of Alcohol and Other Drugs: Prevalence of use and related harms: Detailed report. Ottawa, Canadian Centre on Substance Abuse. Available online: 42 Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: 43 Ibid Page 24

25 Table 8. Ecstasy use by Quebeckers and Canadians in 2010 Last 12 months Lifetime Quebec 1.1% 4.4% Canada 0.7% 3.9% According to a study conducted in 2002 among rave participants in Montreal, 65.2% of the latter have used ecstasy in their lifetime and 59.3% in the preceding year 44. Heroin Heroin is a powerful opioid obtained from morphine. It is usually injected intravenously, after being diluted and heated. Heroin can also be snorted or smoked 45. According to the results of CADUMS % of the Canadian population has taken heroin at least once in their lifetime. This figure is on the decline because in 2004, we saw a prevalence of use of 0.9%. Interestingly, toxicology analyses conducted in Montréal between 1999 and 2002 reveal the presence of heroin in 52.9% of 121 persons who died due to accidental fatal accidental poisoning, which puts it in second place behind cocaine among substances identified 47. Change in consumption Table 9 shows, through CADUMS results 48, a certain variability in the prevalence of drug use for the Canadian population. In fact, we note a significant (downward) difference in cannabis use between 2008 and 2004 and in cocaine/crack use between 2010 and Table 9. Change in use by Canadians 49 Last 12 months (%) Cannabis Cocaine/crack Amphetamines Ecstasy ,2: significant difference 44 Drugs: Know the facts, Cut your risks. (2006). CQLD, Montréal. 45 Ibid 46 Canadian Alcohol and Drug Use Monitoring Survey (2010). Health Canada Available online: 47 Drugs: Know the facts, Cut your risks. (2006). CQLD, Montréal. 48 Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: 49 Ibid Page 25

26 3. Use of psychoactive drugs Psychoactive drugs are the drugs most prescribed to participants in the Quebec public drug insurance plan (about 2,200,000 persons) in 2001 (12.9% of all prescriptions) and in 2005 (15.5% of all prescriptions). When prescribed and used with prudence, this drug makes it possible to diminish or eliminate psychological distress: anxiety, fear, insomnia, depression, psychoses, bipolar disorder, etc. Problems with sleeping are a frequent reason for medical consultation and prescription of psychoactive drugs. A great many people use psychoactive drugs, with or without prescriptions, to deal with problems caused by their daily difficulties (see Table 10). These people include the elderly living alone, as well as persons burdened by excessive responsibilities, stress or a traumatic event. Problems with sleeping are a frequent reason for medical consultation and prescription of psychoactive drugs. These problems can be temporary or occasional and may sometimes become chronic. The causes may be physical, psychological, psychiatric or simply due to conditions not conducive to sleep. Table 10. Use of psychoactive drugs by Canadians 50 in the last 12 months 2010 Painkillers 20.6 For euphoric effects 1.1 Stimulants 1.0 For euphoric effects S Sedatives 8.7 For euphoric effects 0.5 S: Estimate deleted due to high sampling variability. 4. Other substances 4.1 Steroid use Anabolic steroids are synthetic versions of testosterone that are chemically altered to reduce androgenic effects (effects on male sex characteristics), increase anabolic effects (allow the synthesis of substances that promote growth in muscle mass, in particular) and reduce the undesirable effects. Steroids have many legal therapeutic applications, but are also used illegally, as doping substances, by athletes. They are administered orally or intramuscularly. CAS reveals that 0.6% of Canadians have used anabolic steroids. 50 Canadian Alcohol and Drug Use Monitoring Survey. (2010). Health Canada Available online: 51 Canadian Addiction Survey (CAS): A National Survey on Canadians Use of Alcohol and Other Drugs: Prevalence of use and related harms: (2005). Health Canada Available online: Page 26

27 4.2 Use of energy drinks Energy drinks claim to contain a mix of ingredients whose property is to enhance energy and liveliness levels 52. They are seen as natural health products. The principal ingredients in these drinks are generally water, sugar and synthetic or natural caffeine (e.g., from guarana, herba mate). Caffeine is the chief active ingredient which contributes to their stimulant effect 53. There are also energy drinks premixed with alcohol. These drinks are not recommended, because certain studies suggest that caffeine could reduce the sensation of inebriation without reducing the weakening of certain faculties by alcohol 54. There have been few studies on this phenomenon or on the extent of consumption of these drinks. On the other hand, according to the statistics of the Centre antipoison du Québec (CAPQ), the number of calls about energy drinks has grown sharply in the last few years; this number grew from 4 in 2003 to about 100 in 2008 and Although the majority of cases reported did not require medical follow-up, 33% of the calls received had to be referred to an emergency department because of the nature and severity of the symptoms Close to 10% of poisoning cases with energy drinks involved children age 11 and under. experienced (mainly cardiovascular symptoms) when these calls were made 56. Nearly 75% of poisoning cases involved persons ages 12 to 30. This is the age group which uses the most energy drinks or which is the most susceptible to present symptoms of poisoning after their use. In addition, although Health Canada does not recommend the use of energy drinks by children, close to 10% of poisoning cases involved children age 11 and under, indicating that young children have used this type of drink Portrait of use by young people. Every two years since 1998, the Institut de la statistique du Québec has been conducting the Quebec survey on tobacco, alcohol and drug use and gambling in Quebec secondary school students. This survey makes it possible to monitor changes in these areas among secondary students in Quebec. The last survey was conducted in , among 4,736 secondary school students (7th-11th grades) in 144 Francophone and Anglophone schools, both public and private, in the province. All data are based on self-evaluations from an anonymous questionnaire administered in class. 52 Les boissons énergisantes: entre menace et banalisation. (2011). Institut national de santé publique du Québec. Available online: 53 Ibid 54 Ibid 55 Rapport sur les boissons énergisantes: risques liés à la consommation et perspectives de santé publique, 2010, conducted by the Institut national de santé publique du Québec (INSPQ). 56 Ibid 57 Ibid 58 Enquête québécoise sur le tabac, l alcool, la drogue et le jeu chez les élèves du secondaire (2008). Institut de la statistique du Québec. Available online: Page 27

28 5.1 Alcohol use The survey shows that about 60% of secondary school students have used alcohol, at least once, during a 12-month period. This proportion does not differ significantly from that of the preceding survey (2006), but is down compared to previous surveys. In fact, the numbers have gone from 71.3% in 2000 to 59.7% in 2008 (see figure 6). Figure 6. Biennial change from 2000 to 2008 in alcohol use among Quebec adolescents 59. [Vertical axis: Percentage ] Out of the secondary school students who have used alcohol (60%), at least once, during a 12-month period (see figure 7): 8% have experimented with alcohol; 37% have used it occasionally; 14% regularly; 0.2% daily. Figure 7. Biennial change from 2000 to 2008 in type of alcohol users among Quebec adolescents 60. [Vertical axis: Percentage Legend: "Abstainers Experimenters Occasional Regular - Daily ] 59 Enquête québécoise sur le tabac, l alcool, la drogue et le jeu chez les élèves du secondaire (2008). Institut de la statistique du Québec. Available online: 60 Ibid Page 28

29 In 2008, 85,6% of young people in 11 th grades were alcohol users Note that the number of alcohol users increases gradually with the grade in school. In fact, in 2008, 27% of young people in 7 th grade were alcohol users (experimental, occasional, regular or daily), versus 47% in 8 th grade, 65% in 9 th, 79% in 10 th and 85.6% in 11 th grade. As in 2006, the average age of first alcohol use is 12.6 years. This is a slight improvement, because it was 12.4 in Certain characteristics were noted among young people who say they have used alcohol during a 12-month period. The proportion of students who have used alcohol is higher: among students who have a job than among those who do not (69% vs. 49%); among students who have a large weekly allowance: o $50 and above: 83% o $31-50: 72% o $11-30: 62% o $10 and under: 40% among students who live in a different family setting (73%) and single-parent setting (68%) than among those in a two-parent family (57%); among students who evaluate their school performance as below the average of their class rather than above average (69% vs. 56%). 5.2 Drug use According to the same survey by the Institut de la statistique du Québec 61, 27.8% of secondary school students used drugs at least once during a 12-month period. This percentage was 36.4% in 2004 and represents a statistically significant drop (see figure 8). This decline in use (between 2004 and 2008) is seen at all school levels, except in 9 th grade. Figure 8. Biennial change from 2000 to 2008 in drug use among Quebec adolescents 62. [Vertical axis: Percentage ] 61 Enquête québécoise sur le tabac, l alcool, la drogue et le jeu chez les élèves du secondaire (2008). Institut de la statistique du Québec. Available online: 62 Ibid Page 29

30 As for alcohol, the number of drug users gradually increases with age 63 : 4.9% among students age 12 and under; 13% among 13 year olds; 28% among 14 year olds; 37% among 15 year olds; 44% among 16 year olds; 52% among those age 17 and over; The age of initiation of drug use was 13.4 years in We note that the age of initiation grows significantly from one year to the next (13.0 years in 2004; 13.2 years in 2006 and 13.4 years in 2008). The psychoactive substance most widely used by adolescents is cannabis. In fact, about one quarter of them (27.2%) used it at least once in a 12-month period. The number of cannabis users increases gradually with the children s grade in school: 7.6% in 7 th grade; 18.5% in 8 th grade; 28.9% in 9 th grade; 38.2% in 10 th grade; 46.6% in 11 th grade; In , 17.5% of students have used cannabis experimentally or occasionally, while 9.6% use it regularly or daily. These proportions represent a decrease since After cannabis, the most widely used drugs are hallucinogens (LSD, PCP, Mess, mushrooms, acid, mescaline, ecstasy, blotter, etc.) and amphetamines (speed, uppers). In 2008, 7.6% of secondary school students said that they had used hallucinogens and 7.3% amphetamines, at least once, in a 12-month period. The other substances used by young people are cocaine (3.4%), solvents (0.8%) and heroin (0.9%) as well as other types of drugs (including overthe-counter drugs) (2.2%). The proportions of young people having used these various substances in 2008 are comparable to those from Statistically speaking, only amphetamine use fell significantly between 2006 (9%) and 2008 (7%). However, significant drops in the number of users were observed between the 2004 survey and that of (see figure 9): cannabis: from 36% to 27%; hallucinogens: from 11% to 8%; cocaine: from 5% to 3.4%; solvents: from 1.9 % to 0.8%. 63 Enquête québécoise sur le tabac, l alcool, la drogue et le jeu chez les élèves du secondaire (2008). Institut de la statistique du Québec. Available online: 64 Ibid 65 Ibid Page 30

31 Figure 9. Biennial change from 2000 to 2008 in use of cannabis, hallucinogens, amphetamines and cocaine among Quebec adolescents 66. [Vertical axis: Percentage Legend: "Cannabis Hallucinogens Amphetamines - Cocaine ] Certain characteristics were noted among students who say they have used drugs during a 12-month period. Thus in 2008, the proportion of students who have used drugs is higher: among students who have a job than among those who do not (33% vs. 23%); among students who have a large weekly allowance: o $51 and above: 47% o $31-50: 38% o $11-30: 27% o $10 and under: 14% among students who speak French at home compared to those who speak another language (29% vs. 15%); among students who live in a different family setting (42%) and single-parent setting (39%) than among those in a two-parent family (24%); among students who evaluate their school performance as below the average of their class rather than above average (41% vs. 23%). 5.3 DEP-ADO and use by young people 88% of secondary school students have no obvious problem with alcohol or drug use (DEP-ADO). In , the results collected using the DEP-ADO questionnaire demonstrate that 88% of secondary school students have no obvious problem with alcohol or drug use (green light). However, 6% show signs of a developing problem with use (yellow light) and about the same proportion show clearly established problems for which professional intervention is suggested (red light) (see Table 11). 66 Enquête québécoise sur le tabac, l alcool, la drogue et le jeu chez les élèves du secondaire (2008). Institut de la statistique du Québec. Available online: 67 Ibid Page 31

32 Table 11. Index of alcohol and drug problems (DEP-ADO) in 2006 and 2008 in Quebec 68. DEP-ADO Green light 87% 88.2% Yellow light 7% 5.9% Red light 7% 6.0% Among young alcohol users, 67% indicate that they binge drink (5 or more drinks on the same occasion) and 22% say that they binge drink repetitively. These proportions have been maintained for a few years now (see figure 10). Figure 10. Biennial change from 2000 to 2008 in binge drinking and repetitive binge drinking among Quebec adolescents who have used alcohol 69. [Vertical axis: Percentage Legend: "Binge drinking (5 drinks) Repetitive binge drinking ] 6. At-risk populations Although adult men remain the target group in the field of addiction, special attention must be paid to certain population groups whose specific needs must be taken into account, whether in prevention, early intervention, treatment or social reintegration. 68 Enquête québécoise sur le tabac, l alcool, la drogue et le jeu chez les élèves du secondaire (2008). Institut de la statistique du Québec. Available online: 69 Ibid Page 32

33 6.1 Pregnant women A Canadian study conducted in 2006 shows that for 4 out of 10 Canadians, the effects of alcohol use on fetal development are unclear, and this is as widespread in Quebec as elsewhere in Canada. Along the same lines, a higher proportion of Quebeckers know the terms Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Spectrum Disorder (FASD) than in the past (25 points compared to 2002 and 41 points since 2001), but a lower proportion know these terms than in other Canadian provinces. In addition, Quebec women are generally less likely to say that they are aware of alcohol-related birth defects and to have detailed knowledge about these defects. In Canada, 72% of women claim that they would not use alcohol if they were to become pregnant; again, this proportion is lower among Quebec women, who are more likely than others to say they would just cut back on their alcohol use Youth in crisis The use of psychotropic agents leads certain young people to dependency. Among those most affected, this dependency leads to major problems, including distress Young people in youth centres Between July 2008 and May 2009, the Direction de santé publique conducted a study on the lifestyles and behaviours associated with sexually transmitted infections among young people age 14 and older and housed in Quebec youth centres 71. This study reveals that: The family history of young people housed in youth centres is often marked by alcohol or drug problems; A high proportion of these young people use cannabis on a daily basis; More than one half already have an obvious with alcohol or drug abuse problem, for which a specialized intervention is necessary (according to the DEP-ADO screening index). More specifically, the results show that, in the 12 months before their admission to the youth centre, 5.9% of girls and almost 10% of boys (9.2%) used alcohol every day. In addition, about 30% of young people had used alcohol excessively (8 or more drinks for boys and 5 or more for girls, on the same occasion). 18.5% of girls and 24.5% of boys had even binged more than 52 times in the 12 months preceding their admission. As for drug use, the results show that, in the 12 months before their admission to the youth centre, the vast majority of youth have already used drugs at least once in their lifetime (girls: 91.4%; boys: 89.9%). Among the youth having used a drug at least once in their lifetime, the majority of girls experience this first initiation at between In the 12 months before their admission to the youth centre between 39% et 57% of young people used cannabis. daily. 70 Alcohol Use During Pregnancy and Awareness of Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorder. (2006). Public Health Agency of Canada Lambert, G., Haley, N., Jean, S., Frappier, J.-Y, Otis, J. and Roy, E. (2011). Sexe, drogues et autres questions de santé: Étude sur les habitudes de vie et les comportements associés aux infections transmissibles sexuellement chez les jeunes hébergés edans les centres jeunesse du Québec. Research report. Montréal: Agence de la santé et des services sociaux de Montréal and Institut national de santé publique du Québec. Direction de santé publique. Page 33

34 12 and 13 years (54.5%) while the majority of boys experience this first initiation at 12 years (39.5%). Also in the 12 months before their admission to the youth centre, 39% of girls and 57% of boys used cannabis daily. Among the other drugs, amphetamines and ecstasy are the most widely used, especially among girls. Following these are: Cocaine (girls: 37.1%; boys: 35.2%); Over-the-counter drugs (girls: 38.5%; boys: 27.9%); Salvia (girls: 27.4%; boys: 39.7%); Heroin (girls: 6.8%; boys: 1%). The majority of young people entering a youth centre (58.4% of girls; 63.1% of boys) receive a red light score on the DEP-ADO, i.e., they have an obvious problem with drug or alcohol use Street youth Between July 2001 and December 2005, the Direction de santé publique de Montréal carried out a prospective cohort study with street youth in Montréal. Roy and his colleagues indicate that, among the 858 young people (ages 14 to 23) recruited in their study, close to one half (46.6%) had injected drugs at least once before their participation in the study. Among street youth, the initiation to injection is a major phenomenon, with about 5% of young people being initiated each year. Daily use of alcohol, heroin, cocaine or crack and prostitution increases the risks of initiation. Street youth have a mortality rate 11 times higher than that of young people their age Persons with mental health problems Many people among the addicted population have mental health problems. There is little screening, and thus poor treatment, for this growing phenomenon. It is believed that between one third and one half of patients treated in psychiatry have addiction problems and that between one half and two thirds (65%) of people in treatment for addiction suffer from mental problems 73. It is believed that between one third and one half of patients treated in psychiatry have addiction problems. The success rate for addiction treatment in persons with mental health problems is generally low, and the rate of relapse and rehospitalization is high. These people have a greater resistance to treatment, whether medication-based or otherwise. By integrating first-line services and specialized services, more adequate help can be provided for persons suffering from both addiction and mental health problems. Also, several factors conducive to this integration appear in the best- 72 Roy, É., Haley, N., Godin, G., Boivin, J.-F., Claessens, C., Vincelette, J., Leclerc, P. and Boudreau, J.-F.(2008). L hépatite C et les facteurs psychosociaux associés au passage à l injection chez les jeunes de la rue. Direction de santé publique of Montréal. 73 Mercier, C. and Beaucage, B. (1997). Toxicomanie et problèmes sévères de santé mentale: recension des écrits et état de situation pour le Québec. Bibliothèque nationale du Québec. Page 34

35 practices recommendation for treatment of mental health 74 or alcoholism and addiction. The integration of alcoholism and addiction specialists in mental health services and the establishment of combined teams are two of the strategies proposed for this purpose. In Quebec, there are few specialized programs for people suffering from both addiction and mental health problems. Early evaluation of the use of psychotropic agents makes it possible to offer them better suited services and to prevent duplication of services or use of inappropriate services. In addition to promoting the adoption of best practices in rehabilitation centres and psychiatric services, existing programs must be supported and specialized treatment programs must be developed across sectors. Intensive and coordinated monitoring in the environment permits effective patient management. The Centre for Addiction and Mental Health of Canada offers several guidelines for establishing this coordination 75. Services for persons using injection drugs are offered by public and community agencies. However, a lack of medical staff and services close to addicted persons is reported. This situation creates many problems when trying to provide adequate help: restriction of access to services, absence of appropriate services, exclusion of active users, lack of continuity in services, shortage of medical treatment services, partnership difficulties, etc. To reduce harm, improving the organization and integrating services for injection drug users demands innovative projects to promote their reception and social reintegration. 6.4 Young homosexuals According to certain authors, young gay men are more likely than their heterosexual counterparts to have problems with substance use and abuse 76. A study on drug use, sex and risks in the gay seronegative Montréal community 77 reports increased use of cocaine, ecstasy, hallucinogens, speed and GHB, between 1997 and 2003, among this clientele. This study suggests a greater problem among younger gay men compared to older ones. In fact, more men under age 30 than over reported having used different substances in the six months preceding the study. The prevalence of consumption of each of these drugs appears to be two to ten times higher, compared to male respondents to the Canadian Addiction Survey. The results of the ARGUS study 78 among 1,957 gay Montréal men indicate that in those under age 30, 79.8% had used alcohol, 47.6% cannabis, 25.2% cocaine, 26.4% ecstasy, 26.2% amphetamines, 16.9% GHB, 15.7% ketamine, 6.3% magic mushrooms, 5.1% heroin, 3.5% other opioids and 3.5% LSD, two hours before sexual relations, at least one time in the last six months. 74 Review of Best Practices in Mental Health Reform. (1997). Advisory Network on Mental Health, Ottawa, Clarke Institute of Psychiatry. 75 Best Practices - Concurrent Mental Health and Substance Use Disorders (2002). Health Canada 76 Lampinen, T, McGhee, D, and Martin, I. (2006). Use of crystal methamphetamine and other club drugs among high school students in Vancouver and Victoria. 48(1): Otis et al. (2006). Drogues, sexe et risques dans la communauté gaie montrélaise Drogue, santé et société, vol.5, no. 2, pp Survey of HIV, viral hepatitis, STIs and associated risk behaviours among Quebec men who have sex with men Available online: Page 35

36 6.5 First Nations It is difficult to present the exact scope of addiction among First Nations people of Canada. However, certain indicators confirm that the problem is indeed present 79. Quebec surveys seem to confirm this 80, 81. Solvent inhalation is widespread among these youth, and appears to begin at about ages 12 to 13. Alcohol is a substance of choice among First Nations people. Those who use it do so until they are intoxicated, resulting in serious social consequences. However, this type of consumption and the consequences associated with it are tolerated within certain communities, and even seen as normal 82. In addition, solvent inhalation is widespread among these youth, and appears to begin at about ages 12 to The situation is also problematic among these youth living in an urban setting. In fact, they appear to be two to six times more susceptible to alcohol problems than their peers in urban communities. More of them also use marihuana or solvents. For example, statistics show that in Canada about one in five First Nations youths have already inhaled solvents, and that in Quebec 9% use them often. Finally, women also use alcohol when they are pregnant. This use can result in fetal alcohol syndrome in the child. And unfortunately, this problem seems to be even more common within certain First Nations communities Homeless people Homeless people frequently have addiction problems, and dependency problems are often a factor explaining or aggravating homelessness 85. According to a survey 86,87 conducted in the Québec City and downtown Montréal regions, close to one half (46%) of homeless people show a current or recent problem with drug or alcohol use. Men and people under 30 are the most represented. 79 For each of these indicators, the percentage of Aboriginal peoples is considerably higher compared to the rest of the Canadian population. 80 Daoust, G. (1995). Centre de réadaptation au Nunavik, Kujjuaq. Nunavik Regional Board of Health and Social Services Nunavik. 81 Faits saillants de l enquête sur la santé des Cris (1997). Ministère de la Santé et des Services sociaux. 82 Korhomen, M. (2004). Alcohol Problems and Approaches: Theories, Evidence and Northern Practice. Ajunnginiq Centre, National Aboriginal Health Organization 83 Three-year consolidation Plan ( ). (1999). Kuujjuaq, Nunavik Regional Board of Health and Social Services Nunavik. 84 April, N. and Nourret, A. (2004). Status Report on Fetal Alcohol Syndrome in Quebec, Montréal, Direction du développement des individus et des communautés, Institut national de santé publique. 85 Fournier, L. (2001). Enquête auprès de la clientèle des ressources pour personnes itinérantes des régions de Montréal-Centre et de Québec. Institut de la statistique du Québec. 86 Ibid 87 Study involved clientele of the twenty-four centres in Montréal (including eleven residential centres) and six centres in Québec City (including six residential centres). All centres exclusively receive people under age 18 and some receiving older young people were excluded from the survey. In all, 757 people were interviewed. 509 in Montréal and 248 in Québec City. Page 36

37 Drugs appear to be used abusively and in unsafe conditions. In addition, IV drug users are at greater risk of contracting infectious diseases (HIV/AIDS, hepatitis C or sexually transmitted infections). HIV/AIDS and hepatitis C are two major diseases among homeless people. This situation is worrying among youth, because they are the biggest users of IV drugs. Special attention must be paid to homeless people living with both mental health problems and addiction. Alcoholism and addiction are frequently combined with other problems, making the organization of services more complicated. The services offered must be adapted, integrated and continuous. Certain initiatives demonstrate promising results, such as liaison teams in emergency departments. 6.7 IV drug users IV drug users are a heterogeneous group of men and women, of varying age and background, who inject different illegal substances, the most common being cocaine, heroin and certain opioids. There may be close to twenty-three thousand IV drug users in Quebec (1/3 heroin; 2/3 cocaine). According to the various studies performed among groups of IV drug users, we note a prevalence of HIV of about 15% in Quebec (5%-20% according to the region). On the other hand, certain regions, such as Montréal, may see this number climb to about 19% in 2006, or above the epidemic threshold of 10%, while in the region of Québec City this percentage may be about 11%. Many young people inject drugs. This is the case in particular for a significant proportion of young people in the street (27%-29% of this population are regular users). The data from a longitudinal study 88 ( ) on Montréal street youth indicate that 45.9% of them have injected drugs at least one time before entering the study, that those who inject do so on average at about age 16.7 years and that 60% of street youth who have injected drugs during the month preceding the study did so with a used syringe. Street youth have a high risk of HIV and hepatitis C infections: in 2000, 20.5% of IV drug users have hepatitis C and under 2% have HIV 89. Injection of drugs results in serious consequences, both physical and social. Blood-borne infections; Overdoses; Hospitalizations; Deaths; Newborn withdrawal syndrome after childbirth; Marginalization; Exclusion; Increase in criminality. 20.5% of IV drug users have hepatitis C. 88 Roy, E. et al. (2004). L hépatite C et les facteurs psychosociaux associés au passage à l injection chez les jeunes de la rue. Direction de la santé publique, Agence de développement de réseaux locaux de services de santé et de services sociaux de Montréal-Centre. 89 Usage de drogues par injection et interventions visant à réduire la transmission du VIH et du VHC. (2007). INSPQ. Page 37

38 In Quebec, the distribution of safe injection supplies helps prevent the spread of AIDS and hepatitis. In addition to providing safe injection supplies, this initiative offers the opportunity to reach IV drug users and refer them towards other types of services, such as detox, rehabilitation and HIV screening. These services are offered by public and community agencies. 6.8 Incarcerated persons The drugs most often used in a prison setting are cannabis and cocaine. The health problems of people with both addiction and delinquency are significant. The data reveal a high prevalence of HIV and hepatitis C 90. In addition, many women in prison settings abuse psychotropic drugs. Addicted female inmates appear to be in a more serious situation than men: they use more often, they are more likely to use several psychotropic drugs and to use hard drugs such as heroin and cocaine. Addiction problems among these women were usually present before their incarceration. Most of them may have grown up in households where drug use was common and where they were more likely to be victims of physical or sexual violence. Thus their needs are great and are different from those of male inmates Members of street gangs According to Public Safety Canada 92, in 2002 there were about 25 street gangs in Quebec. The number of street gang members was then evaluated at 533, representing about 0.07 street gang members per 1,000 inhabitants. Public Safety also notes that the youth most likely to join a gang or who are already gang members usually come from groups that experience social inequalities and are the most socially disadvantaged. In addition, the largest proportion of street gang members is represented by Afro-Canadians (25%), followed by First Nations (21%) and young whites (18%). Some of the reasons reported for joining a street gang include a search for strong emotions, prestige/protection, the desire to make money and the feeling of belonging. The phenomenon is more diverse and more visible the closer one is to large cities. Small towns are not spared, however. Other than the fact that street gangs have repercussions on citizens quality of life in all regions of Quebec, certain facts connected to them are alarming. 11% of students attending Montréal schools say they had participated in a gang fight. Thus, a recent study conducted by the International Centre for Comparative Criminology (ICCC) at the Université de Montréal indicates that 11% of students attending Montréal schools say they had participated in a gang fight. 90 Alary, M., Godin, G and Lambert, G. (2004). Étude de prévalence du VIH et de l hépatite C chez les personnes incarcérées au Québec et piste pour l intervention. Direction générale des services correctionnels and the Institut national de santé publique. 91 Langan, N.P. and Pelissier, B (2001). Gender differences among prisoners in drug treatment, Journal of Substance Abuse, vol. 13, November 2001, p Youth Gangs in Canada: What Do We Know? (2008). Public Safety Canada Available online: Page 38

39 Along the same lines, 20% of street gang members are between 11 and 16 years old. 60% of them are between 17 and 28 years old, and 20% are between 29 and In addition, data from Public Safety Canada reveal that a significant number of young people who join gangs are already drug users and already committing acts of violence and serious crimes. Just as alarming, a study 94 conducted jointly by Canada and the United States shows that there are certain obvious connections between gangs, weapons and drugs, including among Montréal youth. Thus, there is a clear correlation between the presence of gangs and the ease of procuring firearms and drugs in schools. This same study reveals that in Montréal, 18.7% of boys ages 14 to 17 have already brought a firearm to school. Finally, young dropouts who deal drugs are at greater risk of becoming involved in acts of armed violence. Street gangs are also becoming an indispensable part of drug trafficking. Within gangs, narcotic use is part of a completely normal social process. Street gang members in fact adopt consumption much more than non-members. Alcohol and cannabis and its derivatives appear to be the drugs most widely used by street gang members. 95 According to an international study conducted in 2004 among 251 cities, Montréal is in 18 th place internationally and among the top 5 safest cities in North America. Street gangs are still one of the factors of criminality that have the greatest impact on the population s perception of security. Thus, in December 2007, the Ministère de la Justice and the Ministère de la Sécurité Public of Quebec announced the largest ever investment by the Quebec government to prevent criminality million dollars are injected over three years for prevention on several fronts in the fight against street gangs and will be used to: Provide financial support for community projects tailored to the realities of various environments and aimed at preventing youth from joining gangs; Create actions to prevent recruitment of youth for sexual exploitation throughout Quebec; Implement an intensive follow-up program for delinquents at high risk of recidivism, targeted according to their potential for delinquency; Provide support for parents and cultural communities The elderly 97 The elderly may experience problems with addiction. Although seniors drink less than other population groups, alcohol is the psychotropic drug they use most often. Their alcohol use has been on the rise for about fifteen years. In Canada, 11% to 14% of seniors exceed the limit recommended by the Low-Risk Alcohol Drinking Guidelines. Éduc alcool reports that tools for screening problems with alcohol among seniors are often inadequate, and that there are very few detoxification and treatment programs adapted to the reality of the elderly. 93 Barbeau, D. (2005). Actualités GDR. SPVM. 94 Erickson, P., Butters, J. Cousineau, M.M., Harrison, L. and Korf, D. (2006). Drugs, Alcohol and Violence International (DAVI). J Urban Health September; 83(5): L Écho-Toxico (2005). Vol.15, No.25. Université de Sherbrooke 96 Sécurité publique. (2008). Available online 97 Alcohol and Seniors. (2006). Éduc alcool. Page 39

40 7. Public opinion about consumption In general, Quebeckers believe that smoking is the social or health problem that is costliest at the social, economic and health levels, ahead of drug use, the AIDS virus, medication abuse and alcohol abuse. However, according to persons age 65 and over, and those not initiated in soft drugs, drug use is the costliest problem for society. 98 For the majority of Canadians, the use of alcohol and other drugs is a serious or very serious problem in Canada, within their province and their community. By decreasing order of severity, they rank problems as follows 99 : In decreasing order or severity. illegal drug use; IV drug use; alcohol use; prescription drug use; over-the-counter drug use; inhalant use. This intensity is stable across Canada, the provinces and cities, except for IV drug use, whose perceived severity is lower in the cities. More specifically, in Quebec, 70% of the population believes that drugs are an important or very important concern. Women express more concern than men, 78% versus 63%. 100 Concerning alcohol, 59.1% of Canadians are opposed to increasing taxes on alcoholic beverages. Men (32.7%) are less in favour of it than women (47.4%) and the same is true for residents of Quebec (33.3%) and Alberta (31.9%). Ontario residents are most in favour of a tax increase (46.7%). More than 80% of Canadians say they strongly agree with random spot checks for drinking and driving 101. Cannabis is viewed as less harmful than tobacco. However, 61.4% of Canadians believe that marihuana users wind up using other drugs. They feel (57.7%) that growing of cannabis for personal use must Cannabis is viewed as less be prohibited. And only 36.6% of Canadians agree with harmful than tobacco. the legalization of marihuana. Among those who approve of this legalization, 37.9% are in favour because they believe that marihuana is not a dangerous drug 102. We note that men are more in favour of legalizing marihuana than women (43.8% versus 32.2%), just as residents of British Columbia, (44.0%), Manitoba (39.5%) and Ontario (41.5%) are more in favour of it than the rest of Canada. Quebec (31.3%) and 98 Hamel, D. (2001). Perceptions de la population québécoise en lien avec les programmes de prévention de la toxicomanie et du VIH. Québec: Institut national de santé publique du Québec. Available online: 99 A National Survey on Canadians Use of Alcohol and Other Drugs: Public Opinion, Attitudes and Knowledge. (2006). Health Canada, Available online: Hamel, D. (2001). Perceptions de la population québécoise en lien avec les programmes de prévention de la toxicomanie et du VIH. Québec: Institut national de santé publique du Québec. Available online: A National Survey on Canadians Use of Alcohol and Other Drugs: Public Opinion, Attitudes and Knowledge. (2006). Health Canada Available online: Ibid Page 40

41 Saskatchewan (29.2%) are the least in favour. Heroin and cocaine are considered the most dangerous drugs, because the majority of Quebeckers believe that they cause immediate health damages and cause dependency from the first use 103. Canadians think that the availability of drugs is the main reason that leads to their use (28.4%) and that anyone is at risk for using drugs (52.3%), but also youths (23.5%) 104. Among the measures capable of stemming drug-related problems, the population prefers prevention. In fact, Canadians prefer prevention and treatment (78.0%) to law enforcement and incarceration (18.7%) as means of fighting drug use. 82.8% of Canadians believe that the government should give preference to treatment programs over criminalization of drug use 105. Education programs in the schools, dispensed by police or community workers, and programs to improve the living conditions of young people are more apt, according to them, to reduce problems caused by drug use than repression solutions such as mandatory detoxification for all addictions and zero tolerance in schools 106. For Quebeckers, the various reasons that may lead people to become addicted are the following 107 : low self-esteem (72%); little attention paid to them by society (61%); a hard and competitive society (59%); a family crisis (54%). However, just over one third (36%) believe that sexual abuse is a cause of addiction 108. The Quebec public does not think it is possible to lead a normal social life as an addicted person. In fact, Quebeckers do not think it is possible 109 : to keep a job (68%) and; to raise a child properly (81%) while being an addicted person. 96.4% of Canadians also agree with detoxification programs and 74.4% agree with clean syringe distribution programs Hamel, D. (2001). Perceptions de la population québécoise en lien avec les programmes de prévention de la toxicomanie et du VIH. Québec: Institut national de santé publique du Québec. Available online: A National Survey on Canadians Use of Alcohol and Other Drugs: Public Opinion, Attitudes and Knowledge. (2006). Health Canada, Available online: Ibid 106 Hamel, D. (2001). Perceptions de la population québécoise en lien avec les programmes de prévention de la toxicomanie et du VIH. Québec: Institut national de santé publique du Québec. Available online: Ibid 108 Ibid 109 Hamel, D. (2001). Perceptions de la population québécoise en lien avec les programmes de prévention de la toxicomanie et du VIH. Québec: Institut national de santé publique du Québec. Available online: A National Survey on Canadians Use of Alcohol and Other Drugs: Public Opinion, Attitudes and Knowledge. (2006). Health Canada Available online: Page 41

42 8. The principal approaches used in Quebec There are several approaches in the field of drug addiction in Quebec. These approaches, while they may be dominated by Harm reduction, or Abstinence, or fall under another treatment philosophy, can be grouped under the term Biopsychosocial since they are addressed at the individual s physical and mental health, as well as his family and social environment. 8.1 The harm reduction approach The approach «harm reduction» was put forward in the 1980s. Harm reduction is a collective health approach aimed at allowing users to develop the means to reduce their use as well as the negative consequences connected to their behaviours. This approach was put forward in the 1980s as a response to the danger of HIV transmission among IV drug users. They are aimed at decreasing the harmful consequences of using alcohol and drugs, both legal and illegal, and they attempt to mitigate the negative repercussions associated with this use. The harm reduction approach does not immediately seek to reduce or eliminate drug use. The objective is thus not abstaining from using any substance, but rather implementing a series of prioritized objectives aimed at addressing the most urgent problems first (for example, stabilization of health, finding housing, etc.) 111. The field of action in harm reduction today covers the entire continuum of intervention Programs involving alcohol In Quebec, there are many harm reduction programs involving alcohol. Here are some examples: Éduc alcool Independent non-profit organization which brings together parapublic institutions, associations in the alcoholic beverage industry and people from various settings (public health, universities, journalism). These organizations, aware of their social mission, implement prevention, education and information programs to help youth and adults make responsible, informed decisions about using alcohol. Operation Red Nose A ride home program for people who have consumed alcohol. This program operates during the holiday season and is neutral about the use and abuse of alcohol. Action Serveurs An education program for bar and restaurant servers, to help them implement new strategies to reduce the harm associated with alcohol use. These strategies include specific actions for inebriated customers: convincing the customer not to drive, calling a cab, delaying the departure, taking keys away, refusing to serve Page 42

43 alcohol, offering alcohol-free drinks, serving food, administering a breathalyzer test, informing the boss, calling the police, etc Programs involving drugs There are also several types of harm reduction programs associated with drugs. Some of them are connected to syringe exchange; others target sexually transmitted diseases or teach moderation or the safe use of drugs. They appeared in 1989, with the creation of Cactus in Montréal, and have multiplied and diversified since then. Many of them are organized around dispensing sterile supplies, including syringe distribution. They are now present throughout the Quebec territory, although there are more in Montreal than in Québec City. There are three major types of syringe access programs: Specialized prevention centres 112 (CSP) Fixed sites for syringe exchange in urban neighbourhoods with a high concentration of IV drug users; in addition to syringe exchange, these centres generally offer, on site, a wide variety of services (referral, screening, care, etc.) and they have also developed specific components such as prison interventions and interventions with prostitutes or at places where drugs are used. Community approach programs (PAC) Fixed sites or mobile units, sometimes also using outreach to IV users in the community, such as parks, shooting galleries, in the street and in any other setting; the programs Gens de la rue and Pic-Atouts do specialized intervention for HIV prevention among IV drugs users, while Pact de rue and L Anonyme integrate HIV prevention among other concerns when they work with their clients. Programs with multiple non-specialized sites (PSM) Established by the Directions régionales de santé publique, they are primarily located in healthcare institutions (CSSSs, hospital ERs) and in pharmacies, in order to ensure accessibility of sterile injection supplies outside of the major urban centres, where there are fewer addicted persons. The other services offered to addicted persons (screening, medical care, psychosocial support) vary greatly from one site to another, but all of these programs claim to provide basic services, such as information and education, and listening and psychosocial support, referral to STI/AIDS screening and addiction resources; a majority of them also dispense on-site counselling, STI/AIDS screening and healthcare services. Out of 18 administrative regions, 16 have a program for access to injection supplies in one form or another. In , 787 service points offered access, marking a slight increase over the preceding year. The general community organizations, as well as those specializing in STI prevention among IV drugs users, are the ones that offer the greatest access to injection supplies. Here are some examples 113 : Cactus Montréal The first syringe exchange centre in North America, CACTUS has experience in harm reduction, through multiple activities with IV drug users and sex workers in Montréal. 112 Statistiques sur les services relatifs aux programmes de prévention du VIH et des hépatites B et C offerts aux utilisateurs des drogues par injection du Québec (2004).MSSS Page 43

44 Méta d Âme Day centre and self-help group for people who are or have been dependent on opioids and are receiving treatment for it. Portail francophone d appui aux professionnels, pour l avancement du traitement de la dépendance aux opioïdes Result of collaboration between the Centre de recherche et d'aide pour narcomanes (CRAN) and the International Center for the Advancement of Addiction Treatment (ICAAT). At the site, you will find national and international news on treatments for opioid dependency, guides for practice and the possibility to consult an expert by . Spectre de rue This Montréal organization helps marginalized persons living with addiction, homelessness, sex work or mental health problems. Spectre de rue supports people through several projects and activities, including TAPAJ (alternative work paid daily), the fixed site, day centre, outreach work and community work Methadone support treatment The use of replacements for certain psychoactive substances is one of the most widely known and recommended harm reduction measures, primarily concerning methadone for treatment of opioid users. CRAN (Centre de recherche et d aide pour narcomanes) is an organization which offers a high-threshold, prolonged intervention program. Addicted persons are treated on an outpatient basis and receive their methadone in one of the affiliated community pharmacies. They have regular meetings with a psychosocial support worker and access to healthcare services. In addition, when their situation is deemed to be stable, they can be referred to one of the generalists who belong to the therapeutic partner network. In 1992, a second program was added in Montréal, which is integrated in the detoxification unit of Hôpital Saint-Luc. This is a brief intervention model, offering addicted persons the possibility of methadone-assisted withdrawal (decreasing dose), lasting 14 days on an inpatient basis and 48 days in outpatient services. During the process, patients have access to healthcare services, screening exams and various preventive measures. They have weekly meetings with a support group and may be referred to a rehabilitation program once the detoxification is complete. A low-threshold methadone program, sponsored by CRAN and Cactus, also helped its first clients in fall This project, Relais-Méthadone, is part of a harm reduction perspective. It puts a priority on decreasing risky behaviours and improving health rather than abstaining from drug use. The program specifically targets clients who do not present spontaneously at existing services. The community organizations that do streetwork are the primary source of referrals for this program. Services are offered by a multidisciplinary team (doctor, nurse, social worker and community worker). Page 44

45 8.2 The therapeutic communities approach The philosophy of intervention of the «therapeutic communities approach» is based on peer support and the construction of a new set of references. The therapeutic communities approach is found in certain treatment centres, most of them private, throughout Quebec. This approach is inspired by the treatment dispensed at the Centre Le Portage, the oldest and biggest centre using this approach. Their philosophy of intervention is based on peer support and the construction of a new set of references to guide the lives of addicted persons. While some of these centres have a professional staff, their employees are mainly former clients who have risen in the hierarchy according to their seniority and their ability to act as a leader in the therapeutic community. Acceptance of individual responsibility, group meetings and behaviour modification techniques are central elements of the programs 114 (Nadeau and Biron, 1998). Treatment is done internally and generally lasts three months to one year, making it a preferred choice for those whose condition requires a longer-term program or as an alternative to incarceration. Treatment is free in some of these centres, thanks to subsidies from the Ministère de la Santé et des Services sociaux or agreements with the Ministère de la Sécurité publique or the Ministère de l Emploi et de la Sécurité sociale The new mandatory MSSS certification program will in part disrupt these programs, which rely on non-specialized labour. The requirements for this certification pose both a challenge and an additional financial hurdle for organizations using this approach. 8.3 The approach connected to the self-help group philosophy The Self-Help group approach, inspired by the philosophy of Alcoholics Anonymous (AA), is found in many private centres in Quebec, some of the best known of which are Maison Alcoholism and other addictions are Jean Lapointe and Pavillon Pierre-Péladeau considered illnesses that can be held Inc., which owe their notoriety to their name. in check by abstinence and adhering This approach comes from the use of the to the lifestyle of these groups. philosophy of self-help groups as a central element of treatment. Alcoholism and other addictions are considered illnesses that can be held in check by abstinence and adhering to the lifestyle of these groups. The majority of the staff are counsellors who are themselves rehabilitated alcoholics or addicted persons. In certain centres, this team also includes the support of healthcare professionals (doctors, nurses, psychologists, etc.). In most cases, treatment is offered internally for periods varying from three to six weeks and follow-up, which can be more or less intensive or structured, is offered according to the organization of services within each resource. Longterm involvement in self-help groups and abstinence from all psychotropic substances are essential to treatment 115 (Cook, 1988). Just as for the other approaches used in the private and community network, the new mandatory certification requirements pose both a challenge and an additional financial hurdle for organizations who use this approach and make do with limited budgets. 114 Nadeau, L. and Biron, C. (1998) Pour une meilleure compréhension de la toxicomanie. Québec: Collection Toxicomanies, Presses de l'université Laval/De Boecke, 142 pages. 115 Cook, CCH. (1988). The Minnesota model in the management of drug and alcohol dependency: Miracle, method or myth. Part 1. The philosophy and the program. British Journal of Addiction. 83: Page 45

46 Part II Governments, Health and Dependencies Page 46

47 To prepare a complete portrait on the environment concerning issues of alcohol and drug use, we must first describe the governmental and paragovernmental structures, as well as the principal players and their orientations. First, it is important to know that the Constitutional Act of 1867, which gave birth to modern Canada, grants provinces jurisdiction over most public health services (health, education, natural resources, justice, municipal affairs, civil rights, public safety, employment, etc.). Thus, health, and consequently all problems connected to alcohol and drug use, fall under provincial competence. The administrative framework of the government of Quebec consists of about twenty departments, which make up the foundation of the government organization. However, in the interest of autonomy, specialization, efficacy and visibility, the legislator decided to transfer or attribute certain administrative functions to autonomous agencies rather than departments. Consequently, the government organization chart includes about public agencies (corporations, councils, bureaus, boards, commissions and administrative tribunals). Each of these agencies is placed under the responsibility of a minister who is accountable for their management. In the Quebec government, it is the Ministère de la Santé et des Services sociaux (MSSS) which is responsible for offering the population addiction prevention and treatment services. The mission of the Ministère de la Santé et des Services sociaux (MSSS) is to maintain, improve and restore the health and well-being of Quebeckers by providing a body of integrated, quality health care and social services, thereby contributing toward Quebec s social and economic development. The Ministry has sole responsibility, at the government level, for organizing health and social welfare services. However, it shares this responsibility with several agencies and partners. 117 The referrals of the MSSS are carried out through the health and social services network and through the networks of departments which support addicted persons or those at risk of addiction among their clientele. The establishment of these referrals is deployed at the national, regional and local levels. In recent years, the MSSS has made public two reference documents on addiction. The first document was developed in 2006, by the MSSS, in collaboration with eight other ministries. This is the Plan d action interministériel en toxicomanie This interministerial plan covers all aspects, from prevention to social reintegration, including the research aspect. The second reference document entitled Offre de services : Programme-services Dépendances: Orientations relatives aux standards d'accès, de continuité, de qualité, d'efficacité et d'efficience 119 is more specifically targeted at services which should be offered by agencies in the health and social services network. 116 Quebec Portal. (2008) Departments and agencies. Available online: Ministère de la Santé et des Services sociaux. (2006). Available online: Le Plan d action interministériel en toxicomanie Ministère de la Santé et des Services sociaux. (2006). Available online: L Offre de services : Programme - services Dépendances. Orientations relatives aux standards d accès, de continuité, de qualité, d efficacité et d efficience pour le Programme-services Dépendances.(2007). Ministère de la Santé et des Services sociaux. Available online: Page 47

48 9. Government agencies There are nine organizations which fall directly under the MSSS: Le Bureau des projets Centre hospitalier of the Université de Montréal (CHUM), McGill University Health Centre (MUHC), and Centre hospitalier universitaire (CHU) Sainte- Justine The Provincial Committee for the provision of health and social services to persons from ethnocultural communities The Provincial Committee for the delivery of health and social services in the English language The Health and Welfare Commissioner The Institut national de santé publique du Québec. The Institut national d'excellence en santé et en services sociaux The Office des personnes handicapées du Québec The Régie de l'assurance maladie du Québec Urgences-santé 9.1 Bureau des projets Centre hospitalier de l Université de Montréal (CHUM), McGill University Health Centre (MUHC) and Centre hospitalier universitaire (CHU) Sainte-Justine The mission of the Bureau des projets is to ensure that the regulatory guidelines of the program, budget and calendar set by the government are complied with, while striving to reduce the risks inherent in large-scale, complex projects. This fosters integrative and participative dynamics between University Health Centres (UHC) and partners. The synergy of these efforts will create a management culture conducive to the projects being carried out in a sustainable development perspective. 9.2 The provincial Committee for the provision of health and social services to persons from ethnocultural communities This provincial committee has been given the mandate to advise the Minister on the provision of health services and social services to persons from ethnocultural communities in Quebec. The Committee may conduct consultations, request opinions, receive and listen to requests from persons, organizations or associations. Thus, it must give its advice to the Minister of Health and Social Services, promoting organization of health services and social services taking diverse cultural realities into account. 9.3 The Provincial Committee for the delivery of health and social services in the English language This committee is charged with giving advice on: The provision of health and social services in the English language; The approval, assessment and modification by the Government of each access program developed by a regional agency. Page 48

49 The Committee may conduct consultations, request opinions, receive and listen to requests from individuals, organizations or associations. 9.4 The Health and Welfare Commissioner The Health and Welfare Commissioner takes the place of the Conseil médical du Québec and the Conseil de la santé et du bien-être. Its mission is to provide perspective for public debate and governmental decision making that will contribute to enhancing the health and welfare of women and men in Quebec. The Commissioner appraises the results achieved by the health and social services system and evaluates all facets of the system, with particular emphasis on factors such as quality, accessibility, continuity and funding of services. He makes public information that will make it possible to provide perspective for debate and decision making. He recommends changes that should help to increase the overall performance of the system. 9.5 The Institut national de santé publique du Québec (INSPQ) The Institut national de santé publique du Québec (INSPQ) 120 is a state-mandated government agency. Created by virtue of the Loi sur l'institut national de santé publique du Québec in 1998, the Institut supports, through its expertise, the Minister of Health and Social Services (MSSS) of Quebec, the regional public health authorities and the healthcare institutions in the exercise of their responsibilities. Dependency is a concern of the INSPQ, principally at the level of promotion of health and dependency prevention. This work consists primarily of: Developing knowledge and helping to monitor the health and well-being of the population and its determinants; Developing new knowledge and approaches to health promotion, prevention and protection; Promoting the development of research and innovation in public health; Providing advice and consulting services; Evaluating the impact of public policies on the health of the population; Supporting the establishment of the Quebec Public Health Program ; Supporting research or development of new knowledge; Supporting training and information activities; Supporting specialized laboratory services. 9.6 Institut national d excellence en santé et en services sociaux (INESSS) The Institut national d excellence en santé et en services sociaux (INESSS) was established in January The INESSS succeeded the Conseil du médicament and the Agence d évaluation des technologies et des modes d intervention en santé (AETMIS). Its mission is to promote clinical excellence and the efficient use of resources in the health and social services sector by assessing the clinical advantages and the costs of the technologies, medications and interventions used in health care and personal social services. The INESSS 120 Institut national de santé publique du Québec (INSPQ). Available online: Page 49

50 also has a mandate to issue recommendations concerning their adoption, use and coverage by the public plan, and develops clinical practice guides in order to ensure their optimal use. INESSS blends the perspectives of network professionals and managers and those of patients and beneficiaries. This collaboration brings together knowledge and know-how from myriad sources. The INESSS also contributes to the mobilization of the partners concerned to improve care and services to the public. 9.7 Office des personnes handicapées du Québec The mission of the Office is to ensure compliance with the Act to ensure that handicapped persons can exercise their rights with a view to achieving social, school and workplace integration. The Office must ensure that government departments and their networks, municipalities and public and private agencies continue their efforts to integrate handicapped persons and to enable the latter to participate fully in society. The Office also plays a role in coordinating and assessing the services offered to handicapped persons and their families. It promotes the interests of the latter and informs, advises and assists them and makes representations in their behalf both on an individual and a collective basis. 9.8 Régie de l'assurance maladie du Québec The Régie administers the public health and prescription drug insurance plans: it informs the public, manages individuals eligibility, compensates healthcare professionals and ensures the secure flow of information. 9.9 Urgences-santé The mission of Urgences-santé consists of providing the population of Montréal and Laval with high-quality, efficient and appropriate emergency prehospital services, in order to reduce the mortality and morbidity associated with the clientele s urgent medical conditions. These services include: A health communication centre; Emergency prehospital care, ambulance transportation, as well as transportation between institutions. Urgences-santé is also responsible for planning, organizing, coordinating and assessing the services in the prehospital intervention chain. 10. Plan d action interministériel en itinérance In autumn 2008, the Commission des affaires sociales du Québec held public hearings on the issue of homelessness in Quebec. The objective was to: Prepare a profile on homelessness today; Take stock of trends observed in intervention settings; Identify priority action needs. Page 50

51 After these hearings, the Plan d action interministériel en itinérance was developed. This plan is a result of the wish of many government departments and agencies to work together in their commitment to prevent and counter homelessness in Quebec. 2 basic observations The situation of homelessness in Quebec remains troubling; The situation of homelessness requires harmonization and coordination of actions. Reinforce the prevention of homelessness; Promote residential stability; Improve, adapt and coordinate intervention among homeless people; Promote tolerant and secure cohabitation among the various groups of citizens; Increase research. 5 priorities We know that living on the street includes many risks, including dependency. Close to one half of the homeless have a dependency problem. These problems may explain or aggravate homelessness. In addition, the problems of alcoholism and addiction are often combined with other problems, and can become very troubling, particularly among street youth. We know that the majority of them have problems with alcohol use or serious drug problems. More than half of them also use IV drugs. Because of this, the first priority, Reinforce the prevention of homelessness, emphasizes early detection of addiction and mental health problems. These persons are offered support and referred to the appropriate services. Hospitals, health and social services centres, rehabilitation centres and community organizations play a strategic role in realizing this priority. 11. Plan d action interministériel en toxicomanie The MSSS drew up the Plan d action interministériel en toxicomanie in cooperation with the following eight ministries: The principal ministries are: The Ministère de l Éducation, du Loisir et du Sport du Québec (MELS); The Ministère de la Justice (MJQ) and the Ministère de la Sécurité publique (MSP); The Ministère de l Emploi et de la Solidarité sociale (MESS); The other ministries are: The Ministère des Transports (via the Société de l assurance automobile du Québec - SAAQ); The Ministère de la Famille et des Aînés (formerly the Ministère de la Famille, des Ainés et de la Condition féminine (MFACF)); Page 51

52 The Ministère du Conseil exécutif (Secétariat à la jeunesse et des affaires autochtones); The Ministère de l Immigration et des Communautés culturelles (MICC). In the context of establishing and assessing this plan, the MSSS will play a unifying role among its partners which will have as a mandate, in their respective network, to implement actions at the provincial, regional and local levels, taking their respective priorities into account Ministère de l Éducation, du Loisir et du Sport (MELS) The mission of the Ministère de l'éducation, du Loisir et du Sport du Québec (MELS) is to ensure that Quebeckers have access to high-quality educational services and a learning environment to enable them to fully develop their skills and use their potential throughout their life. The MELS entrusts the Minister with the power to develop and propose to the government policies concerning the above-mentioned fields in order, in particular, to: Promote education; Contribute, through the promotion, development and support of these fields, to the elevation of the scientific, cultural and professional level of the Quebec population and of the individuals within it; Promote access to higher forms of knowledge and culture for anyone with the desire and aptitude; Contribute to the harmonization of orientations and educational activities with all government policies and with the economic, social and cultural needs of Quebec society. Intervention in the school environment must promote the integration of various programs and action plans aimed at prevention. According to the Ministère de l Éducation, du Loisir et du Sport du Québec (MELS), intervention in the school environment, to prevent drug use and abuse, must promote the integration of various programs and action plans aimed at prevention and targeted at youth and their health. In the spring of 2003, the Quebec Ministre de la Santé et des Services sociaux and the Ministre de l'éducation signed a new agreement on complementarity of services among their respective networks around a common objective: youth development. This agreement includes several lines of intervention, including promotion of health and well-being, as well as prevention. To carry out this line of intervention, the agreement Addiction prevention is now part of a broader approach to health called École en santé. builds on the development and deployment of global, cooperative intervention for schoolbased promotion and prevention. Addiction prevention is now part of a broader approach to health called École en santé. This École en santé approach 122 is inspired by recognized principles and the results of research done around the world. It is recommended by the World Health Organization (WHO) and by the US Center for Disease Control (CDC) to permit increasing the 122 Approche École en santé. (2007). Ministère de l'éducation, du Loisir et du Sport du Québec. Available online: Page 52

53 effectiveness of promotion and prevention measures aimed at school-age youth. In addition, it applies the fruitful experience acquired in several Quebec school environments in the past few years. The École en santé approach will be examined more specifically in the section Other activity sectors The Ministère de la Justice (MJQ) and the Ministère de la Sécurité publique (MSP) The actions of the Ministère de la Justice (MJQ) are closely linked to those of the Ministère de la Sécurité publique (MSP). These two ministries work closely with each other because alcohol and drug abusers are often involved in different processes connected to justice and public safety. The interventions of the MSP take place either upstream from the criminal justice system (through its police services) or downstream (through its correctional services). These interventions thus require a link-up with the Ministère de la Justice (MJQ). The links between justice and the use of psychotropic substances may be viewed under two different angles, which are often interrelated. First of all, we find illegal acts directly associated with alcohol and drugs, including manufacturing, possession and trafficking. We can then think about acts and situations more indirectly linked to consumption, such as spousal and family violence, driving while impaired, conflicts among neighbours, etc Prevention of criminality Until now, the addiction prevention carried out by the Ministère de la Sécurité publique (MSP) primarily involved efforts by police in schools. The various provincial and municipal police forces, alone or in cooperation with government, paragovernment, community or private support workers, offered information programs on drugs, their effects and laws. Certain workers gradually integrated more educational approaches with youth, but also with their parents and the community. These approaches were targeted, among other things, at acquisition of social skills to enable people to be better able to resist the offer to use substances. Collaborative efforts among the instructors, non-teaching staff and police officers were also established in the school setting, in order to intervene with young student users or among those caught dealing drugs in school. Here are some prevention programs used by Sûreté du Québec 123 which are receiving special attention: Vivre fièrement a support tool for police interventions in youth prevention, targeted more specifically at young Amerindians in primary and secondary school. It approaches a growing problem with Aboriginal communities: solvent inhalation. It offers a wide range of activities for reconciliation, awareness and education and emphasizes the partnership with youth, the community and available youth resources. Cool pour vrai! - a package designed for year olds, with the objective of crime prevention and conflict resolution. In addition to violence and wrongdoing, drugs and alcohol are among the problems targeted. The strategic approach is used to solve certain problems. Je réfléchis avant d'agir a program for ages 6 to 12 in primary schools which deals with the topic of drugs and alcohol. 123 Sûreté du Québec (2011). Web site: Page 53

54 Several other initiatives have come out of the Ministère de la Sécurité publique (MSP), or been encouraged by the latter, in the area of prevention of harm connected to alcohol and drug use, such as awareness and support programs for bar owners, awareness for the correctional population, etc Reduction of criminality through enforcement Alcohol supply management In 1996, the Ministère de la Sécurité publique, in collaboration with many partners, including the Sûreté du Québec, implemented the ACCES alcool program. (Concerted actions to counter underground economies). The objective of this program consists of fighting illegal commerce in alcoholic beverages. Many thousands of systematic inspections are performed annually in licensed establishments. These inspections help to detect speakeasies and major illegal alcohol supply networks. Marihuana production intervention In 1989, the Sûreté du Québec started the Cisaille program to fight expansion of marihuana production and trafficking. This program is primarily aimed at destabilizing the criminal organizations which direct marihuana production and distribution activities, by limiting the expansion of marihuana production in Quebec. It is also intended to increase public awareness about marihuana production, particularly among groups able to provide information. This program thus specifically targets associations of farmers, pilots and purveyors. It gives them information about concrete resources available to them, including the Info-Crime Québec line and reporting to the local police department, both of which are completely anonymous. Limiting alcohol permitted behind the wheel and road blocks Driving while impaired is one of the main causes of collisions causing bodily injuries in Quebec. In , 5.1% of collisions with bodily injuries were due to alcohol use. 124 For this reason, the Sureté du Québec is implementing road blocks and performing random spot checks on drivers to test their blood alcohol. In , 7,789 arrests were made for operation while impaired Ministère de l Emploi et de la Solidarité sociale (MESS); The mission of the Ministère de l Emploi et de la Solidarité sociale (MESS) is to contribute to Québec s social development and economic prosperity by encouraging individuals to realize their full potential: first by working to promote employment, developing the labour force and improving labour market operations; and second by providing financial support to economically-disadvantaged people, and combatting poverty and social exclusion. To achieve this, the MESS offers employment and social solidarity services found in the Déclaration de services aux citoyennes et aux citoyens. The assistance and services offered to the public can be grouped around basic services, specialized services and more specific intervention programs. Since 2010, the MESS, through legislative regulation, has required MSSS certification for private organizations offering residential addiction services so that their clients can claim special addiction benefits. 124 Rapport d activité (2010). Sureté du Québec. Available online: Page 54

55 11.4 The other ministries In addition to the MSSS, the MELS, the MJQ, the MSP and the MESS, four other ministries are involved in implementing the Plan d Action Interministériel: the Ministère des Transports, the Ministère de la Famille et des Ainés, the Ministère du Conseil exécutif (Secrétariat aux affaires autochtones et Secrétariat à la jeunesse) and the Ministère de l Immigration et des Communautés culturelles. Somewhat more indirectly, these ministries, through their mission, ensure their collaboration with the various strategies implemented by the other ministries. Here are brief summaries of the orientations of these ministries: Ministère des Transports 125 The mission of the Ministère des Transports is to ensure the mobility of people and goods throughout Quebec on safe, efficient transportation systems that contribute to the development of Quebec. It acts as a major player in the organization of transportation systems in Quebec. It builds on close cooperation with its partners to optimize the efforts of everyone, respecting the responsibilities of each Ministère de la Famille et des Ainés 126 The Ministère de la Famille et des Ainés provides financial assistance to families, and organizations whose responsibilities involve families, the elderly and childcare services. It organizes and supports the supply of educational childcare services. It acts as an expert advisor for the coherence and coordination of government interventions, with regard to the elderly and its provides information to people and families Ministère du Conseil exécutif Secrétariat des affaires autochtones 127 Maintains ties between Aboriginal peoples and the government of Quebec; Negotiates agreements, disseminates appropriate information and provides support for the social, economic and cultural development of Amerindians and Inuit; Coordinates all government actions in aboriginal communities and ensures coherence in the policies, interventions, initiatives and positions of the various departments and agencies of Québec involved in this action. Coordinates training and awareness activities on the Aboriginal issue, in order to meet the needs of government departments and agencies. 125 Ministère des Transports. (2011). Website: Ministère de la Famille et des Ainés. (2011). Website: Secrétariat des affaires autochtones. (2011). Website: Page 55

56 Secrétariat à la jeunesse 128 Ensures coherence of the government policies and initiatives concerning youth, in particular by performing strategic monitoring of issues important to youth, requesting advice and opinions from individuals, groups or organizations concerning these questions, and exercising leadership among the departments and agencies concerned. Supports youth actions, in cooperation with its various partners, including youth agencies operating at the national, regional and local levels. Provides young people and the entire population with information about youth. Develops and implements government youth policies, including the Stratégie d action jeunesse Ministère de l Immigration et des Communautés culturelles 129 The Ministère de l Immigration et des Communautés culturelles promotes immigration, selects immigrants and fosters their integration in society Clientele targeted The Plan d action interministériel en toxicomanie is addressed at the general population and pays special attention to certain groups with special needs. Note that these clientele are very similar to the At-risk groups identified in Part I: Young people; Youth in crisis; Pregnant women; The elderly; Members of cultural communities; Members of First Nations; Offenders; Persons with mental health problems; IV drug users; Homeless people. 128 Secrétariat à la jeunesse. (2011). Website: Ministère de l Immigration et des Communautés culturelles. Page 56

57 11.6 Four lines of action Through its actions, the plan aims to prevent, reduce and treat addiction within Quebec society. It anticipates four lines of intervention: Line 1: Prevention of addiction Line 2: Early intervention Line 3: Treatment and social reintegration Line 4: Research The four lines 130 target very specific objectives and are associated with particular actions: Line 1: Prevention of addiction Objective 1: Improve access to coherent and credible information on psychotropic use. Objective 2: Reinforce prevention directly with people with special needs or through preferred intervention settings. Objective 3: Reduce the supply of psychotropic agents. 19 concerted actions have been selected to meet these objectives Line 2: Early intervention Objective: Accentuate addiction detection and early intervention among various clientele 6 concerted actions have been selected to meet this objective Line 3: Treatment and social reintegration Objective: Ensure access to a range of specialized services in each region. 11 concerted actions have been selected to meet this objective Line 4: Research Objective: Increase knowledge and monitoring of addiction. 5 concerted actions have been selected to meet this objective Table 12 presents all of the actions in the Plan d action interministériel en toxicomanie , the ministries responsible for each objective, as well as collaborating ministries. 130 Plan d action interministériel en toxicomanie (2006). Ministère de la Santé et des Services sociaux du Québec. Available online: Page 57

58 Table 12. Actions of the Plan d action interministériel en toxicomanie Line 1 Objective 1 Actions Responsible Collaborators Reinforcement of the cooperative mechanisms to ensure coherence and MSSS MELS***, MJQ, credibility of addiction prevention messages coming from the ministries, MSP, MESS, SAAQ, state agencies, and their partners. SAJ, SAA, MFACF Improvement and intensification of addiction prevention campaigns, including those involving developing drug use phenomena (synthetic drugs, guzzling, doping agents, GHB, etc.) and the increasingly commonplace nature of regular alcohol and cannabis use. Improvement and intensification of the promotion of the telephone assistance line Drugs: help and referral. Improvement of web sites offering information and tools on addiction prevention (use of doping agents, synthetic drugs, guzzling, etc.). Establishment of a mechanism for recognition and exchange of information permitting a rapid reaction when new drugs and new modes of use come on the market, and distribution of information to partners concerned. MSSS MELS* MSSS MSSS MELS* MSSS MELS** SAAQ, SAA MELS***, MJQ, MSP, MESS, SAAQ, SAA, MFCAF MELS** SAAQ, MFACF MELS***, MSP Line 1 Objective 2 Actions Responsible Collaborators In collaboration with the community workers concerned, development and MSSS distribution of a frame of reference and a best practices guide to support them in their interventions with: adolescents and young adults; MELS** young athletes; MELS*** delinquents; MSP homeless people. MSP Awareness of the addiction phenomenon for student affairs services, college and university settings. Distribution of training activities adapted to the following settings: school (youth and adult); correctional; police. Improvement of information, awareness and education strategies to permit intensifying practices aimed at: awareness for adolescents and young adults about the consequences of guzzling, cannabis use and solvent inhalation; awareness for families of young athletes about the harmful effects of doping agents; prevention for young drivers on driving while impaired; awareness for women about the consequences of prenatal exposure to alcohol and other psychotropic agents. MELS** MSSS MSSS MELS* SAAQ MSSS MSSS MELS** MSP MSP MELS***, MSP, SAA MSSS MELS***, MSP, MSSS MELS**, SAA Page 58

59 Line 1 Objective 3 Actions Responsible Collaborators Harmonization of interventions aimed at reducing accessibility of legal and illegal substances. MSP MELS***, MSSS Study of the possibility of modifying and proposing appropriate legislative and regulatory provisions permitting better control of illegal drug production. Facilitation of the application of laws and regulations aimed at restricting accessibility of alcohol for young people under age 18. Design and promotion of the most promising prevention strategies to reduce alcohol intoxication, in collaboration with the networks concerned, the provincial groups of public houses and the distribution environment. Awareness for authorities of the implementation of mandatory training activities for public houses and distribution environments on the risks and consequences of using alcohol and other substances. Initiation of collaboration between workers in the networks concerned and the organizers of large gatherings in order to prevent or reduce the consequences of consumption (school proms, techno parties, carnivals, etc.). Reinforcement of coordination and cooperation of inspection with regard to the laws and regulations prohibiting minors from alcohol. Reduction of the illegal supply of drugs by suppression of organized crime. Promotion of collaboration among police forces to reduce the illegal supply of substances and improve both the coherence and synergy of the means used to fight organized crime. Improvement and intensification of public awareness campaigns about the consequences of drug production, including insecurity of campaigns (urban and rural settings). MJQ MJQ MSSS, SAAQ MSSS, SAAQ MSSS MSSS MSP MSP MSP MSP, MSSS MSP MSP MSP MSP MSSS Line 2 Actions Responsible Collaborators Development and distribution, in collaboration with the settings concerned, of a frame of reference and best practices guide for detection and early intervention. MSSS MELS***, MSP, MESS, SAA Production and distribution, in collaboration with the settings concerned, of a detection and early intervention toolkit for addiction. Distribution of training in cooperation with the following networks: school (youth and adult); correctional; police. Systematic detection of addiction including among: incarcerated offenders. Intensification of addiction detection and referral toward appropriate resources, particularly for the following clientele: children of alcoholic or addicted parents; adolescents and young adults; seniors; people in poverty. MSSS MSSS MSP MSSS MELS***, MSP, MESS, SAA MELS** MSP MSP MSSS MELS**, MESS Page 59

60 Line 3 Actions Responsible Collaborators Development and distribution of a frame of reference and a best practices guide for rehabilitation and social reintegration, including to treat offenders. MSSS MSP Development and distribution of combined training programs with addiction networks (including the correctional setting) in order to increase expertise and permit concerted intervention plans. Improvement of accessibility: services close to IV drug users, homeless people and street youth; treatment services for offenders; post-treatment follow-up services and support for reintegration in the community; detox services (troubleshooting and temporary housing) to reduce the use of hospital services or incarceration. Study of the feasibility of implementation of pilot projects aimed at implementation of methadone replacement treatment programs in provincial correctional settings. Determination of alternative sentencing options for addicted persons, including the study of the appropriateness of implementing an addiction tribunal. Intensification of the Program for certification of private or community agencies working in addiction and offering residential care. MSSS MSP MSSS MSSS MSSS MSSS MSSS MJQ MSSS MSP MSP MSP, MESS MSP MSP MSP, SAAQ, MSSS MJQ, MSP MESS Improvement of accessibility: MESS MESS, MSP post-treatment follow-up services and support for reintegration in the community. Application of job assistance measures and services for addicted persons. MESS MESS MELS**, MSP Intensification of the Program for certification of private or community MSSS MESS, MSP, MJQ agencies working in addiction and offering residential care. Development of specialized treatment programs adapted to the needs and particularities of treaty First Nations communities (Cree, Inuit and Naskapi) in cooperation with them. MESS SAA Line 4 Actions Responsible Collaborators Development and coordination of a thematic research program on MSSS MELS*** addiction, calling on the services of the various partners. MSP, MESS, MJQ Development of monitoring of addiction. MSSS MELS*, MSP, MJQ, SAAQ, MESS Application of the results of research to improve policies, programs and interventions across sectors. MSSS, MSP, MELS***, MESS, MJQ, SAAQ * Loisir et sport ** Éducation *** Éducation, loisir et sport Page 60

61 11.7 Preferred settings for action In order to reach the objectives in each of these lines of action, the collaborating ministries plan to act in the following preferred settings: The community; The family; School settings; Work settings; Sports and leisure settings; Community correctional and penal settings; Settings where psychotropic agents are produced and distributed. 12. Programme-services Dépendances (MSSS) Clientele targeted The clientele of Programme-services Dépendances are persons who have at-risk behaviours, abuse or dependency problems with alcohol, drugs and gambling. Certain clienteles are especially targeted by the service offer and must be systematically considered. These persons must be referred, as a priority, to alcoholism and addiction rehabilitation centres (CRPAT) when they present a problem severe enough to correspond to a diagnosis of abuse or dependency. These are: Pregnant women and mothers of young children; Youth in crisis; Persons with mental health problems Definition The purpose of this program is to prevent, reduce and treat dependency problems. The Programme-services Dépendances brings together services intended for people with at-risk behaviours involving the use of psychotropic drugs or people with abuse or dependency problems. This program also includes services for families and loved ones of dependent people. The purpose of this program is to prevent, reduce and treat dependency problems by deploying and consolidating a range of services throughout Quebec. In the configuration of programs in the health and social services network, the Programmeservices Dépendances consists, among other things, of services offered by the CSSSs in psychosocial services activity centres. The services are as follows: 131 L Offre de services : Programme - services Dépendances. Orientations relatives aux standards d accès, de continuité, de qualité, d efficacité et d efficience pour le Programme services Dépendances. (2007). Ministère de la Santé et des Services sociaux. Available online: Page 61

62 Services offered by the CSSS Detection and early intervention; Detoxification in the hospital setting; Non-intensive outpatient detoxification; Post-treatment psychosocial monitoring; Psychosocial and medical follow-up for methadone support. It also includes specialized rehabilitation and reintegration services provided by the CRD and consists of the alcohol, drugs and gambling activity centres. The services offered are as follows: Services offered by the CRD Specialized regional evaluation program; Intensive outpatient detoxification; Residential detoxification; Inpatient and outpatient rehabilitation (including methadone support); Social reintegration; Support to families Principal observations and challenges The population both fails to recognize and underestimates the risks associated with the use of psychotropic agents. People seem not to be Many seem not to be aware of the major risks of acute aware of the major risks intoxication (due to alcohol, sometimes during guzzling of acute intoxication due sessions) or the mixture of drugs and alcohol). Most to alcohol. people also don't know the actual composition of drugs and the risks they run when they use them (e.g., ecstasy, PCP, GHB, etc.). Community workers face a major challenge from people with a double diagnosis. We note a deterioration in the health and well-being of people dealing with addiction. It seems that, in many cases, people in treatment have a more complex set of physical, mental and social problems than in the past. Already in 1996 there were reports of an aggravation of the situation with abuse of psychotropic agents and an increase in clients in specialized treatment. Community workers face a major challenge from people with a double diagnosis (addiction in addition to mental health problems, homelessness, delinquency or IV drug use) and pregnant women who use substances. People struggling with a two-fold problem of addiction and delinquency generally have a more difficult psychosocial profile. Additionally, close to one half of homeless people have a problem with alcohol or drug use. In Montréal in 2002, there were more than three thousand hospitalizations for use of psychotropic agents. Close to three quarters (73%) of these hospitalizations were due to alcohol overconsumption. Hospitalizations for drugs are usually due to suicide attempts and self-poisoning, pharmacodependency and intoxication with tranquilizers or antidepressants. Consumption practices are becoming varied and worsening. Page 62

63 We observe : Use of alcohol and illegal drugs at an early age; Accentuation of the phenomenon of poly-drug use; The popularity of guzzling sessions, when the person drinks so much in one sitting that loss of consciousness and even death can result; The emergence, since the mid-90s, of a social phenomenon known as techno parties (raves) which are conducive to the use of synthetic drugs ; Inhalation of gasoline vapours or other solvents by young people, in particular in certain First Nations communities. These observations suggest that efforts must be continued in order to consolidate services accessible close to where the individuals and their families live, so that the situations do not deteriorate. However, for these efforts to yield the desired results, they must be accompanied by actions that will make it possible: To ensure that the necessary services to prevent and reduce addiction and pathological gambling are offered, equitably, throughout Quebec; To ensure that the individuals and their families experiencing problems with drugs, alcohol or gambling can have clear, simple and fast access to general, specific and specialized services when they need them; To improve the cohesion and continuity of intervention by strengthening its coordination; To raise the quality of services and clinical interventions. This quality is based on reinforcing the skills of the workers and managers Orientations of the Programme-services Dépendances The Programme-services Dépendances 132 of the Ministère de la Santé et des Services sociaux (MSSS) aims to meet the needs of all persons struggling with abuse or dependency problems, no matter their age. It takes into account the roles and responsibilities of each partner concerned: the health and social services centres, alcoholism and addiction rehabilitation centres, hospitals or community groups. The program: Aims to deploy the following services : Detection; Assessment; Brief intervention; Detoxification; Rehabilitation; Social reintegration. 132 L Offre de services : Programme - services Dépendances. Orientations relatives aux standards d accès, de continuité, de qualité, d efficacité et d efficience pour le Programme-services Dépendances. (2007). Ministère de la Santé et des Services sociaux. Available online: Page 63

64 Offers various activities: Offers general and specific services : Offers specialized rehabilitation services : Annual addiction prevention campaign; Annual campaign on promotion of health and healthy lifestyles; Deployment of certification of private agencies which offer residential addiction services; Training community workers on addiction. Detection and early intervention; Detoxification in the hospital setting; Non-intensive outpatient detoxification; Post-treatment psychosocial monitoring; Psychosocial and medical follow-up for methadone support. Regional specialized assessment program; Intensive outpatient detoxification; Residential detoxification; Inpatient and outpatient rehabilitation (including methadone support); Social reintegration; Support for friends and family. We can also count on a significant number of private and community agencies which offer prevention services, residential therapy or social reintegration for addicted persons Organization of services All activities and services are dispensed both locally and regionally. There are 18 health and social service agencies in Quebec distributed as follows (see figure 11): 01-Bas St-Laurent; 02-Saguenay-Lac Saint-Jean; 03-Capitale-Nationale; 04-Mauricie-Centre-du-Québec; 05-Estrie; 06-Montréal; 07-Outaouais; 08-Abitibi-Témiscamingue; 09-Côte-Nord; 10-Nord-du-Québec; 11-Gaspésie-Iles-de-la-Madeleine; 12-Chaudières-Appalaches; 13-Laval; 14-Lanaudière; 15-Laurentides; 16-Montérégie; 17-Nunavik; 18-Terres-Cries-de-la-Baie-James. Figure 11.Geographic distribution of the 18 health and social services agencies of Quebec. Page 64

65 At the local level At the local level, there are 95 Health and Social Services Centres (CSSS) distributed among the 18 agencies mentioned above. Each of these centres was born out of the merger of local community service centres (CLSC), residential and long-term care centres (CHSLD) and, in most cases, a hospital centre (79 of the 95 CSSS have a hospital centre 133 ). The CSSSs work in close cooperation with: General and specialized care hospital centres; University hospital centres; Children and youth protection centres; Rehabilitation centres, particularly for dependency; Community pharmacies; Partners in education and the municipal setting; Community agencies and private institutions. The CSSSs have responsibilities toward the population of a territory which they fulfill through clinical and organizational projects. Thus, the various CSSS workers are able to respond to all of the needs of the population and to help them move through the system At the regional level At the regional level, there are 18 health and social services agencies (ASSS). Their respective management is ensured by a board of directors appointed by the Ministre de la Santé et des Services sociaux 135. These agencies are responsible for: Improving the health and well-being of the population; Allocating and managing available financial resources; Planning the distribution of human resources; Organizing medical services; Coordinating all local service networks of a region; Collaboration among the regions; Organizing and exercising functions connected to public health (promotion, prevention, monitoring and protection); Managing the regional public health action plan. Finally, the agencies also assume special responsibilities, including dealing with emergency prehospital services and financing of the community work (Programme de soutien aux organismes communautaires (PSOC)). It is important to note that it is the addiction rehabilitation centres (CRD) which are responsible for serving the population with addiction and gambling problems, on a regional basis, at no charge. Figure 12 presents the organization of the Quebec health and social services network. 133 Rapport annuel de gestion (2011). Ministère de la Santé et des Services sociaux (MSSS). Available online: in brief: The Quebec health and social services system. (2008). Ministère de la Santé et des Services sociaux. (2008). Available online: L'intégration des services de santé et des services sociaux. Le projet organisationnel et clinique et les balises associées à la mise en œuvre des réseaux locaux de services de santé et de services sociaux. (2004). Ministère de la Santé et des Services sociaux. Available online: Page 65

66 Figure 12. Organization of the Quebec health and social services network Service Trajectory of the Programme services Dépendances The Ministère de la Santé et des Services sociaux has developed a service trajectory for detection, referral and treatment of persons struggling with drug or alcohol dependency (see figure 13). The Health and social services centres (CSSS) and the addiction rehabilitation centres (CRD) are two essential service units with very specific roles. The CSSSs primarily refer clientele to general and specific first-line services, while the CRDs refer to specialized rehabilitation services. There are two basic principles underlying the organization of health and social services: Public responsibility: community workers have the duty to offer services to the public of a local territory and to share responsibility in that location. The following are required: o Accessibility to all services as complete as possible; o Treatment and support for people in the health and social services system; o Convergence of efforts to maintain and improve the health and well-being of the population. 136 Ministère de la Santé et des Services sociaux (MSSS). (2011). Available online: Page 66

67 Prioritization of services: connection mechanisms between service providers were created in order to facilitate the flow of people between service levels. This prioritization of services, in fact, defines the degrees of responsibility and accountability to ensure that the person is referred to the right service, at the right time and in the place with the necessary expertise. Figure 13 presents the service trajectory of the Programme-services Dépendances as defined by the MSSS. Figure 13. Service Trajectory of the Programme services Dépendances (MSSS) L Offre de services : Programme - services Dépendances. Orientations relatives aux standards d accès, de continuité, de qualité, d efficacité et d efficience pour le Programme services Dépendances. (2007). Ministère de la Santé et des Services sociaux. Available online: Page 67

68 12.6 Services connected to dependencies Detection of cases (screening) and direction to appropriate services (referral) Detection, referral and early intervention activities are first-line services 138. Consequently, individuals (youth or adults) who are having difficulties with alcohol or drugs and want help must first go to their local CSSS. The CSSS reception service then evaluates the request, and if the need is determined to be a one-time need, they refer the person to general services for treatment. If follow-up is required, the person is referred to specific services, to an appropriate resource in the local network (e.g., community agency) or to the specialized services, including the addiction rehabilitation centres (CRD). For various reasons, certain regions might not be able to offer some specialized services. In that case, interregional agreements take place between the health agencies. In the same way, because certain CRDs are not able to offer sufficient residential addiction services, a service agreement with a community or private agency offering residential care (in accordance with MSSS certification) is then considered. To be eligible for services offered in CRDs, the person must have received a diagnosis of abuse or dependency and must need rehabilitation or social reintegration services. Other services are also offered to the beneficiary, including detoxification services, replacement treatments, professional reintegration services, as well as aid and support services for families and friends. Note that the CRDs also act as expert advisors with the CSSSs. Liaison teams specialized in dependency in hospital emergency rooms Since 2008, the MSSS has granted financial support to the addiction rehabilitation centres (CRD) to support the deployment of liaison teams specialized in dependency in Quebec hospital emergency rooms. In 2008, the MSSS published an implementation guide, setting the operating guidelines for these teams 139. Establishing these teams makes it possible to better reach clientele struggling with abuse or dependency problems, and possibly mental health and/or homelessness problems. In addition, these teams help free up emergency rooms. A liaison team includes the following personnel: A liaison team includes : The medical and clinical team of the hospital centre with access to psychiatric consulting services; The CRPAT liaison team: o A liaison nurse; o A rehabilitation professional assigned to liaison; o A doctor. 138 L Offre de services : Programme - services Dépendances. Orientations relatives aux standards d accès, de continuité, de qualité, d efficacité et d efficience pour le Programme services Dépendances. (2007). Ministère de la Santé et des Services sociaux. Available online: Guide d implantation. Équipes de liaison spécialisée en dépendances à l urgence. (2008). Ministère de la Santé et des Services sociaux (MSSS). Available online: Page 68

69 It also includes : Multifunctional beds to support detoxification; Detoxification services. The liaison teams, in collaboration with the hospital centre team, identify persons with an abuse or dependency problem or concomitant dependency and mental health problems or in a homeless situation, so that they can be assessed and then referred to the service that can best respond to their condition. Detection and assessment tools for adults Several detection tools are available for evaluation and referral of adult clientele. They make it possible to evaluate the severity of alcohol or drug overconsumption and the associated problems. They also make it possible to refer them to appropriate treatment. The most commonly used are: Addiction Severity Index (ASI) Évaluation de la toxicomanie chez l adulte (ETA) Global Appraisal of Individual Needs (GAIN), currently being developed. Detection and assessment tools for youth Several detection tools are also available for evaluation and referral of adolescent clientele. The most commonly used are: Detection of Alcohol and Drug Problems in Adolescents (DEP-ADO); Addiction Severity Index for Adolescents (IGT-ADO). Youth access mechanisms Access mechanisms for addiction, for youth under age 18 in the Montréal region, is the doorway to free specialized rehabilitation services, both inpatient and outpatient 140. This mechanism presents two distinct doorways, one for Francophone and Allophone clients, the other for Anglophone clients. It brings together establishments and agencies that ensure the integration of their various programs and services with a view to complementarity, in order to ensure a response tailored to the needs of youth. The general objectives of such a mechanism are to: Ensure coordination of access to inpatient or outpatient rehabilitation services for youth with addiction problems; Ensure coordination of access to specialized addiction consulting services for family and friends of youth in crisis; Make optimum use of existing specialized resources in the region and take advantage of the specific features of their programs; Improving collaboration with the other establishments in the region, the institutions, private centres and community agencies involved for youth clientele. 140 Trajectoire de services et mécanisme d accès en toxicomanie pour les jeunes de moins de 18 ans de la région de Montréal. (2006). Centre Dollard-Cormier. Available online: Page 69

70 Early intervention The CSSS assume responsibility for early intervention. This intervention targets at risk clientele, those who are the most susceptible to alcohol and drug dependency. It is characterized by aid and individual, family or group support services. The objective of such an intervention is to prevent the aggravation of a situation and reduce the consequences associated with maintaining problematic behaviours. In this way, the use of specialized services can be avoided. In early intervention, the professionals in the network use counselling intervention techniques such as motivational interview as well as controlled consumption programs such as Alcochoix. These interventions last much less time than those used in specialized services. The motivational interview The motivational interview is a brief (one to six meetings) intervention which aims to help an individual make a decision and find enough motivation to change a problem behaviour 141. The first phase of the intervention makes it possible to develop an overall snapshot while attempting to move the client toward the decision to resolve a difficult situation. The second phase makes it possible to consolidate this decision to change and to begin follow-up actions. The Alcochoix+ program The Alcochoix+ 142 program is addressed at adults who are concerned about their alcohol use and want to change their habits. This program enables them to gradually become aware of their alcohol use, to then help them to cut back. Three objectives are targeted: No more than 12 drinks per week for women and no more than 14 per week for men; No more than 3 drinks per day for women and no more than 4 per day for men; Abstain at least two days a week. The program lasts six weeks and is accompanied by a work guide. In , a total of 92 service points and 64% of the CSSSs were offering the program in Quebec L'Entrevue motivationnelle: une approche novatrice en toxicomanie. (1999). Association des intervenants en toxicomanie du Québec, l'intervenant, Ministère de la Santé et des Services sociaux (MSSS). (2011). Rapport annuel de gestion (51). Available online: Ibid Page 70

71 APTE Individuel The APTE Individuel program is a targeted prevention program, developed by the Centre québécois de lutte aux dépendances (CQLD) with the financial support of Health Canada. The program is addressed at youth ages 12 to 18 with a developing alcohol or drug problem and who present risks of developing a bigger problem (yellow light on DEP-ADO). The program is currently being assessed in several schools in the Montréal region Psychosocial follow-up after a specialized treatment 144 This aid is offered to people who need one-off support and care to meet their reintegration objectives. The goal is to consolidate the progress made in the treatment, reduce the risks of relapse and facilitate the return to the community. It also makes it possible to avoid the use of specialized services, offers psychosocial support for people after a specialized treatment and establishes a mechanism for referral from the CRPAT to the CSSS Psychosocial and medical follow-up with methadone support This service offers medical and pharmaceutical follow-up, as well as access to psychosocial services for people after specialized opioid dependency treatment with a replacement drug. This individual or group aid and support is offered to people who need one-off support and care to meet their reintegration objectives. The goal is to consolidate the progress made in the specialized treatment, reduce the risks of relapse and facilitate the return to the community. It also makes it possible to avoid the use of specialized services, thus making room for addicted persons waiting for specialized services. The service must also favour the development of the skills necessary for maintaining sobriety behaviours or reduced consumption of other types of psychotropic agents Inpatient and outpatient detoxification with psychosocial support It is important to distinguish between detoxification and treatment of dependencies. Detoxification is a physiological process through which an individual, who is clinically dependent, regains normal physical and mental functioning by suddenly or gradually stopping administration of the drug. This process takes place with or without medication and can happen in a natural or hospital setting 145. Detoxification can be preceded by treatment of dependencies (for example, reaching out with the homeless), can constitute the preliminary phase of treatment of dependencies or can take place without being followed by treatment of dependencies. 144 L Offre de services : Programme - services Dépendances. Orientations relatives aux standards d accès, de continuité, de qualité, d efficacité et d efficience pour le Programme services Dépendances. (2007). Ministère de la Santé et des Services sociaux. Available online: Drugs: Know the facts, Cut your risks. Montréal, CQLD, 2006, 205 p. Page 71

72 In the continuum of services offered to alcoholic or addicted persons, detoxification is essential for persons with a physiological dependency. The evaluation for detoxification that has obtained the consensus of Quebec experts is that of the American Society of Addiction Medicine (ASAM). Based on the results of the evaluation, the individual is placed in one of the levels of intensity in detoxification management. Four levels of care are defined and adapted to the different degrees of severity of withdrawal of the user. Level I Level II Level III Level IV Ambulatory detoxification without extended on-site monitoring: these are generally outpatient medical consultations which accompany the withdrawal process. The withdrawal here is qualified as light. Ambulatory detoxification with extended on-site monitoring: a nurse is available for daily monitoring of the users. The withdrawal here is qualified as light to moderate. Residential detoxification; first level, lighter, managed by personnel with psychosocial training; second level, more severe withdrawal, managed by nursing personnel on site 24/7. Medically managed residential detoxification: this type of inpatient detoxification services is offered by nursing and medical staff, in a general hospital offering all services appropriate for or associated with severe withdrawal. Withdrawal is severe and necessitates hospital intervention. Detoxification is offered in Quebec by private and public agencies. Certain hospitals or hospital centres have a department or beds reserved for detoxification. Residential treatment may be necessary for any of these reasons. When this is not available in a CRD, the client is referred to an additional network (community or private resource certified by the MSSS) Specialized regional evaluation program A specialized regional evaluation program permits reception, evaluation and referral of adults and youth who need specialized dependency services. In the context of this program, it also offers support and motivation maintenance activities for persons who have to wait to be admitted to the rehabilitation program to which they have been referred. The specialized assessment establishes the severity of the use or behaviours of an addict and is done using validated and standardized tools. The results of the assessment become the matrix used to establish intervention plans. The assessment takes into account the person's different spheres of life, such as the substance use situation (alcohol, drugs), physical health, psychological state, relational, social and family context, employment or school situation, resources and legal status. This service is ensured by a collaboration between the CSSS, the CRD and certain private and community agencies. Page 72

73 Inpatient and outpatient rehabilitation The degree of severity of the consumption problem determines distinct levels of care. Thus, people with substance abuse or dependency problems will be referred to specialized services, while individuals with at-risk or problematic consumption, who do not have a diagnosis, will benefit from a briefer and less intense first-line service. The treatment of alcoholism and addiction occurs principally in public, community and private alcohol and addiction treatment centres. The following are the substances for which people are principally treated: Alcohol (49.25%); Illegal drugs (49.25%); Psychotropic drugs (1.5%) 146. The intervention plan implemented will permit 147 : Choosing between inpatient or outpatient treatment; Evaluating the need for detoxification or another accessory measure (e.g., treating the comorbidity, if possible, and increasing motivation) before undertaking more formal treatment; Choosing between an AA approach (total abstinence) or a psychosocial approach more focused on harm reduction; Evaluating the need for minimal treatment or intensive long-term treatment. The services offered by the alcoholism and addiction rehabilitation centres (CRPAT) are specialized services which the clientele can access with or without a professional recommendation 148. These specialized services are offered in addition to first-line services Social reintegration Specialized social reintegration services and alcohol rehabilitation services are intimately connected. Reintegration services are aimed at helping dependent persons relearn how to live in society. This is an essential process for many users. It builds on several strategies, including the acquisition, by individuals, of autonomy and knowledge through study, work and reinforcement of their networks of belonging 149. Reintegration services are offered individually or as a group. They sometimes come down to an intervention with the network or the person. Reintegration services are occasionally offered on a residential basis, according to the individual's needs. Responsibility for these services is incumbent on the institutions in the health and social services network and is realized by: 146 Rapport du sous-comité sur les normes en dépendance. (2005). Sous-comité sur les normes en dépendance. Montréal: Unpublished report presented to the Ministère de la Santé et des Services sociaux du Québec. 147 Brown, T.G. and Wood, W.J. (2002). Abus de substances: tous les traitements se valent-ils? Montréal: Comité permanent de lutte à la toxicomanie. 148 Offre de Services de bases des CRPAT, Version (2004). Fédération québécoise des centres de réadaptation pour personnes alcooliques et toxicomanes. Unpublished document. 149 Tremblay, Joël et al. (2004). Les Centres de réadaptation pour personnes alcooliques et autres toxicomanes. Chefs de file des services en toxicomanie et jeu pathologique. Fédération québécoise des centres de réadaptation pour personnes alcooliques et toxicomanes, Montréal, 70 p. Page 73

74 Referral to specific services of the CSSS at the end of treatment; Service or partnership agreements for additional services among the CRDs, community agencies and self-help groups Support to families The CRDs are responsible for offering aid and support services to the friends and family of dependent persons. The services consist of structured aid, focused on supporting the family and friends of the person with alcoholism and addiction problems. The aid can be personalized according to the needs of the friends and family. It includes individual, group, spousal or family therapies and thematic workshops. Note that in September 2011, the Association des centres de réadaptation en dépendance du Québec (ACRDQ) published a document entitled Les services à l entourage des personnes dépendantes Guide de pratique et offre de services de base. This guide to practice and basic service offer for the families and friends of dependent persons is intended to be a tool to support decision making and transfer of knowledge based on best practices in service organization, clinical intervention, skills development, research and program assessment. It is primarily intended for managers, CRD workers and their partners involved with services for the friends and families of persons struggling with alcohol, drugs or gambling dependency problems. 13. The Federal Government The National Anti-Drug Strategy focuses on prevention and access to treatment for those with drug dependencies, while at the same time getting tough on drug dealers and producers. It is made up of three action plans: The Enforcement Action Plan which aims to combat the production and distribution of illicit drugs (Justice Canada); The Prevention Action Plan which aims to prevent illicit drug use among young people (Health Canada); The Treatment Action Plan which aims to treat those with drug dependencies (Health Canada). Enforcement Action Plan Justice Canada is responsible for the Enforcement Action Plan. This plan bolsters law enforcement efforts to investigate and prosecute drug crimes. It will increase law enforcement s capacity to combat marihuana grow operations and synthetic drug production and distribution operations. 150 Tremblay, Joël et al. (2004). Les Centres de réadaptation pour personnes alcooliques et autres toxicomanes. Chefs de file des services en toxicomanie et jeu pathologique. Fédération québécoise des centres de réadaptation pour personnes alcooliques et toxicomanes, Montréal, 70 p. Page 74

75 Prevention Action Plan The Prevention Action Plan aims to prevent illicit drug use among young people. It will provide information to those most affected by drug use, including parents, young people, educators, law enforcement authorities, and communities. Health Canada, through the Drug Strategy Community Initiatives Fund (DSCIF), contributes to reducing illicit drug use among youth ages 10 to 24 by funding health promotion and prevention projects aimed at youth in this age group. Projects focus on: Informing and educating on illicit drugs and their adverse health and social effects; Offering tools to foster resiliency and coping skills among youth; and Promoting healthy behaviours and supportive environments that discourage drug use among young people. Projects are at the national, provincial, territorial and local community level and can include a wide range of activities such as awareness campaigns, school-based and peer support programs and outreach. Project activities can also include development and distribution of resource materials as well as sharing best practices. Treatment Action Plan The Drug Treatment Funding Program (DTFP) makes money available to provincial and territorial governments to assist in strengthening treatment systems and invest in early intervention treatment services for at-risk youth. 14. Other activity sectors We cannot approach the drugs and alcohol phenomenon without touching on other activity sectors that complement the more specific services connected to treatment of dependencies. The entire continuum of activities connected to the drugs and alcohol phenomenon includes a great many resources Health promotion Health promotion is a process which offers individuals the possibility of greater control of their health determinants, enabling them to improve their health. Health promotion targets increased personal and collective well-being by developing protection factors and conditions favourable to healthy lifestyles. Its action targets the population in general or particular groups. In the area of alcohol and other drug dependencies, it is based on an overall intervention intended to create, in the population, the conditions that will favour a healthy attitude toward psychotropic substances. Among young people, it will focus more particularly on the early development of responsible behaviours in the face of stresses and social pressures to use alcohol and drugs. In Quebec, many programs or activities are implemented to promote health. Some of them encourage us to have a healthy diet, others praise the benefits of physical activity or teach Page 75

76 us about the harmful effects of cigarettes. The Government of Québec recently published the Programme national de santé publique , where we find various promotion and prevention activities for each of the fields of health intervention in Quebec. Among the important programs that promote health in the field of addiction, the Ministère de la Santé et des Services sociaux, in collaboration with the Ministère de l Éducation, has developed the Écoles en santé approach. This approach proposes to support the school and its partners in order to increase the effectiveness of health promotion and prevention interventions performed to improve the academic success and health of youth. This is a process which brings together a set of appropriate measures for health promotion and prevention (including addiction), in the educational project and the school s success plan as well as in the partners action plans. These measures, which target youth, the family, school and community, complement and reinforce each other. They aim to influence certain key factors which are common to the educational success, health and well-being of youth. These key factors are: Self-esteem; Social skills; Lifestyles; Safe behaviours; Positive environments; Preventive services. Note that this approach proposes a theoretical framework, a philosophy, orientations, objectives with which the settings are invited to comply voluntarily Prevention Addiction prevention aims to prevent the emergence of a problem connected to the use of psychotropic agents within the population or to limit the consequences of this problem among addicts. In 2001, the MSSS published a framework document on addiction prevention entitled Pour une approche pragmatique de prévention en toxicomanie 151. The actions proposed in the MSSS document are divided into two lines of intervention: Proactive action for social adjustment problems; Prevention of the risks of negative consequences or aggravation of problems connected to the inappropriate use of psychotropic substances. Several programs and actions have been developed in connection with these lines of intervention proposed by the MSSS. Some of them are more targeted at the transmission of information to the population, others go beyond this strategy by building on the development of personal and social skills as well as environmental design. In addition, it is not uncommon for programs to combine more than one strategy Pour une approche pragmatique de prévention en toxicomanie - Orientations - Axes d'intervention - Actions. Ministère de la Santé et des Services sociaux (MSSS). (2001). Available online: endocument 152 Hawks, D. Scott, K et al. (2002). Présentation de l alcoolisme et autres toxicomanies: les programmes qui marchent auprès des jeunes, Toronto, Centre for addiction and mental health. Page 76

77 Prevention activities and programs Web site Parlons drogues In 2004, the Ministère de la Santé et des Services sociaux started an informative web site on drugs, Designed especially for young people, it is very appealing and has, among other things: A question and answer section; A list of the various drugs to inform young people; A section devoted to Drug Awareness Week (games, activities, information); Vox populi; Links to other interesting sites. Drug Awareness Week. As part of Drug Awareness Week, the MSSS coordinates different awareness activities. Each year, the third week of November is devoted to increasing public awareness about psychotropic use. Many prevention activities are offered to youth and adults in each region of Quebec. Système-D In 2007, the Directions de santé publique of Montérégie, Laval and l Outaouais developed the program Système-D 153. Système-D targets young people at the end of elementary cycle 3 and their parents. The program offers four classroom workshops copresented by a community worker and an instructor. For each workshop, the parents receive written communication to tell them the objectives of this workshop, the sources of information on the themes discussed and the measures to apply at home to promote the adoption of healthy lifestyles and stimulate dialogue with their child Education College level The majority of addiction workers are trained to work with young and adult clients in the context of the college diploma of correctional worker. These involve: Cégep d Ahuntsic Cégep de la Gaspésie in Carleton Cégep François-Xavier-Garneau Cégep de Maisonneuve Cégep John-Abbott In addition to these, some cégeps offer the possibility of completing an Attestation of Collegial Studies. These are the cégeps St-Jean-sur-Richelieu (Socio-community intervention) and Collège Laflèche (Intervention with addicted persons). 153 Système-d: Activités de développement des compétences en milieu scolaire pour la prévention des toxicomanies et de l usage des jeux de hasard et d argent dans le cadre de la transition du primaire au secondaire. (2007). Directions de santé publique de la Montérégie, de Laval et de l Outaouais. Available online: extranet.santemonteregie.qc.ca/menu_gauche/4-publications/3- Monographies_Orientations_Rapports/Santé_Physique/dsp_pub_systeme_d_fr_aout_2008.pdf Page 77

78 University level Several universities in Quebec offer training programs in the field of addiction. They are: Université de Sherbrooke: o Certificat en toxicomanie (undergraduate) o Diplôme en intervention en toxicomanie (master s) o Maîtrise en intervention en toxicomanie (master s) o Maîtrise en recherche (master s) o Doctorat en recherche (doctoral) o Annual programming of training days in collaboration with AITQ o Tailored training projects developed in concert with various agencies in the setting. McGill University: o Addiction training program. Treatment of dependencies and concomitant mental illnesses Université de Montréal o Certificat en toxicomanies: prévention et réadaptation (undergraduate) Université Laval o Certificat d étude en toxicomanie (undergraduate) Université du Québec à Montréal o Maîtrise en intervention sociale (addiction concentration) Univesité du Québec à Chicoutimi o Certificat en toxicomanies et autres dépendances 14.4 Research Centre Dollard-Cormier Founded in 1997, the Centre Dollard-Cormier is a public rehabilitation agency whose mission is to improve the health, well-being, quality of life and social integration of persons suffering from alcoholism, drug addiction or pathological gambling. It serves the population of all of Montréal Island and intervenes with the individuals themselves as well as with their friends and family. Affiliated with the Université de Montréal and a partner of the Université de Sherbrooke, the Centre devotes great importance to research and development of knowledge in these fields of expertise. Centre de recherche et d'aide pour narcomanes (Cran) Cran is located in Montréal. This is a non-governmental, nonprofit agency specialized in the treatment of opioid dependency using a replacement drug. Cran was founded in 1986 and is today funded in large part by the Ministère de la Santé et des Services sociaux du Québec. Page 78

79 Centre de recherche de l'hôpital Charles LeMoyne (CR-HCLM) Founded in 1995, CR-HCLM is part of the research component of the mission of this hospital, which became a hospital centre affiliated with the Université de Sherbrooke in The research activities are oriented toward innovative health interventions. Several preferred fields of experimentation make up the research themes developed at the CR- HCLM: prevention of inability to work, first-line and emergency services, effectiveness of oncology interventions, exemplary professional practices, mental health and addiction. Centre for Addiction and Mental Health (CAMH) The CAMH is Canada's largest mental health and addiction health sciences centre. The research mandate goes from molecular genetics and cerebral imaging to clinical treatments, along with social research and policy research. Health promotion and illness prevention include clinical, community, research and policydevelopment initiatives. Addiction Research Chair The Université de Sherbrooke has the Addiction Research Chair created by the Fondation de l'hôpital Charles-Lemoyne and the Université. Researcher Élise Roy holds this chair which aims to ensure continuity between research and the needs expressed in the field concerning drug use and addiction. The activities conducted focus on better understanding of the social and individual factors underlying abuse of drugs and the resulting consequences; developing and evaluating interventions designed to avoid severe abuse and the resulting consequences; and developing and maintaining national and international research partnerships and maintaining contact and exchange with practice settings. Groupe de recherche et d'intervention psychosociale (GRIP) GRIP Montreal is a non-profit organization and registered charity that has existed since GRIP s mission is to prevent drug abuse and reduce the harms associated with drug consumption. The preferred approach is to educate and make available unbiased information on psychoactive substances and new consumer trends, to help people (especially young people) make better informed, safer and more responsible decisions regarding drug use. The Research Institute of the McGill University Health Centre (RI MUHC) The RI MUHC is a world-renowned biomedical and health-care hospital research centre. Located in Montreal, it is the research arm of the McGill University Health Centre affiliated with the Faculty of Medicine at McGill University. Unravelling pathophysiology to design novel therapeutics is a priority for modern psychiatric research and a key goal of the mental illness and addiction research axis. The emphasis of this group is to investigate the behavioural and brain correlates of neurotransmitter dysfunction, using functional Page 79

80 neuroimaging techniques, genetic dissection and pharmacological manipulations, while ensuring continuous dialogue between basic and clinical research and rapid knowledge transfer from the bedside, to the bench and back. The team has significant expertise in the social and translational neuroscience of mental disorders. It utilizes a wide array of complementary state-of-the-art behavioural and biological tools to define specific proofof-concept hypotheses of pathophysiology. Addiction Research Studies and Laboratory of the Douglas Mental Health University Institute The laboratory is researching the genetic etiology and underlying mechanisms of addiction as well as the markers of predisposition to addiction, such as: 1)the biological markers for predisposition to addiction, including the reactivity of the opioidergic system to alcohol, 2) experimental, psychological and pharmacological treatments, tested on humans and animals, 3) the influence of alcohol and stress, alone or in combination, on the human hypothalamic-pituitary-adrenal (HPA) axis and pituitary beta-endorphin system, in relation to family history of alcoholism and according to sex and 4) the role of psychoactive substance abuse in high-risk behaviours, particularly with regard to impaired driving. Recherche et Intervention sur les Substances psychoactives Québec (RISQ) The RISQ is a multidisciplinary team with an integrated program of psychosocial research, focused on a central objective to help the communities concerned to better understand the trajectory of addicted persons or those at risk of addiction and to develop more effective intervention strategies for them. The general objective of the CIRASST (Collectif en intervention et recherche sur les aspects sociosanitaires de la toxicomanieis is to implement a program aimed at the development of research projects, studies and analyses in partnership with the communities concerned with addiction, the sharing of knowledge among community workers, researchers, planners and deciders, the training of communities and students interested in the field. Their web site includes the activities in which these agencies participate, many of their publications and research reports, as well as addiction screening questionnaires. Addictions Unit (Griffith Edwards Centre) The Addictions Unit (Griffith Edwards Centre) is part of the McGill University Health Centre (MUHC), a teaching hospital affiliated with the Medical School of McGill University. The Unit is currently participating in a research project aimed at improving services and results for patients. In addition, certain studies are being conducted to better understand the genetic, biological and psychological factors which contribute to the development of addictions. Page 80

81 Part III The Private and Community Network Page 81

82 As defined by the MSSS, community agencies are democratic structures created by and for communities. They define for themselves the problems they wish to tackle and the means necessary for resolving them 154. In collaboration with public services, the actions of community agencies contribute to the social development of Quebec. Most of these agencies belong to the private sector and are generally not for profit. To get an idea of the scope of this activity sector in Quebec, there are currently over 4,116 community and private agencies in the Quebec health and social services network. In the field of addiction, community and private agencies are able to determine for themselves their mission and their practices. Their field of activities may, as a result, be very diverse. Some of them will offer prevention activities, assistance services, support, treatment programs and social reintegration services. 15. Organization of services Unlike the government network, there are no formal structures setting priorities and defining a framework for the private and community network. Many of these resources have more or less formal agreements with the MSSS, the Agences de la santé et des services sociaux (ASSS), the schools and school boards and even with certain hospital centres. Others receive aid directly or indirectly from government departments or agencies for some of all of the services they offer. For example, some resources offering longer-term programs receive support from the Ministère de la Sécurité publique, which uses their services directly or indirectly as an alternative to incarceration. Others survive through the support of the Ministère de l'emploi et de la Solidarité sociale (MESS) to promote access to addiction treatment in certified private centres. Finally, many of them are part of the Tables régionales de concertation which are usually under the responsibility of the ASSSs in the various regions of Quebec. In reality, a good number of the private and community agencies have come out of the good will or initiative of individuals or groups of individuals who, for personal reasons or reasons connected to their own struggles, have decided to spend their time and energy on a cause which motivates them to act for the well-being of people like them. Their success often depends on their ability to organize, on their network of contacts and the interest they can inspire on the part of governments and the community they are trying to serve The Table des regroupements provinciaux d organismes communautaires et bénévoles 155 Although private and community agencies do not have a formal structure, we should not overlook the Table des regroupements provinciaux d'organismes communautaires et bénévoles (Table). The Table is above all a place for mobilization, reflection and analysis. It ensures cooperation among the various agencies that belong to it, and it has a mandate to develop critical analyses on different aspects dealing with the health and social services system in general, as well as any policy that may have an impact on the health and well- 154 Plan d'action gouvernemental en matière d'action communautaire. (2004). Secrétariat de l'action communautaire autonome au Québec. Available online: La Table des regroupements provinciaux d organismes communautaires et bénévoles. (2011). Website: Page 82

83 being of the population. The Table is formed of 35 national groups active throughout Quebec. These groups represent different sectors (women, youth, housing, family, handicapped persons, ethnocultural communities, food safety, etc.) and different problems (mental health, Alzheimer s disease, addiction, etc.) connected to health. Through its members, the Table reaches more than 3,000 basic community groups, in all regions of Quebec and in all sectors. The Table is formed of 35 national groups active throughout Quebec 15.2 Support for community agencies Programme de soutien aux organismes communautaires (MSSS) The MSSS is responsible for the Programme de soutien aux organismes communautaires and has made a series of commitments to help community environments to consolidate their actions and outreach (while respecting the organizations autonomy), determine their missions, their orientations, their interventional approaches and their management methods 156. The MSSS recognizes that the community organizations make an essential contribution to the network. The MSSS and the local network development agencies recognize that the community organizations make an essential contribution to the network. Over the years, these organizations have been able to meet many needs not covered by the public network, as well as meet the needs of certain clienteles with special needs. Currently, a certain number of community or private agencies are being asked to collaborate with the CSSS or the CRD of their region and provide certain types of services that the public network is unable to offer. This collaboration, managed by service agreements, is sought as part of the Projet clinique implemented by the MSSS. In the context of the Projet clinique, the community approach model is used. This approach is based on the organization of primary care and a community-based partnership. In this way, it helps to improve accessibility to different services and reduce inequalities in healthcare services. The community approach has the following characteristics: It promotes maintaining health and well-being; It contributes to the integration of public health practices and first-line practices; It emphasizes services addressed to vulnerable clienteles (with partnerships across sectors). A list of community agencies operating in the fields Alcoholism/addiction and other dependencies is available on the MSSS site Ministère de la Santé et des Services sociaux (MSSS). (2009). Programme de soutien aux organismes communautaires Available online: Liste des organismes communautaires oeuvrant dans les champs Alcoolisme/ toxicomanie et autres dépendances. Available online on the MSSS site: Page 83

84 16. Services connected to dependencies In Quebec, there are many private or community resources which offer an expanded range of addiction services. These services may be dispensed on an inpatient or outpatient basis, in the short or long term, according to their specific philosophy and structure. These resources may require a greater or lesser financial contribution from the people using the services Certification of agencies offering residential addiction services As of July 2011, agencies that offer residential addiction services must be certified by the MSSS or be in the process of obtaining this certification 158. This provincial certification process is a first in Canada. By September of 2011, about 65 had obtained this certification 159 and many others are in the process of obtaining it, totaling about one hundred resources in Quebec. Septembre 2011 : about 65 ressources had obtained this certification. Here are the objectives connected to certification of these agencies as presented by the MSSS: To promote provision of quality services for persons struggling with alcohol, addiction or pathological gambling and to implement a continuous quality improvement process and a search for excellence; To permit resources to contribute to the continuous improvement of their services and enable them to serve as a model of a resource respecting defined requirements; To promote the promotion of services offered by the resources and promote referrals. Certification also includes advantages for the citizen. It fosters the protection of service users, confirms that the resources satisfy the established requirements and makes it possible to have credible information when choosing an intervention resource. Since 2009, several certified centres have been grouped within an association called Association des centres d hébergement certifiés en traitement des dépendances (ACTDQ) Inpatient and outpatient residential rehabilitation As mentioned previously, centres that offer residential rehabilitation services are now subject to the MSSS certification process. This certification presents both opportunities and constraints which, while making it possible to improve the quality of services offered to the population, pose financial and organizational challenges without financial contribution from the government authorities. The inpatient residential rehabilitation resources meet a need that cannot currently be met 158 Règlement sur la certification des ressources en toxicomanie ou en jeu pathologique. (2011). Available online: S4_2R1.htm 159 La liste des organismes certifiés en dépendances. (2011). Available online: Page 84

85 by the Addiction Rehabilitation Centres (CRD). After the shift to outpatient care made by public centres in response to budget constraints in the early 1990s, the public network was left without residential resources for addiction treatment. Private and community centres then took up the baton. While many were already in existence at the time, they have multiplied since then, now numbering more than one hundred all over Quebec, and offering treatment to several thousands of individuals each year. The treatments offered vary in duration according to the philosophy of treatment and the clientele targeted. Today, many private and Many private and community community centres have service agreements with centres have service agreements public centres and provide housing in return for a with public centres. per diem paid by the resource. This approach helps both the private centres, which benefit from it, and the public centres, which would probably have to pay more to assume such services themselves. Outpatient rehabilitation services are nearly non-existent in the private and community network, this sector being well deployed throughout Quebec by the network of public addiction rehabilitation centres Homelessness Homelessness, alcohol and drugs have always gone hand in hand, and the combination of these problems becomes even more troubling when young people and IV drugs are involved. Although budgets aiming to fight homelessness come in large part from the government and health agencies, most of the services offered to this population come from community agencies. For an overview of the extent of the problem, the Réseau d aide aux personnes seules et itinérantes de Montréal (RAPSIM) brings together 94 community agencies working on homelessness. The Réseau Solidarité Itinérance du Québec (RSIQ) brings together about a dozen regional cooperative efforts on homelessness, and thus represents more than 280 organizations in Quebec Social reintegration Social reintegration is a state experienced by those who have lived through a certain form of marginalization in one of the spheres of their life. It is the final stage of the process of rehabilitation for the addicted person, a stage which enables the person to translate the autonomy they have acquired in the preceding phases into actual social participation. There is a path specific to each person and a successful social reintegration, involving cooperation between the addicted person and the other members of society 160. Although many treatment centres offer social reintegration services, a good number of programs come under community agencies. They may be grouped as follows: 160 La réinsertion sociale en toxicomanie: Une voie à découvrir? (2002). Comité permanent de lutte à la toxicomanie. Available online: Page 85

86 Organizations which offer transitional housing after treatment for persons whose environment does not offer the necessary support to pursue the treatment objectives; Organizations which foster the development of skills and of a safe social network; Organizations which encourage and support a return to studies; Training organizations for reintegration in employment. 17. Other activity sectors 17.1 Prevention Although prevention comes under Santé publique and the Agences de la santé et des services sociaux, many addiction prevention initiatives have been started by the private and community network. In fact, since 1998, the Association des intervenants en toxicomanie du Québec (AITQ) has also provided these workers with a kit of 69 addiction prevention tools. The contents of this toolkit were evaluated and updated in 2001, and it is accessible on the site of the organization 161. The documents (posters, brochures, event notebooks, intervention guides, CD-ROMs, games, videocassettes) can be borrowed at no charge at all regional authorities, the Centre québécois de documentation sur les toxicomanies and the AITQ. There are also some prevention programs deployed by the private and community network. Here are some of the best known programs: Cumulus APTE Prévenir pour mieux grandir The Cumulus program Cumulus is a non-profit organization created in 1995 and aimed at developing and implementing addiction prevention programs, services and projects. Cumulus workers are involved in 18 neighbourhoods in the greater Montréal region, in school settings (primary, secondary) as well as in other community organizations (social reintegration, mental health, youth, etc.). The APTE program The APTE program (Activités de Prévention en ToxicomaniEs) was developed, evaluated and deployed by the Centre québécois de lutte aux dépendances through the financing and support of Health Canada. The goal of the APTE program is to persuade young non-users either not to start or to delay as long as possible using psychotropic agents, or to stop or reduce use by young people who are already using them. APTE consists of 5 modules: 1) The awareness module Mon indépendance, j y tiens! for 7 th graders. With the support of the MSSS and the Fondation Jean Lapointe, this module has permitted awareness training for close to 40,000 young people in Quebec over the last three years; 2) the group module (profile A: 7 th and 8 th graders; profile B: 8 th and 9 th graders), Page 86

87 designed according to what young people believe about drugs and alcohol; 3) the individual intervention module (7 th to 11 th graders) is a web application for youth with a developing alcohol or drug use problem (yellow light according to DEP-ADO). The program is currently under evaluation in many schools in the Montréal region; 4-5) the awareness Module for parents and the awareness module for teachers are modules that will be developed on the web and will make a valuable contribution to raising the level of knowledge necessary for effective interventions based on best practices. The awareness module for parents will be available in 2012 and the teachers module is awaiting funding. Prévenir pour mieux grandir This addiction prevention program was created in 1983 by the prevention officers of the Réseau communautaire d aide aux alcooliques et autres toxicomanes. It is designed for students ages 10 to 13 in primary schools. Prévenir pour mieux grandir is based on a global and community approach favouring consciousness-raising and accountability by promoting healthy lifestyles. Since 1983, the program has been modified and improved based on observations and experiments by the workers, as well as the reality of the youth in the settings visited Self-help groups Self-help groups are widely known to the public because of their activities and their approach to alcoholics and persons with drug addictions. They are found in most regions of Quebec and offer assistance over the phone and weekly group meetings. The objective for all of them is the same: to help people suffering from alcoholism or drug addiction and their friends and families find a solution to their problems. Most self-help groups also have web sites telling the time and place of their activities. They are found in most regions of Quebec and offer free assistance over the phone as well as weekly group meetings. The following are some of the self-help groups present in Quebec: Alcoholics Anonymous: for people who have problems with alcohol. Al-Anon and Alateen: for family members and friends of people struggling with alcohol problems. Narcotics Anonymous: for people who have problems with drugs. Nar-Anon: for family members and friends of people struggling with drug problems. Cocaine Anonymous: for people who have problems with cocaine. Co-Anon: for family members and friends of people struggling with cocaine. Pharmacodépendant(e)s Anonymes: for people who have problems with psychoactive drugs. Page 87

88 Part IV Telephone and Internet Resources Page 88

89 There are many resources in the addiction field in Quebec which cover all activity sectors connected to dependencies. Since it is impossible to name them all and describe their respective field of action or the activity sectors to which they belong, we refer the reader to the Répertoire des ressources en toxicomanie au Québec 162, a document produced by the Association des intervenants en toxicomanie du Québec (AITQ) which lists the public, private and community agencies operating in the field of addiction. The first section of this publication classifies resources according to their respective region, and a second section presents the various agencies that specialize in a particular population or problem. For each of the resources, this list presents the services offered, the approaches used, the dependencies targeted, the conditions of admission, the costs (if any), service hours, contact information, etc. 18. Telephone assistance services Drugs: help and referral Telephone help: Among the sources of information, we find the telephone information and referral line Drugs: help and referral, which was established in This resource is accessible 24 hours a day and 7 days a week. Their mission is to provide help and referral services that are free, bilingual, confidential and anonymous, to people who have problems with drugs, to their relatives and peers, and also to community workers. This service can be contacted by telephone, as well as by , to find out about the resources available in their region, to find an attentive ear and obtain information, to get help or to help a loved one break a drug habit. Tel-jeunes Telephone help: Tel-jeunes is a free, confidential resource for young people throughout Quebec, available 24 hours a day, 7 days a week. On the telephone or on the internet, professionals work to build a relationship of trust with young people to answer their questions and support them with their difficulties. The Tel-jeunes site primarily promotes their telephone help line. In addition, the drugs section has a ton of information on drugs and answers to many questions young people often have about this topic. One of the advantages of this site is that it has a questions section where young people can ask questions and a Tel-jeunes worker will answer them in writing within 48 hours Page 89

90 Jeunesse, J écoute Telephone help: Organization whose counsellors offer immediate support, information and referrals, for any kind of problem anonymously. Anyone can call toll free or post a question on line not just young people. La Ligne Parents Telephone help: Ligne Parents is a telephone service for parents. It offers free, confidential support accessible 24 hours a day, 7 days a week. Professional counsellors help fathers and mothers improve the parent-child relationship and find for themselves a means of acting in any circumstance. Association québécoise de prévention du suicide For suicide emergencies anywhere in Quebec Montréal: / Other regions: This association responds to suicide emergencies anywhere in Quebec. It offers a free emergency telephone service 24 hours a day, 7 days a week. It raises the issue of suicide and suicide prevention. The web site makes it possible to obtain documentation, information on suicide prevention, resources in this field and other relevant information. Centre antipoison du Québec Le Centre antipoison du Québec is made up of a team of nurses and doctors specializing in urgent poisoning situations and overdoses. It offers a free emergency telephone service 24 hours a day, 7 days a week, for the public and health professionals. 19. Websites Action Toxicomanie Bois-Francs Action Toxicomanie Bois-Francs came out of the community and its establishment is 1991 was part of a partnership by all of the youth groups in the territories of the CRMs of Érable and Arthabaska. The organization reaches a significant number of young people through its addiction prevention educators, integrated in the educational institutions in the region. The mission of Action Toxicomanie Bois-Francs is to promote health among young people and prevent addictions and associated dependencies. Page 90

91 Association des intervenants en toxicomanie du Québec (AITQ) The mission of the AITQ is to bring together community workers operating in the field of addiction in Quebec and promote community involvement in addiction prevention and treatment. Recognized as a documentation and referral centre, their web site offers a list of their publications and many articles from their quarterly review of information on addictions, L'Intervenant, as well as various brochures and leaflets on addiction. Finally, one section of the site is devoted to an educational toolkit on alcohol, Tiens-toi debout!, which they developed for adolescents. There is also a link to their prevention toolkit. Centre québécois de documentation en toxicomanie (CQDT) Designated since 1991 as the Centre québécois de documentation en toxicomanie (CQDT) by the Ministère de la Santé et des Services sociaux, the documentation centre of the centre Dollard-Cormier is one of the most important documentary resources on addiction in Canada and in the world. Addiction prevention centre (APC) The APC is an organization which came about after the elimination of the Comité permanent de lutte à la toxicomanie. Its field of action covers all dependencies affecting the well-being of the population: alcohol, drugs, problem gambling and cyberdependency. The mission of this new independent agency is to help fight dependencies in Quebec by participating in the development and transfer of knowledge in this field. To realize its mission, it emphasizes the sharing of rigorous and varied expertise, concerted efforts among all the players concerned, as well as awareness of organization and the population about the challenges raised by dependencies. Their publications are accessible on their Internet site. Canadian Centre on Substance Abuse The Canadian Centre on Substance Abuse has a legislated mandate to provide national leadership and evidence-informed analysis and advice to mobilize collaborative efforts to reduce alcohol- and other drugrelated harms. Éduc alcool This site brings together the partners of the alcoholic beverage industry, parapublic institutions and members who, aware of their social mission, inform, prevent and educate to help youth and adults make smart, responsible decisions about using alcohol. The site has information on different programs dealing with alcohol-related problems, a list of publications dealing with alcohol and its use as well as a youth section that suggests informative activities for young people. Page 91