ADHD in Disguise: The Missing Link in Addiction Treatment

by Bree Lawrence

Photo by Anna Shvets. Retrieved from **Pexels** (2021).

The road to recovery for people suffering from a substance use disorder (SUD) is often long and difficult. Many factors can complicate the process; one commonly cited by practitioners is the level of motivation. A strong sense of intent and commitment to change is considered a necessary component to successful treatment and recovery. To address a person’s motivation, practitioners regularly use strategies like motivational interviewing or motivational enhancement therapy (Moos, 2007), often with great success. These strategies aim to address the hesitancy or ambivalence an individual may feel about their drug use. Low motivation can present in many ways; such as a client who’s consistently late to treatment or misses sessions entirely, doesn’t seem to engage in treatment or focus during programming, shows frustration or emotional outbursts, or frequently “quits” treatment. Motivational-based interventions have been shown to help increase engagement in SUD treatment and lower an individual’s substance use (Smedslund et al., 2011). Due to this success, motivational-based strategies have been adopted by many treatment facilities and programs (Hall et al., 2016). Often, when those seeking treatments continue to display signs of low motivation, treatment facilitators may feel they aren’t ready for treatment or don’t want to address their substance use. But what if the tell-tale signs of low motivation in some clients are actually symptoms of something else, something more rigid, that motivational-based strategies don’t properly address?

Attention Deficit Hyperactivity Disorder

Most of us are familiar with attention deficit hyperactivity disorder (ADHD) in one way or another. ADHD is a neurodevelopmental disorder that is categorized into three distinct types, each with unique and overlapping symptoms. This disorder is commonly associated with symptoms like restlessness, excessive daydreaming, trouble focusing, and hyperactivity. It is one of the most prevalent neurodevelopmental disorders, affecting between one and 13% (Attention Deficit Hyperactivity Disorder (ADHD), n.d.) of the population. While our understanding and the public perception of ADHD are improving, there are still plenty of people holding on to misconceptions about the disorder. ADHD is not a diagnosis limited to children and symptoms don’t always improve or fade as someone ages. In fact, without treatment, symptoms often get worse with time. Symptoms of ADHD also aren’t as simple as excessive energy or distractibility. In adults, ADHD symptoms often present themselves as behaviours like missing appointments, poor memory recall, or displaying intense emotional reactions or fluctuating interest. Many of these symptoms have to do with executive functioning: our ability to plan, problem-solve, organize thoughts and feelings, and regulate our emotions. Executive dysfunction is a core element of ADHD. When people struggling with both ADHD and SUD seek treatment for drug use, these symptoms of executive dysfunction are often seen as a lack of motivation or factors that make a patient “treatment-resistant” (Kalbag & Levin, 2005).

The Complexity of Co-Occurring Diagnoses

While every person seeking SUD treatment will have different needs and obstacles that are specific to them, co-occurring ADHD and SUD are very common and unfortunately, often unaccounted for. Research into the co-occurrence of these disorders has found that almost 25% of SUD patients have co-occurring ADHD (van Emmerik-van Oortmerssen et al., 2012). ADHD symptoms are also associated with an increased risk of developing a SUD, regardless of the type of substance (Capusan et al., 2019). Despite this link between ADHD and SUD, SUD treatment has typically failed to address the challenges of treating people with executive dysfunction. Patients with severe symptoms of ADHD are less likely to fully abstain from drug use (Arias et al., 2008), more likely to end their treatment, and are more prone to relapse after treatment (Perugi et al., 2019; Spera et al., 2020). To better understand why people with both ADHD and SUD struggle to succeed in typical drug use programs, it’s important to understand how the symptoms of ADHD aggravate SUD as well as impede common intervention strategies.

Executive Functioning

Let’s go back to executive function, or rather, executive dysfunction. Executive functioning is responsible for how impulsive we are, how much self-control we’re able to exert. It helps us prioritize long-term goals over short-term desires. When these abilities are impacted by ADHD, they also affect behaviours that can help prevent initial drug use or misuse. Empirical studies looking into which ADHD symptoms may be the cause of reduced treatment success aren’t abundant, but researchers have some potential theories. Increased impulsivity has been reported as one reason for initial drug use in people with ADHD (Kronenberg et al., 2014), while lack of self-control and difficulties with conceptualizing future consequences are also believed to be possible factors (Kronenberg, Verkerk-Tamminga, et al., 2015).

Graphic by Bree Lawrence, information retrieved from CADDAC (n. d. a.)

Self-medicating has also been theorized as a potential link between ADHD and SUD (Kronenberg, Goossens, et al., 2015). The use of stimulant drugs, like cocaine, is common in people with ADHD. A recent review of studies estimated that over a quarter of people with ADHD worldwide have used cocaine at some point in their life and 10% have suffered from a cocaine use disorder (Oliva et al., 2020). This may be due to stimulants reducing many ADHD symptoms (Young et al., 2015), implying that someone using stimulant drugs may be seeking relief or trying to address concerns like restlessness or inattention (Kronenberg, Verkerk-Tamminga, et al., 2015).

The Influence of Executive Functioning on Treatment

To understand how executive functioning may hinder treatment, it’s important to look at what most typical substance use disorder programs involve. Cognitive behavioural therapy (CBT) has been shown to work well in reducing substance use by addressing the relationships between thought processes and behaviours. CBT programs often include activities like tracking actions, feelings, and thoughts to address maladaptive patterns, learning to reframe experiences, and meeting with practitioners at regular intervals. But ADHD patients may have difficulty maintaining tracking sheets, remembering to try reframing their thoughts, or planning accordingly to arrive (on time or at all) to therapy appointments (Kalbag & Levin, 2005). These difficulties with treatment programs can lead practitioners to perceive the patient as having low motivation (Kalbag & Levin, 2005). The patient may feel ashamed for not completing what seems like simple tasks. These feelings of failure are common with ADHD and potentially responsible for other challenges with SUD.

Intense Emotions and Impulsivity

Let’s talk about emotional regulation. While emotional regulation is a part of executive functioning, its effect on drug use and treatment is different than other aspects of executive functioning. Emotional regulation is something everyone struggles with at times. Strong feelings can lead to outbursts of emotion, inappropriate responses, or cause us to make impulsive decisions. For most people, these moments are few and far between and limited to infrequent but significant events, such as intense grief from the sudden death of a loved one or fiery anger after a distracted driver rear-ends you in traffic. Often, we can curb strong urges to act on these intense emotions. Individuals with ADHD often experience heightened emotions, frequently in situations where their reaction may seem unnecessarily extreme. They have more difficulty resisting the urge to respond impulsively. For some, this means snapping at a coworker or shouting at an aggressive driver. For others, however, the impulses are more internal. As described earlier, difficulties associated with executive dysfunction can result in performance issues in not only therapy itself but also in school and work. Emotional dysregulation means these performance issues can feel much worse to someone with ADHD, resulting in demoralization, self-hate, or shame (Barkley & Fischer, 2010; Skirrow & Asherson, 2013). For many people, it’s common to reach for a drink, a cigarette, or another drug of choice to soothe intense feelings or cope with stress. For those with ADHD, this impulse can show up more often and be more difficult to ignore. The combination of these unique factors suggests substance use in people with ADHD is a coping behaviour (Kronenberg, Goossens, et al., 2015) and that emotional dysregulation in ADHD may exasperate these issues (Young et al., 2015; Zulauf et al., 2014).

Why is this Connection Important?

Let’s recap: worldwide, a quarter of people seeking treatment for substance use also struggle with ADHD, often undiagnosed (van Emmerik-van Oortmerssen et al., 2012). People with co-occurring ADHD and SUD, often have less success in drug abuse programs (Arias et al., 2008; Perugi et al., 2019; Spera et al., 2020), likely due to ADHD symptoms like executive dysfunction (Kalbag & Levin, 2005; Kronenberg et al., 2014; Kronenberg, Verkerk-Tamminga, et al., 2015; Young et al., 2015) and emotional dysregulation (Barkley & Fischer, 2010; Skirrow & Asherson, 2013; Young et al., 2015; Zulauf et al., 2014). These complications in treating a dual diagnosis of SUD and ADHD have a significant influence on potential patient success. Many symptoms of ADHD appear to practitioners as signs that someone isn’t motivated to change, is treatment-resistant, or just not ready to engage in treatment in a meaningful way. This could potentially cause someone seeking treatment to feel they’re incapable of change, to leave programs before completion, or discourage them from returning after a relapse (Kalbag & Levin, 2005).

So What Do We Do?

If co-occurring ADHD and SUD are so common, why haven’t more treatment programs for drug abuse accounted for these patients’ different needs? This is possibly due to many treatment-seekers not knowing they have ADHD and program facilitators being more likely to see the symptoms of ADHD as merely a lack of motivation. This is why more treatment programs need to screen new patients for ADHD (van Emmerik-van Oortmerssen et al., 2014; Wilens, 2006). By doing so, treatment facilitators will better be able to differentiate between executive dysfunction and low motivation, making it possible to target issues more effectively. For those with mild ADHD symptoms, teaching the use of tools like daily planners, reminder apps, and coping catalogues can improve treatment outcomes (Kolpe & Carlson, 2007). Practitioners that take a “coaching” approach to treatment are also preferred by individuals with co-occurring ADHD and SUD (Kronenberg, Verkerk-Tamminga, et al., 2015). For more severe ADHD symptoms, integrated CBT that targets SUD and ADHD simultaneously may be the best course of action (van Emmerik-van Oortmerssen et al., 2014).

Of course, every person struggling with drug use is going to have different strengths, weaknesses, and needs that should be considered but can’t always be accommodated. The concern worth considering here is that ADHD and SUD are frequently co-occurring, the symptoms of ADHD can aggravate the development or severity of substance use issues as well as inhibit treatment success, and the telltale signs of ADHD in adults look very similar to indicators of low motivation in typical SUD treatment-seekers. By addressing the specific needs of the large demographic of people with comorbid ADHD and SUD, treatment facilitators and health professionals can help more patients more effectively with longer-lasting maintenance and recovery.

References

Arias, A. J., Gelernter, J., Chan, G., Weiss, R. D., Brady, K. T., Farrer, L., & Kranzler, H. R. (2008). Correlates of co-occurring ADHD in drug-dependent subjects: prevalence and features of substance dependence and psychiatric disorders. Addictive Behaviors, 33(9), 1199–1207. https://doi.org/10.1016/j.addbeh.2008.05.003

Attention Deficit Hyperactivity Disorder (ADHD). (n.d.). Retrieved April 1, 2021, from https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/attention-deficit-hyperactivity-disorder

Barkley, R. A., & Fischer, M. (2010). The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. Journal of the American Academy of Child and Adolescent Psychiatry, 49(5), 503–513. https://doi.org/10.1016/j.jaac.2010.01.019

Capusan, A. J., Bendtsen, P., Marteinsdottir, I., & Larsson, H. (2019). Comorbidity of Adult ADHD and Its Subtypes With Substance Use Disorder in a Large Population-Based Epidemiological Study. Journal of Attention Disorders, 23(12), 1416–1426. https://doi.org/10.1177/1087054715626511

Executive Functioning – Centre for ADHD Awareness Canada. (n.d.). Retrieved April 20, 2021, from https://caddac.ca/understanding-adhd/in-general/executive-functioning/

Hall, K., Staiger, P. K., Simpson, A., Best, D., & Lubman, D. I. (2016). After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing? Addiction, 111(7), 1144–1150. https://doi.org/10.1111/add.13014

Kalbag, A. S., & Levin, F. R. (2005). Adult ADHD and substance abuse: diagnostic and treatment issues. Substance Use & Misuse, 40(13-14), 1955–1981, 2043–2048. https://doi.org/10.1080/10826080500294858

Kolpe, M., & Carlson, G. A. (2007). Influence of attention-deficit/hyperactivity disorder symptoms on methadone treatment outcome. The American Journal on Addictions / American Academy of Psychiatrists in Alcoholism and Addictions, 16(1), 46–48. https://doi.org/10.1080/10601330601080073

Kronenberg, L. M., Goossens, P. J. J., van Busschbach, J., van Achterberg, T., & van den Brink, W. (2015). Coping styles in substance use disorder (SUD) patients with and without co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). BMC Psychiatry, 15, 159. https://doi.org/10.1186/s12888-015-0530-x

Kronenberg, L. M., Slager-Visscher, K., Goossens, P. J. J., van den Brink, W., & van Achterberg, T. (2014). Everyday life consequences of substance use in adult patients with a substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD): a patient’s perspective. BMC Psychiatry, 14, 264. https://doi.org/10.1186/s12888-014-0264-1

Kronenberg, L. M., Verkerk-Tamminga, R., Goossens, P. J. J., van den Brink, W., & van Achterberg, T. (2015). Personal recovery in individuals diagnosed with substance use disorder (SUD) and co-occurring attention deficit/hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). Archives of Psychiatric Nursing, 29(4), 242–248. https://doi.org/10.1016/j.apnu.2015.04.006

Moos, R. H. (2007). Theory-based active ingredients of effective treatments for substance use disorders. Drug and Alcohol Dependence, 88(2-3), 109–121. https://doi.org/10.1016/j.drugalcdep.2006.10.010

Oliva, F., Mangiapane, C., Nibbio, G., Berchialla, P., Colombi, N., & Vigna-Taglianti, F. D. (2020). Prevalence of cocaine use and cocaine use disorder among adult patients with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Journal of Psychiatric Research. https://doi.org/10.1016/j.jpsychires.2020.11.021

Perugi, G., Pallucchini, A., Rizzato, S., De Rossi, P., Sani, G., Maremmani, A. G., Pinzone, V., & Maremmani, I. (2019). Pharmacotherapeutic strategies for the treatment of attention-deficit hyperactivity (ADHD) disorder with comorbid substance-use disorder (SUD). Expert Opinion on Pharmacotherapy, 20(3), 343–355. https://doi.org/10.1080/14656566.2018.1551878

Skirrow, C., & Asherson, P. (2013). Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder. Journal of Affective Disorders, 147(1-3), 80–86. https://doi.org/10.1016/j.jad.2012.10.011

Smedslund, G., Berg, R. C., Hammerstrøm, K. T., Steiro, A., Leiknes, K. A., Dahl, H. M., & Karlsen, K. (2011). Motivational interviewing for substance abuse. Cochrane Database of Systematic Reviews, 5, CD008063. https://doi.org/10.1002/14651858.CD008063.pub2

Spera, V., Pallucchini, A., Maiello, M., Carli, M., Maremmani, A. G. I., Perugi, G., & Maremmani, I. (2020). Substance Use Disorder in Adult-Attention Deficit Hyperactive Disorder Patients: Patterns of Use and Related Clinical Features. International Journal of Environmental Research and Public Health, 17(10). https://doi.org/10.3390/ijerph17103509

Svets, A. (2020). Medication Pills Isolated on Yellow background [Photo]. Pexels.com. https://www.pexels.com/photo/medication-pills-isolated-on-yellow-background-3683098/

van Emmerik-van Oortmerssen, K., van de Glind, G., Koeter, M. W. J., Allsop, S., Auriacombe, M., Barta, C., Bu, E. T. H., Burren, Y., Carpentier, P.-J., Carruthers, S., Casas, M., Demetrovics, Z., Dom, G., Faraone, S. V., Fatseas, M., Franck, J., Johnson, B., Kapitány-Fövény, M., Kaye, S., … Schoevers, R. A. (2014). Psychiatric comorbidity in treatment-seeking substance use disorder patients with and without attention deficit hyperactivity disorder: results of the IASP study. Addiction, 109(2), 262–272. https://doi.org/10.1111/add.12370

van Emmerik-van Oortmerssen, K., van de Glind, G., van den Brink, W., Smit, F., Crunelle, C. L., Swets, M., & Schoevers, R. A. (2012). Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. Drug and Alcohol Dependence, 122(1-2), 11–19. https://doi.org/10.1016/j.drugalcdep.2011.12.007

Wilens, T. E. (2006). Attention deficit hyperactivity disorder and substance use disorders. The American Journal of Psychiatry, 163(12), 2059–2063. https://doi.org/10.1176/ajp.2006.163.12.2059

Young, J. T., Carruthers, S., Kaye, S., Allsop, S., Gilsenan, J., Degenhardt, L., van de Glind, G., van den Brink, W., & Preen, D. (2015). Comorbid attention deficit hyperactivity disorder and substance use disorder complexity and chronicity in treatment-seeking adults. Drug and Alcohol Review, 34(6), 683–693. https://doi.org/10.1111/dar.12249

Zulauf, C. A., Sprich, S. E., Safren, S. A., & Wilens, T. E. (2014). The complicated relationship between attention deficit/hyperactivity disorder and substance use disorders. Current Psychiatry Reports, 16(3), 436. https://doi.org/10.1007/s11920-013-0436-6

April 25, 2021October 29, 2021

Mind Myths: The Addictive Personality

A podcast episode written and produced by Susanna Lee

A friend jokingly uses it as an excuse for why they can’t resist online shopping. A news article blames it as the reason why some celebrity just can’t seem to shake their drug habit. A family member rejects a glass of wine for fear that it will prevent them from being able to stop themselves. We’ve all heard the term before one way or another. In this episode of Mind Myths, we debunk one of the most popular myths about addiction and substance use: the myth of the addictive personality.

References

Amodeo, M. (2015). The addictive personality. Substance use & Misuse, 50(8-9), 1031- 1036. https://doi.org/10.3109/10826084.2015.1007646

Charles, P. (Writers), & Southam, T. (Director). (2014, March 31). The Turn in the Urn (Season 9, Episode 19) [TV series episode]. In H. Hanson. (Executive Producer), Bones. Josephson Entertainment; Far Field Productions; 20th Century Fox Television

CBC News. (2014, May 30). Aboriginal people and alcohol. CBC News Audio. https://www.cbc.ca/news/aboriginal/aboriginal-people-and-alcohol-not-a-genetic-predisposition-1.2660167

Cervone, D., & Pervin, L. A. (2019). Personality: Theory and research (14th ed.) John Wiley & Sons, Inc.

Griffiths, M. D. (2017). The myth of ‘addictive personality’. Global Journal of Addiction & Rehabilitation Medicine, 3(2). https://doi.org/10.19080/GJARM.2017.03.555610

Kassin, S. M., Fein, S., & Markus, H. R. (2017). Social psychology (10th ed.) Boston, MA: Cengage Learning.

Szalavitz, M. (2015). Genetics: No more addictive personality. Nature (London), 522(7557), S48-S49. https://doi.org/10.1038/522S48a

April 24, 2021

Can cannabis cause psychosis?: Investigating potential health risks of recreational cannabis use

By Hannah Rasiuk

person holding grey tongs and kush

Image description: A cannabis retailer employee weighs cannabis flowers on a scale. Image retrieved from Unsplash (2016).

Amidst the ongoing closures of local businesses during COVID-19, many residents have noticed an explosion of new cannabis shops opening in Toronto neighbourhoods.¹ As plans have been revealed to license 80 new Ontario cannabis retailers per month, the drug is becoming increasingly accessible.¹ Given that cannabis has become the most widely used mind-altering drug among North Americans,² Torontonians likely make choices about personal cannabis use on a regular basis. However, common misconceptions about cannabis may create difficulty in making informed decisions about recreational use.

Cannabis is often thought of as a harmless substance and tends to be used by individuals to help with medical issues, without concern for its addictiveness.³ In reality, approximately 1 in 3 people who use the drug develop issues with their use, with 1 in 11 people developing the addiction, cannabis use disorder.⁴ Alongside being addictive, cannabis use may actually pose major risks to personal health.⁵ For example, research studies have been finding a connection between cannabis use and psychosis. An important part of understanding this relationship involves answering the question: does cannabis use actually cause psychosis to develop. The following discussion will unpack what psychosis is, as well as the research on this relationship in order to figure out if cannabis use could realistically cause psychosis, and how this might occur.

What is psychosis?

Psychosis is a term used to describe personal problems and disruptions in mental functioning that results in people having difficulty staying in touch with reality. People experiencing psychosis have distressing changes in their normal beliefs, thoughts, behaviours, and ways of perceiving the world around them. The term can be used to describe the broad range of symptoms associated with psychosis, as well as to mental diagnoses that involve psychosis. For instance, schizophrenia is a well known psychotic disorder.^6,7

Infographic by Hannah Rasiuk, template from CANVA is licensed under a CC BY-NC-ND 2.0., information retrieved from Schizophrenia Society of Canada (n.d.).

What are the symptoms of psychosis?

Psychosis can look different among people who are experiencing it and can develop quickly, or gradually over time. The complex symptoms that individuals with psychosis may experience are listed below:

Hallucinations, which may involve perceiving sounds or visions that are not actually occurring
A loss of the sense that one’s experiences are, in fact, their own personal experiences
Difficulty beginning tasks
Reduced range of emotions and speech
Disorganized thoughts, speech, or behaviour (this could include issues in completing daily tasks, or fast and confusing changes in subject matter when speaking).
Decreases in motivation
Spending more time alone and neglecting social relationships
Issues with developing original ideas and thoughts
Delusions, which involve strongly held beliefs that may be bizarre or unrealistic.^6,7

Can psychosis be caught early on?

Although psychosis causes widespread negative effects on daily functioning, health, and well-being, it is a treatable condition.⁵ Treatments for psychosis commonly involve the use of medication, as well as psychotherapy. Antipsychotics are the main medication used to manage psychotic symptoms, and prevent symptoms in the future. Psychotherapy is useful for improving daily functioning and managing living with psychosis. Since psychosis is more easily treated when caught early on in its development,⁷ these symptoms may be important to look out for. Some early warning signs for the development of psychosis include:

Difficulty in completing normal self-care and hygiene practices
Decline in performance at work or school
Difficulty communicating with others
Adopting new ideas that may seem bizarre or intense
New issues in critical thinking and concentration
Feeling suspicious of others
Spending an atypical amount of time by oneself
Trouble separating fantasy from reality.⁹

Infographic by Hannah Rasiuk, template from CANVA is licensed under a CC BY-NC-ND 2.0., information retrieved from CAMH (n.d.a).

What has research shown about the associations between cannabis use and psychosis?

The development of psychotic disorders is complex. There are many factors that may cause psychosis, including imbalances of chemicals in the brain, as well as stressful life events. If drug use does play a role in its development, it can only partially explain its cause.⁷

Researchers believe that cannabis use may lead to psychosis by negatively affecting processes occurring in the brain. THC, also known as tetrahydrocannabinol, is the main ingredient in cannabis that creates changes in the brain that produce the ‘high’ feeling associated with use.¹⁰ Research suggests that THC interacts with chemicals in the brain that interrupt the brain’s ability to function normally. THC has effects on certain areas of the brain’s ‘reward circuit’, and affects the functioning of parts of the brain associated with critical thinking, mood, and meeting goals.¹¹ These changes in the brain may be reflected by the issues in thinking, attention, or memory that individuals often experience shortly after using cannabis. Studies have also shown that people with psychosis also have similar abnormalities and issues in these areas of the brain, which contributes to their psychotic symptoms. Given this overlap, researchers suggest that these disruptions in the brain caused by THC could potentially contribute to the development of psychosis.^11,12

Research that focuses on individuals experiencing psychosis highlights how cannabis use may be linked to psychosis. Some of these findings include:

Psychosis patients who use cannabis have been found to develop psychosis at younger ages. Cannabis users in one study were found to have developed psychosis 6 years earlier than non-users, on average.¹³
Cannabis use has been found to cause ‘acute’ episodes of psychosis. An acute episode of psychosis happens when psychosis-like symptoms develop immediately after using cannabis. These symptoms may extend beyond the time that the individual is intoxicated and may come before a full psychotic episode.⁵
Very few individuals who have already experienced psychosis report that they started using cannabis after their psychosis began.¹⁴
Cannabis is the most commonly used mind-altering drug among individuals with schizophrenia. Within a study of patients with schizophrenia, 25% of patients had also received cannabis use disorder diagnoses.¹⁵
Some studies have shown that psychosis patients using cannabis are readmitted to hospitals more often than those who do not use the drug.¹⁶
37% of psychosis patients in a study shared with researchers that their first psychotic symptoms began while intoxicated from cannabis.¹⁷

Who might be vulnerable to developing psychosis after using cannabis?

Certain individuals are more likely to develop psychosis when using cannabis than others. The age at which individuals begin to use cannabis, as well as a family history of psychosis have been shown to be particularly important in the relationship between cannabis use and psychosis.

Did you begin smoking at a younger age?

Studies have demonstrated that participants who had used cannabis during teenage years had more psychotic symptoms, and were more likely to have schizophrenia later on in life.⁵ These results suggest that the teen years are an important and sensitive period of time for the brain’s development, and that cannabis use may negatively affect this development. For instance, a sample of psychosis patients who began using cannabis prior to the age of 16 developed psychosis at earlier ages than those who began using the drug after the age of 15.¹³ This highlights that using cannabis during adolescence, especially during early teenage years, may be particularly connected to the development of psychosis later on.

Do you have a family history of psychosis?

Generally, individuals with a family history of psychosis are more likely to develop psychosis themselves.⁷ However, research suggests that cannabis use may uniquely increase the risk for developing psychosis among people with these genetic sensitivities.⁵ One study found that patients who were experiencing acute episodes of psychosis who had recently been using cannabis were 10 times more likely to report having a family history of psychosis, compared to patients who had not recently used cannabis.¹⁸ Among psychosis patients who use cannabis, it is common that family members who have experienced psychosis also use cannabis.¹⁹

Other studies have identified that certain genes that are inherited from parents may uniquely contribute to the development of psychotic symptoms after using cannabis. Researchers have found that people who have specific variations of 2 genes, called AKt1 and COMT, have a greater likelihood of experiencing psychosis-like symptoms after using cannabis, as well as developing psychosis later on.^5,19 These findings suggest that certain factors that are inherited from parents may allow some people to become particularly likely to develop psychosis after using cannabis.

How might patterns of personal cannabis use increase the likelihood of developing psychosis?

Certain patterns of cannabis use have been linked to the development of psychosis. Some relevant factors related to personal patterns include the frequency of cannabis use, as well as the strength, or potency of the cannabis used.

Frequency of cannabis use

Many research studies have demonstrated that individuals who use cannabis on a daily basis have an increased likelihood of developing psychosis, including acute episodes of psychosis, compared to non-daily users.^20,5 Researchers in one study found that patients experiencing their first episode of psychosis tended to smoke on a daily basis, smoke more frequently, and for longer periods of time.¹³ Another set of researchers who studied individuals over the course of 25 years also found that daily use was associated with up to 3.3 times more likely to develop psychosis compared to non-users.²¹ These results suggest that daily cannabis use over time may result in an individual being especially vulnerable to developing psychosis.

Potency of cannabis used

High potency cannabis has higher amounts of THC.⁵ This means that higher potency cannabis is able to give users a more intense ‘high’ feeling after consuming smaller amounts, compared to low potency cannabis. High potency cannabis is also becoming more widely available at legal cannabis stores, with a 17% THC content considered to be ‘strong’ among Ontario cannabis retailers.^22,23 Since cannabis retailers may not share information about the potency of their cannabis products, a guideline for this information is provided below:

Infographic by Hannah Rasiuk, template from CANVA is licensed under a CC BY-NC-ND 2.0., information retrieved from Government of Canada (n.d.b).

Numerous studies have found associations between higher potency cannabis and increased rates of psychosis.²² For instance, individuals experiencing their first episode of psychosis were found to have smoked higher potency cannabis at increased rates. The researchers in this study also found that potency was a factor that individually contributed to earlier onsets of psychosis among those who were studied.¹³

Image description: Close-up shot of various types of higher-potency cannabis extracts displayed on a metal spatula. Image retrieved from Pixabay (2018).

How sure can we be about these findings?

There are some limitations to this research that make it unreasonable to conclude that there is a cause-and-effect relationship between cannabis use and psychosis. The research does suggest that cannabis use is a relevant factor among people with psychosis. However, it is unclear whether the people in these studies would have developed their psychosis anyway, without the use of cannabis. Similarly, not everyone who uses high potency cannabis on a daily basis will develop psychosis. It could also be possible that there are other undiscussed factors that allow certain people to be more at risk for both using cannabis, and for developing psychosis. It might be more reasonable to remain cautious in believing that cannabis use causes psychosis, and that it might just partially contribute to its development.²¹

How might these research findings be applied to everyday life?

Overall, these research findings connecting cannabis use to psychosis suggest that its reputation for being harmless may be unrealistic². Evidence points to the idea that using high potency cannabis on a daily basis could contribute to the development of psychosis.^5,13 If individuals have used cannabis since adolescence, and/or have a family history of psychosis, they may be especially vulnerable to developing psychotic symptoms. If the findings in these research studies were able to determine a cause-and-effect relationship between cannabis use and psychosis, they could be applied to daily life by changing patterns of personal cannabis use. In this case, people currently using cannabis should consider using cannabis with lower potencies, and avoid using it on a daily basis.

Cannabis use disorder may be a barrier for those who are motivated to change these patterns of use². Similarly to psychosis, cannabis use disorder is a treatable condition. Specifically, there is evidence that some psychotherapy options may be helpful for the treatment of cannabis use disorder.²⁴ If additional personal support is helpful, readers are encouraged to access the online resources and information about healthcare services related to psychosis and addiction listed below.

Resources for personal support available in Toronto:

GTA Mental Health Resources – Culturally Specific | Health & Counselling Centre

Connex Ontario: Mental Health & Addiction Treatment Services

Partners in Care: Supporting Families in Patient Recovery

To Access CAMH Services, call 416 535-8501, option 2.

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References

¹Saba, R. (2021, January 21). ‘We’ll have stores on pretty much every block’: Noticed a sudden surge in the number of pot shops in Toronto? Here’s why. Toronto Star. https://www.thestar.com/business/2021/01/19/more-cannabis-shops-keep-opening-despite-lots-of-competition-and-the-pandemic.html

²Hasin, D., & Walsh, C. (2020). Cannabis use, cannabis use disorder, and comorbid psychiatric illness: A narrative review. Journal of Clinical Medicine, 10(1), 1-19. doi10.3390/jcm10010015

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¹¹Lutz, B. (2009). From molecular neurodevelopment to psychiatry: new insights in mechanisms underlying Cannabis-induced psychosis and schizophrenia. European Archives of Psychiatry and Clinical Neuroscience, 259(7), 369-370. doi:10.1007/s00406-009-0029-x

¹²Kuepper, R., Morrison, P.D., van Os, J., Murray, R.M., Kenis, G., & Henquet, C. (2010). Does dopamine mediate the psychosis-inducing effects of cannabis?: A review and integration of findings across disciplines. Schizophrenia Research, 121(1), 107-117. https://doi.org/10.1016/j.schres.2010.05.031

¹³Di Forti, M., Sallis, H., Allegri, F., Trotta, A., Ferraro, L., Stilo, S.A., Marconi, A., La Cascia, C., Marques, T.R., Pariante, C., Dazzan, P., Mondelli, V., Paparelli, A., Kolliakou, A., Prata, D., Gaughran, F., David, A.S., Morgan, C., Stahl, D., … Murray, R.M. (2014). Daily use, especially of high-potency cannabis, drives the earlier onset of psychosis in cannabis users. Schizophrenia Bulletin, 40(6), 1509-1517. doi:10.1093/schbul/sbt181

¹⁴Gonzalez-Pinto, A., Alberich, S., Barbeito, S., Gutierrez, M., Vega, P., Ibanez, B., Haider, M.K., Vieta, E., & Arango, C. (2009). Cannabis and first-episode psychosis: Different long-term outcomes depending on continued or discontinued use. Schizophrenia Bulletin, 37(3), 631-639. https://doi.org/10.1093/schbul/sbp126

¹⁵Rabin, R.A., Zakzanis, K.K., & George, T.P. (2011). The effects of cannabis use on neurocognition in schizophrenia: A meta-analysis. Schizophrenia Research, 128(1-3), 111-116. https://doi.org/10.1016/j.schres.2011.02.017

¹⁶Colizzi, M., Burnett, N., Costa, R., De Agostini, M., Griffin, J., & Bhattacharyya, S. (2018). Longitudinal assessment of the effect of cannabis use on hospital readmission rates in early psychosis: A 6-year follow-up in an inpatient cohort. Psychiatry Research, 268, 381-387. https://doi.org/10.1016/j.psychres.2018.08.005

¹⁷Peters, B.D., de Koning, P., Dingemans, P., Becker, H., Linszen, D.H., & de Haan, Lieuwe. (2009). Subjective effects of cannabis before the first psychotic episode. Australian and New Zealand Journal of Psychiatry, 43(12). doi:10.3109/00048670903179095

¹⁸McGuire, P., Jones, P., Harvey, I., Williams, M., McGuffin, P., & Murray, R. (1995). Morbid risk of schizophrenia for relatives of patients with cannabis-associated psychosis. Schizophrenia Research, 15(3), 277-281. doi:10.1016/0920-9964(94)00053-B

¹⁹Murray, R.M., Quigley, H., Quattrone, D., Englund, A., & Di Forti, M. (2016). Traditional marijuana, high‐potency cannabis and synthetic cannabinoids: Increasing risk for psychosis. World Psychiatry, 15(3), 195-204. doi:10.1002/wps.20341

²⁰Compton, M.T., Broussard, B., Ramsay, C.E., & Stewart, T. (2011). Pre-illness cannabis use and the early course of nonaffective psychotic disorders: Associations with premorbid functioning, the prodrome, and mode of onset of psychosis. Schizophrenia Research, 126(1), 71–76. doi:10.1016/j.schres.2010.10.005

²¹Fergusson D.M., Horwood. L.J., & Ridder, E.M. (2005). Tests of causal linkages between cannabis use and psychotic symptoms. Addiction, 100(5), 354-366. doi:10.1111/j.1360-0443.2005.01001.x

²²Di Forti, M., Morgan., C., Dazzan, P., Pariante, C., Mondelli, V., Marques, T.R., Handley, R., Luzi, S., Russo, M., Paparelli, A., Butt, A., Stilo, S.A., Wiffen, S., Powell, J., & Murray, R.M. (2018). High-potency cannabis and the risk of psychosis. The British Journal of Psychiatry, 195(6). doi: 10.1192/bjp.bp.109.064220

²³Ontario Cannabis Store. (n.d.). Cannabis anatomy: What is thc?. https://ocs.ca/blogs/cannabis-anatomy/what-is-thc

²⁴Bobb, A.J., & Hill, K.P. (2014). Behavioral interventions and pharmacotherapies for cannabis use disorder. Current Treatment Options in Psychiatry, 1(2), 163-174. doi:10.1007/s40501-014-0013-6

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April 22, 2021November 12, 2021

Using Mindfulness as a Technique to Quit Smoking

You’ve heard of mindfully meditating, but what about mindfully smoking?

By: Rhiannon Ueberholz

If you google “ways to improve your mental health” it’s likely that any results that pop up will contain some information on mindfulness. In our tech-dominated world, mindfulness has become a saving grace, as it allows us to shift away from our busy minds. Though often conflated with meditation, any activity can be done mindfully, including walking, eating, or making a pot of coffee – being mindful is simply:

paying attention to what you are doing on purpose
with an attitude of openness and curiosity (Kabat-Zinn, 2003).

Mindfulness meditation is a specific type of meditation that involves sitting comfortably while paying attention to any thoughts or sensations in the body, accepting them, and allowing them to pass without judgment (Kabat-Zinn, 2003). You can even try it right now: stop what you’re doing, close your eyes or lower your gaze to the floor and take five deep breaths, in through the nose and out through the mouth. Your mind isn’t going to be completely blank, so just try to notice the thoughts that pop into your head without judgment, and then redirect your attention back to your breath. That’s mindfulness! Don’t worry if you found it difficult (most people do); luckily, it gets a lot easier with practice.

While this may sound like a new-age wellness fad, as often associated with hippie-culture, the research has shown that practicing mindfulness can lead to improvements in stress, depression, insomnia, chronic pain, and anxiety (Grossman et al., 2014; Goldberg et al., 2018; Goyal et al., 2014).

More recently, Psychologists have broadened mindfulness practice to treating nicotine addiction. Mindfulness treatments are different from other therapies because they target nicotine addiction by having patients accept their cravings (ie. the intense urge to smoke) and work through them, rather than avoiding or substituting nicotine with something else (Brewer et al., 2011). This can be compared to behavioural treatments, where a common technique would be to avoid places and items that trigger cravings, for example, someone avoiding the store where they buy their cigarettes (Larimer et al., 1999). In order to understand how mindfulness-based treatment works, it’s important that we have a clear understanding of nicotine addiction and why people continue to smoke when they know cigarettes are bad for them.

Why do people get addicted to cigarettes in the first place?

The Incentive Salience Model describes addiction as a progression; people start smoking because it’s enjoyable until they eventually come to dislike it, but strong cravings make it difficult to quit (Robinson et al., 2016).

A typical case might look like this: Bill smokes for the first time in a social setting; he enjoys the nicotine-induced head rush and looks cool for smoking in front of his peers. The next time Bill is at a party with his friends and sees a cigarette, the reward system in his brain will light up, reminding him of how much he enjoyed smoking last time he was at a party, and he will be motivated to smoke again (Robinson et al., 2016). This may also happen when Bill experiences negative events, for example stress from work or sadness from a breakup (Brewer et al., 2011). His brain will remember that smoking makes him feel good and will motivate him to smoke a cigarette to make himself feel better. Eventually, this turns into a habit and Bill develops stronger nicotine cravings whenever he experiences a stressful event, is out with friends or sees something that reminds him of smoking. Over time, Bill no longer experiences the same rewards from smoking; by now he’s developed a tolerance for nicotine, so he no longer experiences a head rush and his peers disapprove. Bill might try to quit by distracting himself or using sheer willpower, but whenever he gets tired or stressed, he may not have the mental resources to exert such willpower and end up smoking again (Brewer et al., 2011).

How does Mindfulness Treat Nicotine Addiction?

Mindfulness works to treat nicotine addiction in two ways (1) by allowing people to develop a natural disliking for smoking and (2) helping them cope with cravings (Brewer et al., 2011). In Dr. Brewer’s lab, he actually encourages people to smoke a cigarette while mindfully paying attention to how smoking makes them feel. His research shows that when people actually pay attention to the experience of smoking, for example noticing how the cigarette burns their throat, makes their breath taste bad, and gets smoke in their eyes, they are able to develop a natural dislike for it (Brewer et al., 2011). When people understand on a deeper level that they dislike smoking, they have a much easier time quitting as opposed to simply having the knowledge that smoking is bad for them.

Once people have this deeper sense of how smoking makes them feel, they can start to detach the feeling of craving from the actual behaviour of smoking a cigarette (Brewer & Kabat-Zinn, 2017). Someone adopting a mindfulness technique would be able to (1) notice when a craving occurs, (2) take inventory of the sensations in their body and their surrounding environment, and (3) reflect on their experience of mindfully smoking (ie. remember that they don’t actually enjoy it), rather than impulsively reaching for a cigarette (Klein & Brewer, 2021). They can now recognize the craving as simply a combination of different body sensations that are being triggered by their internal state or environment, which may help them to resist the urge to smoke. Repeatedly experiencing craving without smoking will eventually break the habit (Klein & Brewer, 2021).

Since mindfulness is linked to improved emotion regulation, using mindfulness to quit may have secondary, positive effects for stress – which is often a trigger for smoking! (Penberthy et al., 2017) Bill, who is now trying to quit smoking using mindfulness, might notice that he always smokes a cigarette to calm down after getting in a fight with his spouse. If he replaces this habit with taking ten minutes to practice mindfulness, not only will he reduce the chances of reaching for a cigarette, but he may also be able to better cope with the stress of the fight (Guendelman et al., 2017).

Is Mindfulness Effective?

Mindfulness is a skill and can be quite challenging to develop; however, practicing it regularly has actually been shown to reduce the overall level of activity in an area of the brain linked to craving, the posterior cingulate cortex (Brewer et al., 2013). Mindfulness works by quieting down the “Default Mode Network”, which is a series of brain structures that are responsible for remembering the past and thinking about the future; the posterior cingulate cortex makes up part of this network (Garrison et al., 2015). One study by Dr. Westbrook and colleagues showed that when people with nicotine addictions practiced mindfulness while looking at photos of cigarettes, they rated their craving as lower and had less activity in this area of the brain, compared to participants who didn’t practice mindfulness while looking at the images (Westbrook et al., 2013). Observing the sensations of craving with mindful curiosity actually makes the brain less reactive to the smoking cues that might cause someone to smoke!

Recent studies have shown that mindfulness treatments can be more effective than other popular treatments in reducing the likelihood of relapse (Davis et al., 2014). In these studies, a mindfulness-based addiction treatment program is compared with a treatment program that uses common behavioural techniques for quitting smoking, like avoiding triggers. In one study Dr. Brewer, a top neuroscientist in the field of addiction, and his colleagues compared a four-week mindfulness program to the American Lung Association’s “Freedom from Smoking program”, cited as “America’s Gold Standard” for smoking cessation (American Lung Association, 2021). This program combines group support, behavioural techniques, and the option for nicotine replacement therapy (ie. nicotine patches) or smoking cessation medication (ie. Bupropion). They found that participants in the mindfulness group had greater success in quitting without relapse seventeen weeks after both programs ended (Brewer et al., 2011). One participant in a mindfulness treatment program reported that they had smoked twenty cigarettes a day for 35 years, but after using a mindfulness-based app for smoking cessation, they were able to quit after just 6 days (Craving to Quit, 2021).

The most important takeaway from this research is that mindfulness is a new tool that can be incorporated into personalized treatment for addiction, not that it’s the best and only treatment. Mindfulness treatments may be effective on their own or often, treatment programs will combine mindfulness with other techniques depending on the needs of the individual. For example, the combination of mindfulness training and taking smoking cessation medication has shown to be more effective than taking medication alone. In a study by Dr. Gifford and colleagues, 32% of the participants who did a combination of therapy that incorporated mindfulness, and bupropion were successful in quitting smoking at a one-year follow-up, compared to 18% who just took medication (Gifford, 2011). An example of one program that uses multiple approaches is “Mindfulness Training for Smokers”, offering medication, mindfulness training, cognitive behavioural therapy, and skills training to combat nicotine addiction (Davis, 2021).

What are the Limitations?

It’s important to note, that while mindfulness has shown promise, it can be quite difficult and may not work for everyone depending on their circumstances. Developing a mindfulness practice takes time and effort, and therefore it would be important for the individual to be highly motivated. Additionally, since using mindfulness-based treatment requires that the person comes to an understanding that they don’t actually enjoy smoking, people who don’t consider their addiction to be that severe and subjectively enjoy cigarettes may not be as invested in a mindfulness approach. This was found in Davis’s and colleagues’ study; people who smoked fewer cigarettes per day were more likely to drop out of the mindfulness program compared to people who smoked more frequently (Davis et al., 2014).

Mindfulness programs for smoking have just recently become more common and are still being tested (Spears et al., 2019). While there have been studies that found mindfulness treatments to be more effective than standard treatments, there have also been studies that found no difference when comparing treatment approaches (Goldberg et al., 2018). This is quite common when developing new treatments, but doing more research will help to find the most effective ways to implement mindfulness for nicotine addiction.

Getting Help During the Pandemic

Amidst the COVID-19 pandemic, studies have found that people who had low levels of nicotine addiction before the pandemic are more likely to experience moderate or high levels of addiction, potentially due to increased stress (Fidanci et al., 2021). Interestingly, it has been found that during the pandemic more people are quitting smoking, rather than starting, which may be the result of anxiety surrounding the increased risk of COVID-19 complications for smokers (Yang & Ma, 2021).

If you or someone you know is having a hard time quitting, mindfulness might be the perfect tool! There are some mindfulness-based apps that can offer support while face-to-face treatment programs are unavailable. One mindfulness program for nicotine addiction is Dr. Brewer’s mindfulness-based app, Craving to Quit. This virtual program teaches mindfulness-based exercises to manage cravings, provides personal coaching, and connects users to an online peer community. The program is designed to be 21 days; however, it’s designed to offer support for as long as the client needs.

All things considered, we are living in very stressful times. Developing a mindfulness practice can be a useful tool to reduce stress, depression, and anxiety, whether you’re struggling with a nicotine addiction or not. Try to focus on the things you can manage in the present moment and everything else will fall into place.

References

American Lung Association. (2021). Freedom From Smoking. Retrieved from https://www.lung.org/quit-smoking/join-freedom-from-smoking

Brewer, J. A., Mallik, S., Babuscio, T. A., Nich, C., Johnson, H. E., Deleone, C. M., Minnix-Cotton, C. A., Byrne, S. A., Kober, H., Weinstein, A. J., Carroll, K. M., & Rounsaville, B. J. (2011). Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug and Alcohol Dependence, 119(1–2), 72–80. https://doi.org/10.1016/j.drugalcdep.2011.05.027

Brewer, J. A., Worhunsky, P. D., Gray, J. R., Tang, Y.-Y., Weber, J., & Kober, H. (2011). Meditation experience is associated with differences in default mode network activity and connectivity. Proceedings of the National Academy of Sciences, 108(50), 20254–20259. https://doi.org/10.1073/pnas.1112029108

Brewer, J. A., Elwafi, H. M., & Davis, J. H. (2013). Craving to quit: Psychological models and neurobiological mechanisms of mindfulness training as treatment for addictions. Psychology of Addictive Behaviors, 27(2), 366–379. https://doi.org/10.1037/a0028490

Brewer, J., & Kabat-Zinn, J. (2017). The craving mind: From cigarettes to smartphones to love – why we get hooked and how we can break bad habits. Yale University Press.

Davis, J. M., Goldberg, S. B., Anderson, M. C., Manley, A. R., Smith, S. S., & Baker, T. B. (2014). Randomized Trial on Mindfulness Training for Smokers Targeted to a Disadvantaged Population. Substance Use & Misuse, 49(5), 571–585. https://doi.org/10.3109/10826084.2013.770025

Davis, J. (2021). Quit resources. Retrieved from https://www.quitresources.com/

Garrison, K. A., Zeffiro, T. A., Scheinost, D., Constable, R. T., & Brewer, J. A. (2015). Meditation leads to reduced default mode network activity beyond an active task. Cognitive, Affective, & Behavioral Neuroscience, 15(3), 712–720. https://doi.org/10.3758/s13415-015-0358-3

Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Pierson, H. M., Piasecki, M. P., Antonuccio, D. O., & Palm, K. M. (2011). Does Acceptance and Relationship Focused Behavior Therapy Contribute to Bupropion Outcomes? A Randomized Controlled Trial of Functional Analytic Psychotherapy and Acceptance and Commitment Therapy for Smoking Cessation. Behavior Therapy, 42(4), 700–715. https://doi.org/10.1016/j.beth.2011.03.002

Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., & Simpson, T. L. (2018). Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clinical Psychology Review, 59, 52–60. https://doi.org/10.1016/j.cpr.2017.10.011

Goyal, M., Singh, S., Sibinga, E. M. S., Gould, N. F., Rowland-Seymour, A., Sharma, R., Berger, Z., Sleicher, D., Maron, D. D., Shihab, H. M., Ranasinghe, P. D., Linn, S., Saha, S., Bass, E. B., & Haythornthwaite, J. A. (2014). Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Internal Medicine, 174(3), 357. https://doi.org/10.1001/jamainternmed.2013.13018

Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits. Journal of Psychosomatic Research, 57(1), 35–43. https://doi.org/10.1016/S0022-3999(03)00573-7

Guendelman, S., Medeiros, S., & Rampes, H. (2017). Mindfulness and Emotion Regulation: Insights from Neurobiological, Psychological, and Clinical Studies. Frontiers in Psychology, 8. https://doi.org/10.3389/fpsyg.2017.00220

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Klein E., Brewer J. (2021). Ezra Klein Interviews Judson Brewer [Audio Podcast]. Retrieved from https://www.nytimes.com/2021/04/20/podcasts/ezra-klein-podcast-judson-brewer-transcript.html

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Robinson, M. et al. (2016). Roles of “Wanting” and “Liking” in Motivating Behaviour: Gambling, Food and Drug Addictions. In E.H Simpson & P.D. Balsam (EDS) Behavioural Neuroscience of Motivation (pp. 2015-136), Berlin, Germany: Springer.

Spears, C. A., Abroms, L. C., Glass, C. R., Hedeker, D., Eriksen, M. P., Cottrell-Daniels, C., Tran, B. Q., & Wetter, D. W. (2019). Mindfulness-Based Smoking Cessation Enhanced With Mobile Technology (iQuit Mindfully): Pilot Randomized Controlled Trial. JMIR MHealth and UHealth, 7(6), e13059. https://doi.org/10.2196/13059

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April 21, 2021November 3, 2021

Battling an Epidemic in the Face of a Pandemic:

COVID-19’s Detrimental Effects on the Opioid Epidemic

By: Amy Rzezniczek

The COVID-19 pandemic has impacted the lives of millions of people across the globe. The words “lockdown, quarantine and social distancing” were most likely not a part of your vocabulary in 2019, but now these words seem to appear in every conversation and dictate the ways in which we live our daily lives. While promoting safety amongst communities to prevent transmission of the virus is critical, it appears as though matters regarding mental health and addiction have been placed on the back burner. For example, the opioid epidemic – a crisis that was paid much attention to in previous years – has been seemingly pushed aside in order to have all focus placed on ending the COVID-19 pandemic.

Since the beginning of the pandemic in Canada, there has been a staggering increase in both non-fatal and fatal opioid overdoses. There was a 25% increase in opioid-related fatalities in the early months of 2020, followed by a doubling in drug-related overdoses between June and December of 2020.¹ In the months following initial community mitigation measures, Canada lost 3,351 individuals to opioid-related overdoses, which was a 74% increase from the number of opioid-related deaths six months prior. 96% of these overdoses were deemed accidental.²

Opioids are chemicals that bind to receptors in the brain and are associated with the reward and pain pathways. This class of drugs are typically prescribed by healthcare professionals to relieve pain (oxycodone, buprenorphine, morphine, codeine, methadone and fentanyl) or can be obtained illegally (heroin and fentanyl).³They can provide a sense of pleasure and euphoria, but improper and/or long-term use can lead to Opioid Use Disorder (OUD).³ Further, OUD is characterized by problematic patterns of opioid use which causes severe impairment in various aspects of life and distress.⁴

News reports have falsely attributed the rise of overdoses to the COVID-19 relief fund distributed by the government and allege that the extra money has increased the consumption of alcohol and drugs throughout North America.⁵ In reality, thousands of North Americans continue to struggle with OUD and the pandemic has most definitely had a worsening effect on the condition of the opioid crisis. Research suggests that intersecting risks of both the pandemic and the opioid epidemic heighten the likelihood for individuals with OUD to increase drug use and amplify the risk of overdosing.⁶ This blog post aims to address each of the intersecting factors in order to shed light on the reasoning behind this drastic increase in overdoses over the past 15 months.

Pandemic Social Isolation and Opioid Overdose

A feeling that can be associated with the burden of the pandemic is the sense of loneliness due to social isolation. As part of the attempt to mitigate the spread of COVID-19, Canada has implemented lockdown orders and social distancing measures. These procedures limit the amount of family and friends one can come into physical contact with, and have moved daily tasks such as work and school online. While these measures are incredibly important, they are contributing to the rise in opioid related overdoses in the following ways:

Individuals who have OUDs have extremely high rates of experiencing psychological trauma and other mental health issues.⁷ Lockdowns and social distancing policies may increase the likelihood of death due to overdose as social isolation can negatively impact mental health. Also, when individuals have more than one mental illness, they have a higher risk for opioid overdose.⁸
It is also known that loneliness and social isolation are some of the leading factors that lead to relapse and using drugs can be used as a coping mechanism for individuals who struggle with OUD.⁹ Thus, the consequences of these protective measures (including economic hardship and isolation) paired with the anxiety around contracting the virus can worsen symptoms of OUD.¹⁰
The lack of individuals walking freely around towns and cities due to the “stay-at-home” order can also impact the degree to which individuals experiencing an overdose can receive help. Social distancing prevents bystanders from delivering life-saving naloxone treatment – a medication that can temporarily reverse the effects of an opioid overdose – therefore heightening the risk of overdosing alone.⁸
Due to the fact that individuals are required to stay at home, the risk of overdosing alone increases significantly.⁸

Safety Measures Acting as a Barrier to Accessing Treatment

As a result of the “stay-at-home” orders, access to medications used to treat OUD, opioid overdoses and mental health conditions have been limited as a result of office closures and remote treatment options.⁷ In response to the physical distancing and lockdown restrictions, methadone and buprenorphine treatment (common medication based treatments for OUD) have both been restructured in order to allow for at home administration which are directed by a medical professional over the phone.¹¹ In addition, the rules governing the distribution of these OUD treatment medications have become less rigid to allow for easier access to these medications as well as to make these medications available to be taken outside of a clinic.¹¹ While these modifications seem promising, many individuals with OUD do not have access to cellular phones or computers, which may impact the number of patients able to use these telemedicine services.

Access to residential treatment programs has become more difficult due to the pandemic as well. As a result of government orders, treatment programs in which individuals live for a period of 4-16 weeks are running at limited capacity. These programs have inadequate quantities of personal protective equipment (PPE), limited space for social distancing measures, a limited number of employees to execute the community mitigation methods, and are at high risk of transmission of the virus due to frequent turnover as well as patients sharing a living space.¹²

In a study by Pagano and colleagues (2021), it was shown that there has been an overall threat to program existence due to inadequate resources to apply virus transmission control measures and a decrease in services available. Both of these issues are results of a decline in revenue. Additionally, individuals with OUD have restricted access to receiving residential treatment as these programs now offer shorter stays and fewer services in addition to longer wait lists and delayed treatment initiation. Further, individuals can be faced with difficulties when transitioning out of treatment (i.e lack of or loss of work) as well as inabilities to interact with local recovery communities such as Narcotics Anonymous (NA).¹³

Harm reduction services including safe syringe exchange programs and supervised injection sites have been especially impacted by the COVID-19 pandemic. Harm reduction strategies focus on mitigating the negative effects of drug use as opposed to eradicating drug use completely.¹⁴ In safe syringe programs, individuals can safely dispose of their used syringes and receive new ones in order to reduce the transmission of HIV.¹⁵ Supervised injection sites allow individuals to inject drugs in a safe environment while being supervised by medical professionals in case of the occurrence of an overdose.¹⁶ Due to government orders requiring places to run at limited capacity, as well as social distancing measures and provincial lockdowns, these harm reduction programs have become increasingly difficult to access.

Although many of the treatment options available for OUD such as therapy and telemedicine guidance in drug therapy programs have been able to move online in light of the pandemic, it is impossible for most harm reduction services to be used remotely and many of these programs have been forced to close or limit capacity.¹⁷Harm reduction strategies actively prevent overdoses, transmission of substance-use related illnesses and provide other services such as therapy. The restricted access to these services poses a threat to the lives of individuals struggling with an OUD, increasing the risk of overdoses and overdosing alone.

Subjugated Groups Are Particularly at Risk

Members of minority groups – specifically Black Americans – are experiencing higher rates of overdoses than non-subjugated groups.¹⁸ Preceding the COVID-19 pandemic, Black Americans battled structural obstacles that restricted their access to substance use disorder treatment. These barriers include lack of insurance, access to transportation and healthcare provider prejudice.¹⁹ These obstacles have been furthered by the pandemic and Black Americans face excessive health and financial hardships due to COVID-19 including lack of access to medication to treat OUD.¹⁸ The pandemic has worsened preceding stressors, social isolation, and economic disparity disproportionately for Black individuals, and this has most likely increased substance use among this population.²⁰

In a study by Nguemeni Tiako (2020), it is revealed that the social circumstances that have resulted from the pandemic are contributing to the detrimental impact of the opioid epidemic with a rise in overdose deaths among Black individuals. Prior to the pandemic, Black patients were half as likely to be offered follow-up appointments for OUD care following a non-fatal overdose. In the current climate of the pandemic, it appears as though white individuals are receiving more mental health and substance use disorder treatments via telehealth than Black individuals.¹⁹ Systemic racism, institutional racism and discrimination impact health outcomes through access to healthcare, level of education, income and living conditions. These circumstances affect mental health and are exacerbated by the lack of mental health and substance use disorder treatments available in non-white communities.²¹ Banks et al., (2021) suggests that the pandemic has intensified racial inequities in opioid-related fatal overdoses impacting Black individuals and that funding and policy efforts “should prioritize local strategies that build community trust, such as grassroots organizations engaged in outreach, advocacy, and harm reduction services” (p. 686).

Where Can We Go From Here?

Overall, opioid-related overdose rates have skyrocketed since the pandemic turned our world upside down, and researchers have been working hard to discover the reasoning behind this striking increase as well as how to stop the rates continuing to rise. Thus far, it has been proposed that the following aspects are contributing to the jump in opioid overdoses:

Being stuck in the house during lockdowns and forced to maintain six feet apart from other human beings has increased feelings of loneliness and isolation – factors that worsen mental health and OUD symptoms.
Access to medication-based therapies for OUD have been restructured to be delivered through an online/telephone setting; however, not all individuals may be able to access these services.
Residential treatment centers have been attempting to provide services while abiding by COVID-19 preventative measures, but individuals with OUD are experiencing longer wait times, shorter stays and difficulties transitioning back into society after treatment due to the uncertainties resulting from the pandemic.
Black individuals with opioid-use disorder are overdosing more frequently than non-minority groups due to lack of access to services and mental health issues as well as discrimination exacerbated by the pandemic.

It is imperative for the government to work with Drug Advisory Commissions in determining ways in which treatment and harm reduction services can be delivered in such a way that aligns with community mitigation measures. Similar to the ways in which the government is rolling out vaccines through opening more pop-up clinics, perhaps additional safe injection sites and syringe exchange programs can be temporarily opened up to lessen the risk of overdosing alone. Another possible solution is to open public spaces and provide free computer use for individuals to attend Narcotics Anonymous meetings while maintaining social distancing. Lastly, the government can provide funding to residential treatment programs to prevent these important institutions from permanently shutting down.

COVID-19 precautions remain important as we continue our battle against this virus, but the opioid crisis continues to pose an unrelenting public health threat that will only worsen if it continues to be left on the back burner.

References

¹Blancher, P. (2021, Feb 10). Opioid overdose numbers rise during pandemic. The Canadian Press. http://ezproxy.lib.ryerson.ca/login?url=https://www-proquest-com.ezproxy.lib.ryerson.ca/wire-feeds/opioid-overdose-numbers-rise-during-pandemic/docview/2488773297/se-2?accountid=13631

²Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioids and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada; March 2021. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants

³CAMH. (n.d). Opioid Addiction. CAMH. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/opioid-addiction

⁴Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

⁵Tasker, J.P. (2020, Oct 28). Opioid deaths skyrocket, mental health suffers due to pandemic restrictions, new federal report says. CBC. https://www.cbc.ca/news/public health-annual report-opioid-deaths-skyrocket-1.5780129

⁶Becker, S. J., Garner, B. R., & Hartzler, B. J. (2021). Is necessity also the mother of implementation? COVID-19 and the implementation of evidence-based treatments for opioid use disorders. Journal of Substance Abuse Treatment, 122. https://doi.org/10.1016/j.jsat.2020.108210

⁷Henry, B. F., Mandavia, A. D., Paschen-Wolff, M., Hunt, T., Humensky, J. L., Wu, E., Pincus, H. A., Nunes, E. V., Levin, F. R., & El-Bassel, N. (2020). COVID-19, mental health, and opioid use disorder: Old and new public health crises intertwine. Psychological Trauma: Theory, Research, Practice, and Policy, 12, S111-S112.

⁸Walker, D. D., Jaffe, A. E., Pierce, A. R., Walton, T. O., & Kaysen, D. L. (2020). Discussing substance use with clients during the COVID-19 pandemic: A motivational interviewing approach. Psychological Trauma: Theory, Research, Practice, and Policy, 12, S115-S117. http://dx.doi.org.ezproxy.lib.ryerson.ca/10.1037/tra0000764

⁹Myers, J., & Compton, P. (2018). Addressing the potential for perioperative relapse in those recovering from opioid use disorder. Pain Medicine, 19(10), 1908-1915. http://dx.doi.org.ezproxy.lib.ryerson.ca/10.1093/pm/pnx277

¹⁰Jones, C. M., Guy, G. P., & Board, A. (2021). Comparing actual and forecasted numbers of unique patients dispensed select medications for opioid use disorder, opioid overdose reversal, and mental health, during the COVID-19 pandemic, United States, January 2019 to May 2020. Drug and Alcohol Dependence, 219. https://doi.org/10.1016/j.drugalcdep.2020.108486

¹¹Nunes, E. V., Levin, F, R., Reilly, M. P., & El-Bassel, N. (2021). Medication treatment for opioid use disorder in the age of COVID-19: Can new regulations modify the opioid cascade? Journal of Substance Abuse Treatment, 122,108196-108196

¹²Pagano, A., Hosakote, S., Kapiteni, K., Straus, E. R., Wong, J., & Guydish, J. R. (2021). Impacts of COVID-19 on residential treatment programs for substance use disorder. Journal of Substance Abuse Treatment, 123, 108255-108255. https://doi.org/10.1016/j.jsat.2020.108255

¹³Herrera, A. (2021). A delicate compromise: Striking a balance between public safety measures and the psychosocial needs of staff and clients in residential substance use disorder treatment amid COVID-19. Journal of Substance Abuse Treatment, 122, 108208-108208. https://doi.org/10.1016/j.jsat.2020.108208

¹⁴Schlosser, A., & Harris, S. (2020). Care during COVID-19: Drug use, harm reduction, and intimacy during a global pandemic. The International Journal of Drug Policy, 83, 102896-102896. https://doi.org/10.1016/j.drugpo.2020.102896

¹⁵Centers of Disease Control and Prevention. (n.d). Syringe Services Programs. CDC.gov. https://www.cdc.gov/ssp/index.html

¹⁶City of Toronto. (2019). Supervised Consumption Sites. City of Toronto. https://www.toronto.ca/community-people/health-wellness-care/health-programs-advice/supervised-injection-services/

¹⁷Roxburgh, A., Jauncey, M., Day, C., Bartlett, M., Cogger, S., Dietze, P., Nielsen, S., Latimer, J., & Clark, N. (2021). Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia. Harm Reduction Journal, 18. https://doi.org/10.1186/s12954-021-00471-x

¹⁸Banks, D. E., Carpenter, R. W., Wood, C. A., & Winograd, R. P. (2021) Commentary on Furr‐Holden et al.: As opioid overdose deaths accelerate among Black Americans, COVID‐19 widens inequities—a critical need to invest in community‐based approaches. Addiction, 116, 686– 687. https://doi-org.ezproxy.lib.ryerson.ca/10.1111/add.15362.

¹⁹Nguemeni Tiako, M. J. (2021). Addressing racial & socioeconomic disparities in access to medications for opioid use disorder amid COVID-19. Journal of Substance Abuse Treatment, 122. https://doi.org/10.1016/j.jsat.2020.108214

²⁰Khatri, U. G., Pizzicato, L. N. Viner, K., Bobyock, E., Sun, M., Meisel, Z. F., & South, E. C. (2021). Racial/Ethnic Disparities in unintentional fatal and nonfatal emergency medical services–attended opioid overdoses during the COVID-19 pandemic in Philadelphia. JAMA Network Open, 4(1), e2034878. https://doi.org/10.1001/jamanetworkopen.2020.34878.

²¹Czeisler, M. É., Howard, M. E., & Rajaratnam, S. M. W. (2021). Mental Health During the COVID-19 Pandemic: Challenges, Populations at Risk, Implications, and Opportunities. American Journal of Health Promotion, 35(2), 301–311. https://doi.org/10.1177/0890117120983982b

Photograph References

Immigration Canada. (2020). COVID-19 Isolation [photograph]. Immigration.ca. https://www.immigration.ca/covid-19-anyone-entering-canada-must-have-plan-for-14-day-isolation

Psychiatry Advisor. (2021). Expert Perspective: The Opioid Crisis and COVID-19 [photograph]. Psychiatry Advisor.https://www.psychiatryadvisor.com/home/topics/addiction/opioid-related-disorder/expert-perspective-the-opioid-crisis-and-covid-19/

The Wall Street Journal. (2020). Individual receiving opioid-use disorder medication treatment [photograph]. The Wall Street Journal. https://www.wsj.com/articles/coronaviruspandemic-complicates-opioidtreatment-11586262903

April 20, 2021November 3, 2021

MDMA and the Brain: Is Ecstasy Neurotoxic?

by Ruthie Poizner

MDMA, ecstasy, molly, E (Sharifimonfared & Hammersley, 2020) – no matter what it’s called, this popular club drug has found its way into our collective vocabulary. Ecstasy, which has been a mainstay on the party scene since the early 1990s, is now one of the most commonly used illegal drugs. In fact, over 18 million Americans have reported using MDMA at least once in their lifetime (SAMHSA, 2017). Since this drug has become so widespread, it is important from an individual and public health standpoint to understand both the short- and long-term effects of its use. This article will explore these issues, as well as providing resources for safer ecstasy consumption.

How Does MDMA Affect the Brain and Body?

People mostly use ecstasy because it can produce enjoyable short-term effects. MDMA stimulates the release of neurotransmitters like dopamine and serotonin, which can produce euphoric feelings such as heightening of the five senses and increased empathy (Mustafa et al., 2018). On the flip side, however, it can also cause insomnia, appetite loss, restlessness, jaw clenching, and in rare cases, overdose and death (Curran, 2000).

Ecstasy is generally not considered physically addictive, meaning that although people may crave the high, their bodies will not become dependent on the substance and experience painful withdrawals when they stop using it. For this reason, people rarely require psychological treatment for their use (Sharifimonfared & Hammersley, 2020). But does this mean we don’t have to worry about its long-term effects?

Although researchers have been studying ecstasy toxicity for years, some of the evidence is mixed (Mustafa et al., 2018). This issue is a bit confusing, but it may be more relevant now than ever: not only is MDMA a drug of choice for millions, it is also a potential medicine of the future. While notorious for its recreational use, MDMA was actually first studied as a treatment for psychological disorders (Müller et al., 2019). In recent years, researchers have been taking a second look at this possibility, and are specifically interested in whether it could be an effective treatment for post traumatic stress disorder (PTSD) (Mustafa et al., 2018). This makes it even more important to understand how this drug affects the brain and body. Though MDMA neurotoxicity studies aren’t perfect, they can still provide valuable insight into the possible risks of this drug and how they can be reduced. With that in mind, let’s take a look at what the research says and why these findings are so important.

What is Neurotoxicity?

Neurotoxicity describes a given substance’s harmful effects on the brain and the rest of the nervous system. This can include damage to nerves and neurons, which are responsible for communicating signals (messages) in the brain. Neurotoxins can be found in a variety of substances such as heavy metals, pesticides, and drugs. The severity of neurotoxicity depends on the substance and how it is consumed. There is a significant range in how these neurotoxins affect us, and how much they harm our bodies and functioning (Robertson, 2019).

Is MDMA Neurotoxic?

The short answer is yes, most research suggests that this drug is neurotoxic. MDMA is thought to cause damage to brain cells by disrupting the flow of neurotransmitters, the messengers that allow cells to communicate with one another. It also causes an overflow of free radicals: molecules with an unstable structure that eat away at cells. These molecules can kill brain cells by limiting the cell’s ability to produce energy. Although our bodies are built to flush out free radicals, ecstasy can overload the detoxification process, which puts a strain on the system (Mustafa et al., 2018). Free radicals are possibly linked to the development and/or worsening of a variety of diseases, such as cancer and Alzheimer’s (Halliwell, 2001).

Examining the Evidence

Most of the evidence on MDMA neurotoxicity comes from either animal studies or correlational research, which looks at whether there is an association between two variables. In animal studies, MDMA has consistently shown to be toxic to serotonin structures. This has been observed in every animal tested, and while some animals recover normal serotonin function over time, many suffer lasting effects (Curran, 2000). Additionally, correlational research has found associations between MDMA use and neurotoxicity in humans. This means that MDMA use can predict changes to the brain.

In most correlational studies, researchers use something called SERT (serotonin transporter) density to measure MDMA neurotoxicity. Serotonin is a neurotransmitter that plays a key role in mood regulation, and is often described as producing feelings of wellness and happiness. Studies have shown that ecstasy use can reduce SERT in many parts of the brain, such as the hippocampus and temporal lobe (both of which are associated with memory function) (Müller et al, 2019). There is also evidence that MDMA users have less 5-HT, a receptor that is responsible for binding to serotonin and receiving its signals. This decrease seems to be linked with the amount of MDMA use: in other words, the more MDMA a person has done, the fewer 5-HT receptors they seem to have (Curran, 2000).

What Does this Mean?

If MDMA is technically neurotoxic, does this mean it affects people’s thoughts, behaviour, and daily life? Some research, as described by Mustafa and colleagues (2018), suggests that people who have used ecstasy over long periods of time perform worse on memory tasks (Wunderli et al., 2017). It is also believed that ecstasy can negatively affect the working memory, the system that allows us to pay attention to and manipulate information before we commit it to our long-term memories. In a 2013 study, Potter, Downey, & Stough found that MDMA users performed significantly worse than non-drug users on spatial working memory tasks, which required them to remember visual information. The MDMA group averaged a score of 0.85, while the non-drug group averaged a score of 0.96. The MDMA group also had longer reaction times across tasks, averaging 302.47 milliseconds compared to 286.00 milliseconds in the non-drug group.

Psychological Impact

It is possible that these changes to the brain also have psychological consequences. Even though relatively few people require psychological treatment for their MDMA use, this does not necessarily represent a lack of impact on mental health. In a turn-of-the-millennium study on ecstasy users in the UK, researchers found that 83% reported midweek “low mood”, and 80% reported concentration or memory problems. which are often related to low mood (Curran, 2000). These changes in mood and functioning could be linked to serotonin toxicity, as well as damage to brain regions involved in key tasks such as learning and memory. Interestingly, Potter and colleagues found that the average depression level (as measured by the Beck Depression Inventory) was 13.35 in people who used MDMA, 7 points higher than that of non-drug users (2013). Although this difference was not large enough to be significant, it is still important to note since MDMA users commonly report low mood.

Is the Damage Permanent?

The good news is that the effects of MDMA neurotoxicity might be reversible over time. Researchers have found a link between SERT density and the length of abstinence, a period where the drug is not being used. This means that, without MDMA, serotonin and 5-HT levels may be restored in the brain (Müller et al., 2019), which in turn could possibly lead to improved mood and memory.

What Else Should We Know?

Although these studies share important findings about how MDMA interacts with the brain, there are limits to their design and how well their results can be applied to real life. Let’s explore some of these limitations:

Most researchers study heavy or long-term ecstasy use, but are unable to describe the long-term effects of the drug on people who use it occasionally and moderately. It’s currently believed that the more severe neurotoxic effects are linked to binges, which requires taking lots of ecstasy at once (Müller et al., 2019)
It’s extremely difficult to determine a cause-and-effect relationship between MDMA and neurotoxicity in the human brain, because there could be a variety of other factors that cause these changes. Human participants have unique and complicated lifestyle factors that can be difficult to control for in experiments. For example, many people who use ecstasy also use other recreational drugs that could be responsible for cell damage
The findings from animal studies do not necessarily apply directly to humans, since each animal’s brain functions differently
It is impossible to compare dosage between participants, since it’s unlikely they know the exact amount of ecstasy they have taken in their lifetime (Curran, 2000)
The drugs used in labs are very different from street drugs. Street ecstasy has developed a reputation for its impurity, since it is often cut with drugs like methamphetamine, cocaine, and bath salts (Curran, 2000). Sometimes it doesn’t contain any MDMA at all! This makes it even harder for people using the drug to get a sense of what they’re taking and how it might affect them in the short- and long-term

What Can I Do with This Information?

Like any recreational drug, there are significant risks to using MDMA. Neurotoxicity studies can help us understand how common and severe these risks are in the long run. Since MDMA may soon become legal as a treatment for PTSD, it is also helpful to learn more about how different types of use have different effects. Therapeutic MDMA would be used differently than recreational ecstasy (for example, doses would be small and given by a psychiatrist or doctor), so it is very unlikely that it would have concerning neurotoxic consequences (Müller et al., 2019).

If you do decide to use ecstasy, researchers Sharifimonfared and Hammersley (2020) have outlined some helpful harm reduction tips:

Stay informed about this drug and its effects- it is important that you are making an informed decision, and that you can create harm reduction strategies that best suit you. This can also help you prepare for unwanted side effects
Test your drugs- since ecstasy is often mixed with other substances, it’s important to ensure that you know what you’re putting into your body to prevent a bad trip or accidental overdose
Drink a healthy amount of water while using ecstasy- sweating will cause you to lose fluid, so it’s important to stay hydrated- but make sure not to overcompensate by drinking too much, as this is also dangerous
Don’t mix ecstasy with other drugs- this could increase the risk of a negative outcome
Don’t use too much at once, and don’t use the drug too often

In addition, websites such as www.rollsafe.org provide nonjudgmental advice that helps ecstasy users stay updated and educated. If you are struggling with ecstasy use, strategies such as tapering off the drug, making positive lifestyle changes, or seeking professional help may be useful. Helplines such as ConnexOntario (1-866-531-2600) and therapy providers such as the Centre for Addiction and Mental Health (https://www.camh.ca/) are valuable resources for individuals struggling with their own or a loved one’s drug use.

References

Business Tech. (2015). Ecstasy [Stock image]. Businesstech. https://businesstech.co.za/news/lifestyle/96707/96707/

Camh. https://www.camh.ca/

Canadian Centre on Substance Use and Addiction. https://ccsa.ca/addictions-treatment-helplines-canada

Center for Behavioral Health Statistics and Quality (2017). 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration. 1-2889.

Curran, H. V. (2000). Is MDMA (‘ecstasy’) neurotoxic in humans? An overview of evidence and of methodological problems in research. Neuropsychobiology, 42(1), 34-41. 10.1159/000026668

Halliwell, B. (2001). Role of free radicals in the neurodegenerative diseases: therapeutic implications for antioxidant treatment. Drugs & Aging, 18(9), 685-716. 10.2165/00002512-200118090-00004

Müller, F., Brändle, R., Liechti, M. E., Borgwardt, S. (2019). Neuroimaging of chronic MDMA (“ecstasy”) effects: A meta-analysis. Neuroscience and Biobehavioral Reviews, 96, 10-20. https://doi.org/10.1016.j.neubiorev.2018.11.004

Mustafa, N. S., Bakar, N. H. A., Mohamad, N., Adnan, L. H. M., Fauzi, N. F. A., Thoarlim, A., Omar, S. H. S., Hamzah, M. S., Yusoff, Z., Jufir, M., Ahmad, R. (2020). MDMA and the brain: A short review of the role of neurotransmitters in neurotoxicity. Basic and Clinical Neuroscience, 11(4), 381-388. http://dx.doi.org/10.32598/bcn.9.10.485

Potter, A., Downey, L., Stough, C. (2013). Cognitive function in ecstasy naïve abstinent drug dependants and MDMA users. Current Drug Abuse Reviews, 6(1), 71-76. 10.2174/1874473711306010008

Robertson, S. (2019, September 16). What is neurotoxicity? News-Medical Life Sciences. https://www.news-medical.net/health/What-is-Neurotoxicity.aspx

Rollsafe.org. https://rollsafe.org/

Sharifimonfared, G., Hammersley, R. (2020). Harm reduction and quitting techniques used by heavy MDMA (ecstasy) users. Addiction Research & Theory, 28(3), 222-230. https://doi.org/10.1080/16066359.2019.1622684

Vectormine. (2018). Serotonin vector illustration [Stock image]. iStock. https://www.istockphoto.com/vector/serototin-vector-illustration-labeled-diagram-with-gut-brain-axis-and-cns-gm1053647528-281517929

April 20, 2021October 29, 2021

Childhood Trauma and Personality: How Our Complex Lives Influence the Development of Eating Disorders and Alcohol Abuse

by Jasmine Atwal

Trigger Warning: Mentions of Suicide and Childhood Trauma/Abuse

Demi Lovato wearing a blue shirt: Demi Lovato.

_{^{Singer and Actress, Demi Lovato at Award Function, Gazette, 2020. Retrieved from Justin Bieber and Jennifer Lopez among E! People’s Choice Awards winners | Basingstoke Gazette}}

“I’m tired of running myself into the ground with workouts and extreme dieting. I thought the past few years was recovery from an eating disorder when it actually was just completely falling into it,” -Demi Lovato

Demi Lovato. Russel Brand. Elton John. Amanda Bynes.

Aside from being talented artists, these individuals share one more common link- they have all experienced eating disorders and substance abuse.

In 2018, Lovato was hospitalized due to an overdose and has since shared her heart-wrenching experience with alcohol abuse and eating disorders in the 2021 docuseries, Demi Lovato: Dancing with the Devil.In 2018, after mixing multiple substances, Lovato experienced multiple strokes, a heart attack, brain damage, and legal blindness. Regarding her previous experience with eating disorders, Lovato recounted:

“I was compulsively overeating when I was 8 years old.”
“For the past 10 years I’ve had a really unhealthy relationship with food.”
“I was performing concerts on an empty stomach.”

Lovato’s story is one among many that highlights the life-threatening impact that eating disorders and alcohol abuse can have on an individual.

Eating disorders refer to illnesses in which individuals experience significant disturbances to their eating behaviours and accompanying emotions and thoughts. Often, these individuals are preoccupied with thoughts about food and body weight. There are many types of eating disorders including:

Anorexia nervosa– The individual may have an unusually low body weight and a fear of gaining weight. These individuals will try to control their weight by limiting calories, exercising excessively, or using laxatives.
Bulimia nervosa– These individuals will eat a lot of food and then try to get rid of the calories through unhealthy ways such as vomiting, using laxatives, or exercising too much.
Binge eating– These individuals will likely eat too much and feel that they cannot control their eating. They will continue to eat even if they are full and often feel guilty afterwards.

See the source image

^{The Signs of an Eating Disorder, Rehab Medical, 2020. Retrieved from Eating Disorders: Symptoms, Signs, Types and Causes- Rehab Medical (rehab-medical.com)}

In Canada, eating disorders impact approximately 1 million individuals and these behaviours are often accompanied by other harmful behaviours, such as abusing alcohol. Abusing a substance refers to using too much, too often, or being unable to control use even though it might be harming other parts of your life. Approximately, 50% of individuals with an eating disorder also abuse alcohol.

Clearly, there is a large percentage of people who are experiencing symptoms related to two separate illnesses at the same time. Thus, these individuals require treatments that are able to target both mental illnesses. Treatments are only effective if the roots of the illness are identified and targeted, thus, it becomes extremely important to understand the specific risk factors (i.e., things that increase the likelihood of engaging in a behaviour) that contribute to the development of both disorders. It must be emphasised that the presence of these factors does not necessarily mean that you will definitely develop both/either disorder, it simply means that there may be an increased risk. Also, the factors that will be discussed can also lead to the development of other illnesses, but due to a limited number of studies that focus only on eating disorders and alcohol abuse, it is difficult to determine risk factors that are only related to these two disorders.

Also, alcohol abuse and eating disorders can be risk factors for the development of each other. For example, some individuals with anorexia may use alcohol to suppress their appetite- they drink to avoid eating. Some individuals may use alcohol to relieve themselves of feelings of guilt and shame when they do not eat or eat too much. Thus, while we will discuss what factors contribute to the development of both disorders, each one can contribute to the other as well.

Childhood Trauma

It has been well-established that our childhood influences our adult lives by shaping our personalities, opinions, and memories. Childhood trauma refers to an emotionally painful, scary, violent, or threatening experience that occurs in one’s childhood and has a lasting impact on their mental or physical health. This can include neglect, sexual and physical abuse.

Childhood trauma has been found to be a risk factor for eating disorders and alcohol abuse. For example, a study by Corstorphone et al. (2007) found that individuals who had experienced any form of abuse in their childhood were more likely to develop any type of eating disorder in their adult lives. Further, childhood sexual abuse was the most significantly linked to the development of bulimia and binge-eating, alcohol abuse, and self-harming behaviours. Similarly, a study by Guillaume et al. (2016) found that any form of mistreatment in one’s childhood could predict future development of an eating disorder and accompanying alcohol abuse.

In fact, childhood trauma is fairly common in individuals who are experiencing eating disorders and alcohol abuse. Multiple studies have found that 37% to 100% of individuals with eating disorders have experienced some form of abuse or neglect within their childhoods. While the reasons are likely complex, it is suggested that individuals with traumatic experiences in their childhood may lack proper coping skills and resort to harmful behaviours (such as eating and drinking a lot) as a way to deal with their trauma and emotions. Alongside childhood trauma, one’s personality also influences the development of these illnesses.

See the source image

^{Childhood Trauma and Development of Eating Disorder, ESI, 2019. Retrieved from Childhood Feeding Neglect and Trauma in Developing Eating Disorders}

Personality

Our personality influences many aspects of our lives. Impulsivity (i.e., acting quickly without thinking), how we respond to our emotions, among other factors can increase or decrease the likelihood of committing certain behaviours and in turn what disorders are developed.

A study by Lozano-Madrid et al. (2020) focused on personality traits in female participants with diagnosed eating disorders who displayed symptoms of alcohol or drug abuse. The researchers found that impulsive individuals with executive control problems and emotional dysregulation were at a higher risk of abusing alcohol. Executive control problems refer to one’s ability to make decisions and create/work through goals while emotional dysregulation is one’s inability to control their emotional responses. Essentially, the study found that the symptoms of alcohol abuse in individuals with eating disorders were more likely to transform into a disorder in the presence of the previously mentioned risk factors.

Similarly, a study conducted by Micheeva and Tragesser (2016) focused on multiple personality factors including negative urgency and emotionality. Negative urgency refers to a type of impulsivity in which one reacts rashly when they are in distress, such as using alcohol to cope with a problem in their lives. The researchers found that negative urgency heavily contributed to the development of eating disorders and alcohol abuse. These individuals may turn to food or alcohol as a means to cope with the problems they are currently or have in the past,- experienced and, overtime, these behaviours increase in riskiness and translate to disorders.

Concluding Remarks

While the studies mentioned above provide important information, there are some things that we must remember. Firstly, the above list is not exhaustive as there were many factors that were not discussed in this post including genetics. Also, we must remember that the simple presence of these factors in your life do not automatically guarantee the development of eating disorders and alcohol abuse- it simply increases the risk.

Fortunately, there are many treatments that are available for individuals with eating disorders and alcohol abuse, that target specific risk factors (such as those mentioned above). For example, cognitive-behaviour therapy (CBT) targets negative thoughts and behaviours and has been found to be effective in reducing anorexia and binge-eating. Interpersonal psychotherapy which targets interpersonal problems (i.e., family or relationship issues) in the individual’s life that may be contributing to their poor eating/drinking habits. These treatments may seem vague, but each one can be specialized to target the factors that are causing the individual’s problems. In Canada, organizations such as National Eating Disorder Information Centre (NEDIC) and Ontario Community Outreach Program for Eating Disorders can help you gain access to such treatments.

If you or a loved one require support, please refer to the following website which provides information about Canadian organizations that provide resources and support to individuals with eating disorders and other accompanying problems. https://www.eatingdisorderhope.com/treatment-for-eating-disorders/international/canada/canadas-eating-disorder-organizations-charities

References

Cookson, P. (2020, October 5). 23 Celebrities with Eating Disorders: The Recovery Village. The Recovery Village Drug and Alcohol Rehab. https://www.therecoveryvillage.com/mental-health/news/celebrities-with-eating-disorders/.

Corstorphine, E., Waller, G., Lawson, R., & Ganis, C. (2007). Trauma and multi-impulsivity in the eating disorders. Eating Behaviors: An International Journal, 8(1), 23-30. https://doi.org/10.1016/j.eatbeh.2004.08.009

Guillaume, S., Jaussent, I., Maimoun, L., Ryst, A., Seneque, M., Villain, L., Hamroun, D., Lefebvre, P., Renard, E., & Courtet, P. (2016). Associations between adverse childhood experiences and clinical characteristics of eating disorders. Scientific Reports, 6(1), 35761-35761. https://doi.org/10.1038/srep35761

Hibberd, J. (2021, April 14). Demi Lovato’s Eating Disorder Comedy Pilot Gets NBC Order. Billboard. https://www.msn.com/en-us/tv/news/demi-lovato-s-eating-disorder-comedy-pilot-gets-nbc-order/ar-BB1fCPTX?ocid=uxbndlbing.

Hilliard, J. (2021, April 2). Alcohol and Eating Disorders. Alcohol Rehab Guide. https://www.alcoholrehabguide.org/resources/dual-diagnosis/alcohol-eating-disorders/.

Kass, A., Kolkata, R., Wilfley, D. (2014). Psychological Treatments for Eating Disorders. Curr Opin Psychiatry, 26(6), 549–555. https://doi.org/https://dx.doi.org/10.1097%2FYCO.0b013e328365a30e

Lewaniak, L. (2016, April 1). The Link Between Eating Disorders and Alcohol Abuse. Eating Recovery Center. https://www.eatingrecoverycenter.com/blog/signs-symptoms/The-Link-Between-Eating-Disorders-Alcohol-Abuse.

Lozano-Madrid, M., Clark Bryan, D., Granero, R., Sánchez, I., Riesco, N., Mallorquí-Bagué, N., Jiménez-Murcia, S., Treasure, J., & Fernández-Aranda, F. (2020). Impulsivity, emotional dysregulation, and executive function deficits could be associated with alcohol and drug abuse in eating disorders. Journal of Clinical Medicine, 9(6), 1936. https://doi.org/10.3390/jcm9061936

Malone More Articles April 6, C. (2021, April 6). ‘Dancing With the Devil’: Demi Lovato Was 5 Minutes From Death After Her 2018 Overdose. Showbiz Cheat Sheet. https://www.cheatsheet.com/entertainment/dancing-devil-demi-lovato-overdose.html/.

Mayo Foundation for Medical Education and Research. (2018, February 20). Anorexia nervosa. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591.

Mayo Foundation for Medical Education and Research. (2018, May 10). Bulimia nervosa. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/bulimia/symptoms-causes/syc-20353615.

Mayo Foundation for Medical Education and Research. (2018, May 5). Binge-eating disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/binge-eating-disorder/symptoms-causes/syc-20353627.

Mikheeva, O. V., & Tragesser, S. L. (2016). Personality features, disordered eating, and alcohol use among college students: A latent profile analysis. Personality and Individual Differences, 94, 360–365. https://doi.org/10.1016/j.paid.2016.02.004

National Initiative for Eating Disorders. (2020, November 24). Eating Disorders in Canada. NIED. https://nied.ca/about-eating-disorders-in-canada/.

National Institute of Mental Health . (n.d.). Eating Disorders. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml?ftag=YHF4eb9d17.

Tagay, S., Schlottbohm, E., Reyes-Rodriguez, M. L., Repic, N., & Senf, W. (2013). Eating disorders, Trauma, PTSD, and Psychosocial Resources. Eating Disorders, 22(1), 33–49. https://doi.org/10.1080/10640266.2014.857517

Tavolacci, M. P., Ladner, J., Grigioni, S., Richard, L., Villet, H., & Dechelotte, P. (2013). Prevalence and association of perceived stress, substance use and behavioral addictions: a cross-sectional study among university students in France, 2009–2011. BMC Public Health, 13(1). https://doi.org/10.1186/1471-2458-13-724

U.S. Department of Health and Human Services. (n.d.). Helping Children and Adolescents Cope with Disasters and Other Traumatic Events: What Parents, Rescue Workers, and the Community Can Do. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/helping-children-and-adolescents-cope-with-disasters-and-other-traumatic-events/index.shtml.

April 19, 2021October 29, 2021

Addressing Bisexual Substance Use: A Conversation Long Overdue

By: Karla Kovacek

Bisexuality is a common sexuality, where over half of LGB individuals identify as bisexual¹. In its simplest form, bisexuality is the romantic and/or sexual attraction to more than one sex or gender. This typically includes one’s own gender, and one or more other genders.

While bisexuality has been acknowledged increasingly over the past decade, and more people have started openly identifying as bisexual, bisexual-specific issues are still underdiscussed¹. In extension, the issues have not been appropriately addressed.

Particularly, bisexual individuals tend to commonly present with various substance use issues². For instance, it is estimated that 55% of bisexual individuals are likely to report binge drinking in the past year. Additionally, it is estimated that 46% of them are likely to report non-medical cannabis use, and roughly 14% to report the use of illicit drugs all within the past year. Even more, it is estimated that 31% of bisexual individuals report these uses of substances as a coping response to abuse and violence². It is deeply troubling that these startling numbers are not more commonly discussed. More particularly, the root causes of this problem must be acknowledged.

Are bisexual individuals at a higher risk when it comes to substance use?

In comparison to straight individuals, those who identify as bisexual appear to have much higher rates of substance use and related problems. A study using the U.S National Survey on Drug Use and Health, surveying nearly 150,000 adults, found that compared to straight individuals, bisexual identity was related to significantly higher use of substances such as alcohol, cigarettes, cigars, cannabis, illicit drugs and opioids³. Bisexual individuals were also more likely to be presented with a clinical substance related problem, such as alcohol use disorder, nicotine dependence, and substance use disorder. However, the findings suggest some gender differences in bisexual men and bisexual women’s substance use patterns in comparison to straight men and straight women:

Compared to straight women, bisexual women have higher rates of alcohol use, cannabis use, and illicit drug use (including misuse of opioids).
Compared to straight women, bisexual women are more likely to have a substance use diagnosis, and a nicotine dependence.
Compared to straight men, bisexual men have higher rates of cannabis and illicit drug use.

Interestingly, this pattern is found within the LGBTQ+ community as well. The same study suggests that those who identify as bisexual appear to have increased substance use and substance related problems in comparison to those who identify as gay or lesbian³. Gender differences between bisexual men and women regarding substance use and related problems are suggested:

Compared to lesbian women, bisexual women have higher rates of binge drinking, cannabis use, illicit drug use (including misuse of opioids).
Compared to lesbian women, bisexual women were more likely to be diagnosed with alcohol use disorder.
Compared to gay men, bisexual men have higher rates of cigar use.

A study using the U.S National Epidemiological Survey on Alcohol and Related Conditions, consisting of roughly 36,000 participants, particularly focused on cannabis use differences between gay/lesbian, straight, and bisexual individuals⁴. The results suggest that those who identify as bisexual are more likely to report severe cannabis use disorder compared to straight individuals. Meanwhile, gay and lesbian individuals were only more likely to report mild cannabis use disorder. While both groups display more disordered cannabis use compared to straight individuals, the severity is increased for bisexual individuals.

However, explicit identification with bisexual sexuality may not be necessary for increased substance use problems. In another study, using the same U.S national data, the researchers found that those who engaged in both same sex and opposite sex romantic/sexual behaviour in the past year had higher chances of reporting severe alcohol use disorder and tobacco use disorder in that same year, compared to individuals engaging only in same sex romantic/sexual behaviour. Additionally, in comparison to straight individuals, those who are not sure of their sexual identity label had higher chances of reporting severe alcohol use disorder, tobacco use disorder and drug use disorder⁵.

It is important to note that there are limitations to these findings, as individuals who are “not sure” of their sexuality are often left out of research. This is a limitation because bisexuality is frequently invalidated as a real sexual identity. As such, bisexual individuals report difficulty with accepting their sexuality, and are told by straight and gay/lesbian individuals that there is no such thing as bisexuality – they must be gay/lesbian in denial, or straight, but curious⁵. As a result, this may force bisexual individuals into the “not sure” category more frequently.

This “not sure” label has been found to increase one’s risk of developing not only alcohol and tobacco use disorders, but also drug use disorder⁶. However, this is understudied, as not many studies on sexual minorities and substance use consider individuals who are unsure of their sexuality, although this factor may be directly related to increased substance use as a coping strategy⁶. These limitations also may lead us to underestimate substance use in the bisexual community – meaning that their substance use may be even greater than anticipated.

Why are bisexual individuals at such a heightened risk?

There are several explanations for why bisexual individuals report higher substance use and development of substance use disorders compared to straight and gay/lesbian individuals.

Bi-negativity

Bisexual individuals are faced with a unique set of prejudicial attitudes and discriminatory actions, specifically targeting the aspect of their sexuality that is attracted to more than one gender/sex. Broadly, bi-negativity (also referred to as biphobia) refers to attitudes that are commonly underpinned by beliefs that bisexuality is not real, that bisexual individuals are promiscuous, and that they cannot be trustworthy partners⁶.

For gay and lesbian individuals, LGBTQ+ community spaces are a safety resource that protects them from stigma and harmful stereotyping that occurs in the general population. However, for bisexual individuals, the stigma does not stop, even within the LGBTQ+ community. The notions that bisexual individuals are less gay, straight passing, or at risk of leaving their same sex partner for somebody of opposite sex are widely held in the LGBTQ+ community, which can isolate bisexual individuals from what was intended to be their safe space³.

However, there are suggested differences in bi-negativity across genders. In a study of 253 straight men and women, researchers administered a Gender-Specific Binegativity Scale, and two open ended questions regarding bisexuality in men and women⁷. The results suggest that straight women are equally accepting of bisexual women and men. Meanwhile, straight men are less accepting of bisexual men compared to bisexual women.

The study also suggests notable differences in beliefs about bisexuality based on the gender of the bisexual individual. That is, bisexual men are perceived extremely negatively, and are perceived as gender non-conforming and “actually gay.” Higher acceptance rates of bisexual women, however, may be related to oversexualization of bisexual women by straight men. This is evident in straight male participants describing bisexuality as “sexy” in women. To directly assess the relationship between bi-negativity and substance use in bisexual women, 224 women identifying as bisexual completed a survey to report on their experiences with bi-negativity, substance use, and motivations to use alcohol as a coping strategy. The results suggest that increased bi-negativity experiences are related to more frequent alcohol use as a coping strategy, which in turn generally increased alcohol use in bisexual women⁸. Considering this link between bi-negativity and alcohol use, it is particularly concerning that bisexual individuals cannot escape stigma and discrimination, not even within the LGBTQ+ community spaces.

Sexual violence and oversexualization

Compared to straight and lesbian women, bisexual women are at an increased risk of sexual violence¹. These findings may be applicable to bisexual men, but sexual violence towards bisexual women oftentimes stems from oversexualization of bisexuality in women by straight men. As previously mentioned, straight men report holding beliefs that bisexual women are “sexy”. Consequently, bisexual women are targets of sexual violence.

In a study examining perceived attitudes towards bisexuality by bisexual individuals, both bisexual men and women commonly reported being sexually objectified, sexually harassed, sexually assaulted, and raped. They reported believing that they were specifically targeted because of their bisexuality⁶.

Furthermore, bisexual teenage girls report sexual dating violence and forced sexual intercourse at a higher rate than lesbian girls. Similarly, bisexual adult women report sexual assault more commonly than lesbian women³.

These high rates of sexual violence and oversexualization relate to increased substance use in bisexual women, as they often report using substances to cope with sexual victimization³. Further, bisexual women also report using alcohol to cope with pressure to engage in sexual behaviour, including being pressured to engage in sexual activity with multiple sexual partners at once³. This pressure stems from widely held beliefs that bisexual women are promiscuous and non-monogamous.

Collectively, bisexual individuals are extremely prone to experiences that may increase their substance use and increase the risk of developing substance use disorders. Unlike those identifying as gay/lesbian, bisexual individuals are uniquely targeted both inside and outside of the LGBTQ+ community, isolating a group that is particularly in need of strong social support.

How can substance use issues in bisexual individuals be addressed?

Given that some of the motivation for substance use in bisexual individuals stems from bi-negativity and consequences of stereotyping, those issues must be addressed. Individual-level interventions aimed at bisexual individuals are necessary, but cannot fix issues that are rooted in societal misconceptions and attitudes. As such, a group of authors propose micro, mezzo, and macro solutions for improving mental health and problematic substance use in the bisexual community⁹.

Micro solutions refer to resources that are targeted at an individual bisexual person. This may include developing a specific therapy to help teach bisexual individuals to cope with bi-negativity in more positive ways⁹. The authors suggest that there must be a focus on delivering interventions that are bisexual-affirmative, meaning that the bisexual client is validated and advocated for. This is particularly important, as bisexual clients report being stigmatized by some health care professionals⁶.

Mezzo solutions refer to resources that are targeted at improving environments bisexual individuals may be a part of. This may include educating school counsellors on bisexual issues and creation of bisexual-safe spaces. The authors propose ensuring bisexual-affirmative care before the client even identifies themselves as bisexual. This may take a form of a sign that states that a clinician’s office is a safe space for people identifying as bisexual, and/or including a bisexual pride symbol⁹.

Another proposed mezzo solution is offering multiculturalism training to clinicians, as this could assess their attitudes about bisexuality and provide knowledge and skills that may be required for positive interaction with bisexual clients⁹. This would ultimately ensure that clinicians are competent at providing a service that recognizes the complexity of bisexual experience, and are aware of potential risks that bisexual individuals may face, such as problematic substance use.

In addition, it may be particularly useful to introduce early interventions, as research suggests that sexual minorities tend to be motivated to begin using substances as a coping strategy as early as in adolescence¹⁰. A study found that supportive community resources in gay, lesbian, bisexual, and questioning high school students are related to lower substance use compared to those who did not have access to such resources¹¹. As such, introducing resources to bisexual adolescents may be particularly effective at promoting community inclusion, and decreasing risky coping behaviours, such as substance use.

Macro solutions refer to targeting an entire population in ways that would indirectly improve bisexual issues. This may include campaigns to reduce stigma towards bisexuality. The authors propose that non-discrimination policies must be enacted to protect bisexual individuals. In particular, clinicians are encouraged to advocate for these changes, as advocacy is a large part of bisexual-affirmative care⁹.

In addition, there is a call for research regarding how to reduce bi-negativity in the general population. Although more research is needed, a potential bi-negativity reduction strategy is as simple as exposing the population to bisexual individuals, as there is some evidence that it might decrease negative attitudes towards bisexuality⁹. On that note, another solution at the macro level might involve encouraging contact between bisexual individuals and the rest of the population, either directly or vicariously (through displaying straight-bisexual interaction in the media)⁹.

Bisexual individuals are facing substance use issues at alarming rates compared to gay, lesbian, and straight individuals, and this can be changed. It is important to understand that the proposed solutions do not have to stay limited to clinicians and bisexual individuals themselves. Sharing an informative article, conversationally spreading knowledge about bisexuality, and correcting misconceptions are some of the easiest, yet meaningful, ways in which everybody can tackle some of the root causes of the issues that bisexual individuals face far too often.

Substance use does not have to be the unwritten legacy of bisexual individuals, and meaningful change can start with you.

Superscript References

Gates, G. (2011, April). How many people are lesbian, gay, bisexual, and Transgender? Retrieved April 20, 2021, from https://williamsinstitute.law.ucla.edu/publications/how-many-people-lgbt/
Government of Canada, S. (2020, September 09). Health risk behaviours, by sexual orientation and gender. Retrieved April 20, 2021, from https://www150.statcan.gc.ca/n1/pub/85-002-x/2020001/article/00009/tbl/tbl09-eng.htm
Schuler, M. S., & Collins, R. L. (2020). Sexual minority substance use disparities: Bisexual women at elevated risk relative to other sexual minority groups. Drug and Alcohol Dependence, 206, 7. doi:http://dx.doi.org.ezproxy.lib.ryerson.ca/10.1016/j.drugalcdep.2019.107755
Boyd, C. J., Veliz, P. T., & McCabe, S. E. (2019). Severity of DSM-5 cannabis use disorders in a nationally representative sample of sexual minorities. Substance abuse, 41(2), 191–195. https://doi.org/10.1080/08897077.2019.1621242
Boyd, C. J., Veliz, P. T., Stephenson, R., Hughes, T. L., & McCabe, S. E. (2019). Severity of Alcohol, Tobacco, and Drug Use Disorders Among Sexual Minority Individuals and Their “Not Sure” Counterparts. LGBT health, 6(1), 15–22. https://doi.org/10.1089/lgbt.2018.0122
Doan Van, E. E., Doan Van, E. E., Mereish, E. H., Mereish, E. H., Woulfe, J. M., Woulfe, J. M., Katz-Wise, S. L., & Katz-Wise, S. L. (2019). Perceived discrimination, coping mechanisms, and effects on health in bisexual and other non-monosexual adults. Archives of Sexual Behavior, 48(1), 159-174. https://doi.org/10.1007/s10508-018-1254-z
Yost, M. R., Yost, M. R., Thomas, G. D., & Thomas, G. D. (2012). Gender and binegativity: Men’s and Women’s attitudes toward male and female bisexuals. Archives of Sexual Behavior, 41(3), 691-702. https://doi.org/10.1007/s10508-011-9767-8
Livingston, N. A. (2017). Ecological momentary assessment of daily microaggressions and stigma-based substance use among lesbian, gay, and bisexual individuals
Feinstein, B. A., Dyar, C., & Pachankis, J. E. (2019). A multilevel approach for reducing mental health and substance use disparities affecting bisexual individuals. Cognitive and Behavioral Practice, 26(2), 243-253. doi:http://dx.doi.org.ezproxy.lib.ryerson.ca/10.1016/j.cbpra.2017.10.003
Ramos, J. (2020). Coping motives as a moderator of the association between minority stress and alcohol use among emerging adults of marginalized sexualities and genders (Order No. 27738508). Available from ProQuest Dissertations & Theses A&I: Health & Medicine; ProQuest Dissertations & Theses A&I: Social Sciences; ProQuest Dissertations & Theses Global: Health & Medicine; ProQuest Dissertations & Theses Global: Social Sciences. (2428584534). Retrieved from http://ezproxy.lib.ryerson.ca/login?url=https://www-proquest-com.ezproxy.lib.ryerson.ca/dissertations-theses/coping-motives-as-moderator-association-between/docview/2428584534/se-2?accountid=13631
Eisenberg, M. E., Erickson, D. J., Gower, A. L., Kne, L., Watson, R. J., Corliss, H. L., & Saewyc, E. M. (2020). Supportive community resources are associated with lower risk of substance use among lesbian, gay, bisexual, and questioning adolescents in minnesota. Journal of Youth and Adolescence, 49(4), 836-848. https://doi.org/10.1007/s10964-019-01100-4

Hyperlink References

APA Dictionary (n.d.). Affirmative therapy. In dictionary.apa.org dictionary. Retrieved April 1, 2021, from https://dictionary.apa.org/affirmative-therapy

APA Dictionary (n.d.). Coping strategy. In dictionary.apa.org dictionary. Retrieved April 1, 2021, from https://dictionary.apa.org/coping-strategy

APA Dictionary (n.d.). Multicultural education. In dictionary.apa.org dictionary. Retrieved April 1, 2021, from https://dictionary.apa.org/multicultural-education

Juergens, J., & Parisi, T. (2019, January 2). Illicit drug abuse and addiction. Addiction Center. Retrieved April 01, 2021, from https://www.addictioncenter.com/drugs/illicit-drugs/

Mayo Clinic. (2017, October 26). Drug addiction (substance use disorder). Retrieved April 01, 2021, from https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112

Mayo Clinic. (2018, July 11). Alcohol use disorder. Retrieved April 01, 2021, from https://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/symptoms-causes/syc-20369243

Mayo Clinic. (2020, March 14). Nicotine dependence. Retrieved April 01, 2021, from https://www.mayoclinic.org/diseases-conditions/nicotine-dependence/symptoms-causes/syc-20351584

Merriam-Webster. (n.d.). Microaggression. In Merriam-Webster.com dictionary. Retrieved April 1, 2021, from https://www.merriam-webster.com/dictionary/microaggression

Merriam-Webster. (n.d.). Monogamy. In Merriam-Webster.com dictionary. Retrieved April 1, 2021, from https://www.merriam-webster.com/dictionary/monogamy

Merriam-Webster. (n.d.). Prejudice. In Merriam-Webster.com dictionary. Retrieved April 1, 2021, from https://www.merriam-webster.com/dictionary/prejudice

The Center. (n.d.). Defining LGBTQ. Retrieved April 01, 2021, from https://gaycenter.org/about/lgbtq/

April 19, 2021November 3, 2021

Drinking to cope: How social anxiety plays a role in university students’ alcohol consumption

By Jenna Vieira

While having a beer, glass of wine, or cocktail on occasion might be relatively low-risk, university students tend to drink a lot more alcohol than this on average.¹ In fact, a 2019 national survey found that 33% of students had engaged in binge drinking in the past month and almost 9% were diagnosed with an alcohol use disorder.¹ Since alcohol use is so common among students it’s important for clinicians, universities, and the general public to understand the reasons why they drink, so that the issue can be better addressed.

Figure 1: An anxious emoticon face with a thought bubble coming out of its head, containing the phrases “I feel like such an outcast..”, “They’re judging me..”, and “Everyone’s looking at me..” A group of their peers stands nearby. Graphic by Jenna Vieira, template from CANVA is licensed under a Free Media License Agreement.

One possible reason for university students’ drinking might have to do with social anxiety. At its core, social anxiety is an intense fear of being judged or evaluated when in social situations,² like public speaking, ordering food at a restaurant, or meeting someone new. A person with this kind of anxiety is worried that they will “mess up” or do something that will cause others to think poorly of them. Although social anxiety is something that everyone experiences from time to time, it can be severe and persistent enough to be diagnosed as a mental disorder.³

Alcohol is known to have anxiety-reducing effects.⁴ This means that drinking alcohol might allow someone with social anxiety to feel more relaxed, comfortable, and able to socialize in situations that would normally cause them a lot of distress.

Interestingly, much of the university experience takes place in the form of social events, like living and hanging out with roommates, going to big parties, and visiting bars and clubs.⁵ What do all of these events tend to have in common? The presence of alcohol and the ability to trigger social anxiety. University students often find themselves in situations that present opportunities for both drinking and feeling socially anxious, and as mentioned, alcohol can reduce this anxiety.⁴ So, could it be that some students drink alcohol as a way of coping with their social anxiety?

What the research says

A number of studies have indeed found support for the idea that university students drink alcohol to cope with social anxiety. In one study, highly socially anxious university students reported greater drinking to cope with negative emotions, like sadness and anxiety, compared to students with lower levels of social anxiety.⁵ On top of this, highly socially anxious students tended to report drinking for conformity reasons, or in other words, to fit in with their peers. This suggests that these students drink not only to manage unpleasant emotions, but also uncomfortable experiences that might arise from being rejected and ridiculed by others around them.

Another study found that highly socially anxious university students were more likely to drink to cope with and reduce negative emotions, like nervousness and depression, compared to students with lower levels of social anxiety.⁵ In addition, they reported drinking more to increase positive emotions, like feeling good and having fun. Importantly, highly socially anxious students who reported drinking as a way to manage both negative and positive emotions were more likely to experience problems related to their alcohol use.

Figure 2: A sad face and a happy face next to three alcoholic drinks. Graphic by Jenna Vieira, template from CANVA is licensed under a Free Media License Agreement.

Some studies have even found evidence that university students drink alcohol as a way of coping with anticipatory social anxiety; in other words, anxiety about an upcoming social situation or event rather than one a person is already in. One such study found that highly socially anxious students were more likely to experience anxiety about an upcoming social event, which made them more likely to drink alcohol before that event in order to prepare for and manage their anxiety about it.⁷ It was also found that anticipatory anxiety, social anxiety, and pre-drinking were related to more drinking and feelings of intoxication during that social event.

To sum up, university students with social anxiety tend to drink alcohol, and sometimes greater amounts of alcohol, compared to their non-anxious peers. They appear to do this not only to cope with negative emotions (including anxiety), but also to feel more positive emotions and to prepare for situations in which they are afraid of being judged or rejected.

Why does this matter?

These findings show that a desire to cope with social anxiety is one reason behind university students’ alcohol use. They also suggest that drinking to cope with social anxiety might put university students at higher risk for alcohol-related problems, like developing an addiction.

Using alcohol as a strategy to manage and cope with emotions, whether positive or negative, is generally unhealthy.⁶ For socially anxious university students, it’s associated with drinking more in social situations⁷, which can make a person more likely to become very intoxicated, make impulsive and unsafe decisions, and be unable to remember what happened while they were drinking.

It’s well-known that alcohol use can be unhelpful and dangerous in the long run. However, a socially anxious student might still continue to drink because it makes them feel better in the moment.⁸ If this drinking becomes severe enough that it’s difficult to control and gets in the way of the student’s ability to fulfill their everyday personal, social, and academic obligations, they might end up qualifying for a diagnosis of alcohol use disorder.³ Given that about 20% of people with social anxiety have an alcohol use disorder, this isn’t an unlikely possibility.⁹

So, the question is: how can socially anxious university students who drink alcohol be helped?

What clinicians and universities can do

It goes without saying that it’s unrealistic to ask students to simply stop drinking or going to social events, since these tend to be common and even meaningful parts of the university experience. However, there are a few different ways in which clinicians – such as psychologists, counsellors, and therapists – can approach supporting students who might be at risk.

Figure 3: A university student seeks support from a counsellor. A person sits and talks with a therapist. There are two thought bubbles with ellipses in them. Graphic by Jenna Vieira, template from CANVA is licensed under a Free Media License Agreement.

For socially anxious students who have not yet shown signs of problematic drinking or drinking to cope, preventing these behaviours from developing might be the most important thing clinicians can help with. To do this, they can consider providing evidence-based treatments to students for their social anxiety, such as cognitive behavioural therapy (CBT). This type of therapy involves working with a client to help them change unhelpful thought patterns, beliefs, and behaviours about the situations that provoke their social anxiety.¹⁰ CBT has been found to be useful for reducing anxiety when delivered in both individual and group formats.⁷

For socially anxious students who already use alcohol to cope, clinicians can attempt to treat aspects of both their social anxiety and alcohol use together. One way in which they can do this is by helping a client to identify healthier ways of coping with their emotions in social situations.⁶ Given that drinking to cope is linked to drinking in larger quantities,⁶ they can also work with a client to plan safety behaviours that they can engage in when they are drinking in social situations; for example, switching between alcoholic and non-alcoholic drinks to avoid becoming too intoxicated.⁶

Universities also have a role to play in helping their students overcome problems with social anxiety and alcohol use. Ways in which they can support this initiative include using funding to provide therapy and counselling services to students; making these services accessible by offering them at a range of costs or allowing them to be covered under university health insurance; and spreading awareness about these services through posters, social media, and other avenues to reduce stigma and encourage students to seek help.

What you and I can do

As members of the general public, we can also do a few small but important things to support university students who are drinking to cope with their social anxiety, or facing mental health difficulties generally.

One way to do this is by spreading awareness about mental health resources using platforms that university students are likely to use, such as Instagram and Twitter. If you know someone who is struggling personally, you might even consider letting them know about these resources. Some example resources include free mental health- and therapy-focused apps, like MindBeacon (Ontario) and AbilitiCBT (Ontario, Manitoba), and even the counselling centre at the university you attend (for example, Ryerson University).

Another option is to share resources about alcohol use, again on social media and/or within your personal circles, so that students can become better educated about drinking and its potential harms. For example, this website provides a set of short, easy-to-read of free fact sheets about the effects that alcohol can have on a person’s body, how to calculate alcohol calories and blood alcohol content, and myths about alcohol.

Finally, if you’re a university student yourself, you might think about getting involved in a club or association at your school that is dedicated to mental health advocacy. If this doesn’t exist, consider taking the initiative and start one yourself!

In sum, the research findings discussed in this blog post are only as meaningful as we make them. In other words, uncovering even just one of the factors that encourage university students to drink – in this case, social anxiety – is the very first step in helping them to overcome their mental health struggles. It’s up to us as members of the public, clinicians, and policymakers to put this knowledge into practice and help university students who drink alcohol to cope with social anxiety to live healthier lives.

References

1. Substance Abuse and Mental Health Services Administration. (2019). Results from the 2019 national survey on drug use and health: Detailed tables. https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables

2. Morrison, A. S., & Heimberg, R. G. (2013). Social anxiety and social anxiety disorder. Annual Review of Clinical Psychology, 9(1), 249-274. https://doi.org/10.1146/annurev-clinpsy-050212-185631

3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

4. Goodman, F. R., Stiksma, M. C., & Kashdan, T. B. (2018). Social anxiety and the quality of everyday social interactions: The moderating influence of alcohol consumption. Behavior Therapy, 49(3), 373-387. https://doi.org/10.1016/j.beth.2017.10.002

5. Terlecki, M. A., & Buckner, J. D. (2015). Social anxiety and heavy situational drinking: Coping and conformity motives as multiple mediators. Addictive Behaviors, 40, 77-83. https://doi.org/10.1016/j.addbeh.2014.09.008

6. Buckner, J. D., Lewis, E. M., & Walukevich-Dienst, K. (2019). Drinking problems and social anxiety among young adults: The roles of drinking to manage negative and positive affect in social situations. Substance Use & Misuse, 54(13), 2117-2126. https://doi.org/10.1080/10826084.2019.1637892

7. Buckner, J. D., Lewis, E. M., Terlecki, M. A., Albery, I. P., & Moss, A. C. (2020). Context-specific drinking and social anxiety: The roles of anticipatory anxiety and post-event processing. Addictive Behaviors, 102, 106184-106184. https://doi.org/10.1016/j.addbeh.2019.106184

8. Kim, S., & Kwon, J. (2019). The impact of negative emotions on drinking among individuals with social anxiety disorder in daily life: The moderating effect of maladaptive emotion regulation strategies. Cognitive Therapy and Research, 44(2), 345-359. https://doi.org/10.1007/s10608-019-10045-8

9. Anxiety & Depression Association of America. (n.d.). Social anxiety disorder and alcohol abuse.https://adaa.org/understanding-anxiety/social-anxiety-disorder/social-anxiety-and-alcohol-abuse

10. Heimberg, R. G. (2002). Cognitive-behavioral therapy for social anxiety: Current status and future directions. Biological Psychiatry, 51(1), 101-108. https://doi.org/10.1016/S0006-3223(01)01183-0

Images

1. Canva (March 2021). [An anxious emoticon face with a thought bubble coming out of its head, containing the phrases “I feel like such an outcast..”, “They’re judging me..”, and “Everyone’s looking at me..”. A group of their peers stands nearby].

2. Canva (March 2021). [A sad face and a happy face next to three alcoholic drinks].

3. Canva (March 2021). [A university students seeks support from a counsellor. A person sits and talks with a therapist. There are two thought bubbles with ellipses in them].

April 19, 2021November 3, 2021

The Binary Gender Of Addiction Screening Tools: Can Transgender People Benefit From Them?

by Krisoula Kotassidis

A recent national US study found that transgender people 18-35 years old are more likely than cisgender people to be diagnosed with a substance use disorder¹⁰.Research shows that transgender people face additional stressors due to stigma, compared to the general population¹⁴ which explains their high rates of substance use. As a result, young transgender adults do not feel comfortable accessing medical and mental health care services, including substance use treatment⁷. This is why widespread awareness about transgender stress, and prevention of substance use disorders in these populations is crucial. However, existing prevention tools for substance use screening and treatment may cause more harm than benefit to transgender individuals, as they were designed with exclusively cisgender heterosexual people in mind¹⁰.

*Photo credit: Juan Moyano, 2019*
[Photo description: Person standing in the middle of a beach, shown from the chest and up. The transgender flag including the colours of blue, pink and white covers their head. At the background the sky is clear with only a few clouds].

Let’s talk labels first

Gender is pretty simple, right? You are born with male genitalia; therefore, you are a boy and your caregiver dresses you in blue. You are born with female genitalia; therefore, you are a girl and your caregiver dresses you in pink. This is a binary cisgender identity which assumes that your sex assigned at birth defaults to only one of two gender options. Individuals who feel happy and comfortable with such an identity and expression usually do not have to think about their gender; they just enjoy being accepted for who they are. Gender identity is your individual experience of being man, woman, both, something in between or something else. Gender expression is the way you communicate your gender identity to others through your clothing, behaviour, preferred pronouns etc.¹

People who do not identify as neither a man nor a woman are non-binary. But, what about transgender people? Transgender is an umbrella term describing individuals whose gender identity or gender expression does not conform to the gender norms associated with the sex (female vs. male) they were assigned at birth⁶. In reality, there are many more ways in which people identify with or express their gender.

From minority stress to substance use to substance use disorders

Although research on transgender populations is extremely limited, the evidence about their poor physical and psychological well being is alarming. Transgender people face more discrimination, receive more threats about their safety, and are more likely to be victims of sexual and physical violence compared to non-transgender people ⁶. In the workplace, transgender people are more likely to get fired and be denied a job because of their gender identity and expression compared to non-trans folks. As a result, trans people are more likely to be homeless.¹⁴

*Image by:* *NCTE*
[Photo description: Activists on the street protesting for transgender rights. They are standing in front of a historical building and only their heads are depicted in the picture. One person, closest to the camera, holds a sign reading “We want to live free”. The rest of people are holding primarily transgender flags, and one person is holding the US flag].

This image has an empty alt attribute; its file name is K_Image3.jpg — Infographic made on Canvas by: Krisoula Kotassidis

Transgender people learn to expect such stressful events to happen, which makes them hide their gender identity to protect themselves from emotional and physical harm⁶. However, this often exacerbates their distress¹³. At the same time, transgender folks often agree with stigmatising beliefs about the way they identify with and present their gender (aka internalised transphobia) which hinders their ability to cope and accept themselves for who they are¹³. To make things worse, transgender individuals are less likely to access available health care and report gender-based violence to the police ⁶. This is because transgender prejudice and discrimination is deeply rooted in social institutions, such as our education, healthcare, and law enforcement.¹²

All these experiences are traumatising to the transgender person who lives each day with fear because of the stigma they experience due to their minority status. As a result, trans populations are found with high rates of psychological disorders, substance use disorders, and suicide attempts.⁴⁶

Screening & timely intervention: An example

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) model is a public health screening process used to identify individuals who use substances⁶. The goal of this process is to:

identify users who are at risk of developing a substance use disorder
intervene when the individual is engaged in high-risk substance use, and
refer individuals with severe use to a specialist.

*Image by:* *SAMHSA*
[Image description: Four smaller pictures places next to each other creating a square and showing images of family, friends, and a hospital setting with a doctor standing in front of the camera having their hands crossed. On the right side the background of the image is in blue reading “SBIRT: Screening, Brief Intervention and Referral to Treatment”].

The model is usually used in clinical settings by doctors, nurses, social workers and other healthcare professionals⁶; however, there is evidence that the model is also beneficial in non-professional settings used by individuals with little or no clinical training⁶. Plenty of research supports the effectiveness of this screening tool particularly with vulnerable populations such as racial minorities⁶, prenatal and parenting women, adolescents, and the elderly.⁶

Is SBIRT trans inclusive?

The answer is: no. In fact, this model uses screening tools supported by binary research using gender binary biological standards and language, without taking into account transgender-specific stressors and stigma ⁶. For example, the pre-screening questionnaire only refers to binary risk limits for alcoholic drinks per day, by expecting individuals to choose only between the risk limits for men (5 or more/day) or women (4 or more/day) when answering the questions.⁷ However, these drinking thresholds are based on biological sex and only refer to biological females or males who also identify as women or men, respectively, in terms of gender. This may be harmful for trans folks because we do not even know how many drinks for them are too much, and also because of the non-affirming language being used.

Gender binary language also includes the use of only she/her and he/him pronouns without considering whether the individual feels comfortable with these pronouns. If you consider the gender-based emotional trauma that transgender folks have to live with, you can understand why language and representation in screening measures are important for them to feel safe in substance use screening and intervention settings. If the person does not feel accepted for who they are, they will be reluctant to receive any advice or treatment no matter how well intended it is.

*Image by: Shutterstock*
[Image description: Six people standing next to each other, all of different ethnicities wearing a pink, orange, yellow, green, violet, and purple clothing. They each have their preferred pronouns written on their tops].

What if SBIRT (trans)itions?

Just because something doesn’t work the way it’s supposed to doesn’t mean that we should give up on it. Transgender focused research is almost non-existent, while there are very few transgender-specific substance use disorders healthcare professionals. But, transgender people are still struggling with substance misuse. Transgender people, especially those who are racialized, homeless or involved in sex work are overdosing ¹².Therefore, we need to act fast by changing our already existing tools. Here is how SBIRT and the medical and mental health care field can change:

By giving priority to transgender healthcare professionals in developing and administering transgender-specific substance use prevention and treatment programs⁶.
By changing the language of screening questionnaires used in the interviewing process to include gender neutral pronouns ⁶.
By training healthcare professionals to be sensitive to the lived experiences of trans folks⁶ and aware of their other social identities, such as race and socioeconomic status without making binary assumptions about the individual
By making use of effective peer support

How does peer support work?

According to research, peers helping each other is effective for HIV prevention, as well as, depression and substance misuse treatment.¹¹ Therefore, some researchers believe that training transgender individuals to use tools like SBIRT in transgender spaces could be effective, especially for those at higher risk for substance use¹⁹. Peer support can help with gender-based stressors and build resilience to cope with stigma by creating a non-judgmental environment, while preventing substance use or preparing those with heavy use for treatment⁶.

How you can help

Be a transgender ally! You do not have to be transgender nor a healthcare professional to support transgender folks at risk of substance use disorders. Although there are available courses for SBIRT training online, you do not have to undergo training in order to help. Instead:

*Photo credit: John Keon, 2018*
[Photo description: Portrait of writer and performance artist, ALOK. They are wearing a pink, blue, and light brown hair extension. Their make-up is in pink, white, and purple tone. They are also wearing long purple and white earrings and a navy blue and white striped, long sleeved top with gold buttons].

Learn more about transgender individuals through social media spaces. My favourite Instagrammer is ALOK. They have helped me so much in understanding gender. The best way to learn about transgender people and be an ally is to listen to them. It is the first big step in removing any stereotypical thinking you might have adopted.

Remember the suggestion about SBIRT (trans)itioning? Well, you can do it too! You can change your language by using gender neutral pronouns when you feel ambivalent about one’s gender. Or even better: you can just ask the person what their preferred pronouns are. Trust me, they will very much appreciate it.

Call out (in a civilised manner) on transphobic jokes or other acts of discrimination against transgender people. If you actively show your allyship, a transgender person will feel more comfortable around you and even trust you in talking to you about their substance use. Take the first step to become an ally here.

Donate, donate, donate here. Even if you cannot donate, you can volunteer! Don’t have the time to volunteer? No worries! You can make the continuous effort to use the proper pronouns and simply accept transgenders for who they truly are. This is an important first step to allyship.

Dealing with substance use disorders is challenging, especially for transgenders who live with additional stressors because of their gender identity and expression. Be there for them, listen, and give them voice. Provide them with valuable peer support to identify those at risk and point them to trans-affirming treatment environments. Try it! You might save a life.

References

American Psychological Association. (2014). Transgender people, gender identity and gender expression. Retrieved from: https://www.apa.org/topics/lgbtq/transgender
Bavinton, B., Gray, J., & Prestage, G. (2013). Assessing the effectiveness of HIV prevention peer education workshops for gay men in community settings. Australian and New Zealand Journal of Public Health, 37(4), 305–310. doi: 10.1111/1753-6405.12076
Candian Centre for Addictions. (2019). Addiction in the LGBTQ community: LGBTQ individuals tell their stories. Retrieved from: https://canadiancentreforaddictions.org/addiction-lgbtq/
Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53–69. doi: 10.1300/J082v51n03_04
Day, J. K., Fish, J. N., Perez-Brumer, A., Hatzenbluehler, M. L., Russel, S. T. (2017). Transgender youth substance use disparities: Results from a population-based sample, Journal of Adolescent Health, 61(6), 729-735. doi: https://www-sciencedirect-com.ezproxy.lib.ryerson.ca/science/article/pii/S1054139X17303257
Dentato, M. P., Ortiz, R., Orwat, J., Kelly, B. L., Gates, T. G. & Propper, E. (2019) Peer-based education and use of the SBIRT model in unique settings with transgender young adults, Journal of Social Work Practice in the Addictions, 19:1-2, 139-157, doi: 10.1080/1533256X.2019.1589884.
Gilbert, P. A., Pass, L. E., Keuroghlian, A. S., Greenfield, T. K., & Reisner, S. L. (2018). Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies. Drug and alcohol dependence, 186, 138–146. https://doi.org/10.1016/j.drugalcdep.2018.01.016
Glynn, T. R., & van Den Berg, J. J. (2017). A systematic review of interventions to reduce problematic substance use among transgender individuals: A call to action. Transgender Health, 2(1), 45–59. doi:10.1089/trgh.2016.0037
Gonzalez, C.A., Gallego, J.D., Bockting, W.O. (2017). Demographic characteristics, components of sexuality and gender, and minority stress and their associations to excessive alcohol, cannabis, and illicit (noncannabis) drug use among a large sample of transgender people in the united states. J. Prim, 38, 419–445. doi:
Hughto, J. W., Quinn, E. K., Dunbar, M. S., Rose, A. J., Shireman, T. I. & Jasuja, G. K. (2021). Prevalence and co-occurrence of alcohol, nicotine, and other substance use disorder diagnoses among US transgender and cisgender adults. JAMA Network Open, 4(2), e2036512–. doi: 10.1001/jamanetworkopen.2020.36512
Kelly, J. F., & Yeterian, J. D. (2015). Outcome research on twelve-step programs. In M. Galanter & H. D. Kleber (Eds.), Textbook of substance abuse treatment (5th ed., pp. 579–595). Washington, DC: American Psychiatric Press.
Laye, B. (2019). The Overdose Crisis Isn’t Gender Neutral. West Coast Leaf. Retrieved from: http://www.westcoastleaf.org/2019/08/07/the-overdose-crisis-gender/
Martino, W., Kassen, K. & Omercajic, K. (2020) Supporting transgender students in schools: Beyond an individualist approach to trans inclusion in the education system, Educational Review, doi: 10.1080/00131911.2020.1829559
Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56. Doi: https://www-jstor-org.ezproxy.lib.ryerson.ca/stable/2137286?pq-origsite=summon&seq=1#metadata_info_tab_contents
Meyer, I. H., Schwartz, S., & Frost, D. M. (2008). Social patterning of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources? Social Science & Medicine, 67, 368–379. doi:10.1016/j.socscimed.2008.03.012
SBIRT training. (2021). Retrieved from: https://sbirt.clinicalencounters.com/aboutus/
Trans Pulse. (N/A). Drug use among transgender people in Ontario. Retrieved from: https://transpulseproject.ca/research/drug-use-among-transgender-people-in-ontario-canada-disparities-and-associations-with-social-exclusion/
Trans Equality Canada. Retrieved from: https://www.transequalitycanada.com/background
Hughes TL, Wilsnack SC, Kantor LW. The Influence of Gender and Sexual Orientation on Alcohol Use and Alcohol-Related Problems: Toward a Global Perspective. Alcohol Res. 2016;38(1):121-32. PMID: 27159819; PMCID: PMC4872607. doi: https://pubmed.ncbi.nlm.nih.gov/27159819/

Images & social media

CBC News. (2020). 4 Canadian transgender activists you should know. Retrieved from:https://www.youtube.com/watch?v=zbKXfme1Wkc&ab_channel=CBCNews
Moyano, J. (2019). Retrieved from: https://www.stocksy.com/3251846/covered-by-a-transgender-pride-flag
Keon, J. (2018). Retrieved from: https://www.alokvmenon.com/photo