Your Body Image is More Important Than You Think: Body Dysmorphia and Drug Use

By Samira Hussein

Image by @gstudioimagen1. Retrieved from

Annie is an eighteen year old girl attending university for the very first time. For as long as she could remember, she never had any issues with her appearance other than brief, superficial concerns about a new hairstyle  or trying on a different outfit in the changing room. It wasn’t until recently, entering this completely new environment, that she began to become concerned with her looks and the way she presents herself to other people. One of her major worries is that her face is asymmetrical, and that one side of her jaw appears larger than the other. As well, she is extremely concerned that she will soon be unable to fit into her clothing, despite maintaining her weight.

These body image concerns begin to overwhelm Annie. To relieve some of her worries, she begins to uncontrollably check every reflective surface she passes by, including shop windows and bathroom mirrors, as well as taking numerous photos with her smartphone. Some days, she finds it difficult to gather the courage to leave her dorm room and attend class or hang out with her friends because of her appearance concerns. She is intensely worried about what other people might think of how she looks, and unfortunately finds herself slowly withdrawing from the new friendships she’d acquired in this new environment. Annie feels very alone and isolated due to this, so sometimes she’ll have a couple of drinks to pass the time and help her calm down. At first, it’s only a few glasses of wine before bed to help relax after missing an important class, or when she fears her friends hate her for missing another outing, but soon she finds herself needing more to get that same effect. Unfortunately, Annie ends up failing two classes in her first semester, much to the disappointment of her parents. Despite trying to cut back on the amount of alcohol she drinks, Annie finds it extremely difficult.

What is Body Dysmorphia?

Image by @gstudioimagen1. Retrieved from

The intense stress Annie experiences as a result of her unhealthy obsession with her body image is consistent with a psychological condition called Body Dysmorphia, or Body Dysmorphic Disorder (BDD). This is a disorder where people tend to become extremely focused on a perceived defect of their appearance  (such as weight gain, whether it is there or not) that causes the person extreme feelings of distress. This distress often interferes with their ability to function on a daily basis, such as in their ability to keep up with their personal relationships, schoolwork, and even work obligations (Grant et al., 2008). BDD can be characterized by:

  • Obsessive thoughts that disrupt daily
  • Making constant comparisons with others
  • Extremely frequent grooming behaviours (such as  skin picking, pulling hair, applying makeup, etc.)
  • Camouflaging or hiding the area of insecurity (e.g., wearing baggy clothes)
  • Behaviours that are repetitive or even ritualistic in order to reduce distress (this includes searching for constant reassurance from others, body checking in reflective surfaces, taking photos, and more)

Body dysmorphia can interfere greatly with one’s functioning in everyday life, as misperceptions about their appearance can often occupy their attention for extended periods of time (Buhlmann et al., 2008). Social situations may be extremely difficult to attend, as individuals with BDD are prone to feelings of anxiety, shame, discomfort, and embarrassment due to their concerns (Cunningham et al., 2017). The difficulties associated with BDD can lead to a variety of poor health outcomes that require greater attention, including but not limited to potential eating disorders as well as issues with substance use.

Trends to Consider

BDD tends to arise within young adults and adolescents, and due to the stigma and secretive nature of this disorder, it most commonly can become chronic in duration, thus increasing the potential for poor health outcomes (Veale et al., 1996; as cited in Buhlmann et al., 2008; Grant et al., 2008). Many individuals do not receive treatment until the disorder has significantly progressed in severity due to stigma and barriers, and taking into account mental health issues that may arise over the course of one’s life, symptoms and treatment will vary from person to person (Schneider et al., 2019). A lower quality of life, increased risk of suicide, and substance use in particular are heavily implicated in trends associated with BDD. Recent research suggests some individuals may misuse substances to help cope with the negative emotions and feelings that come with BDD, especially among university students who may use drugs for social engagements (Cunningham et al., 2017). These trends are extremely alarming when considering the potentially severe impact this disorder can have over the course of a lifetime, highlighting an increasingly important area for further research.

So, how is Body Dysmorphia and Drug Use Related?

Image by Anna Shvets. Retrieved from Pexels.

            Many individuals living with BDD understandably struggle to manage their intense feelings of distress even with their compulsive and ritualistic behaviours, and in recent years, researchers have noticed a link between BDD and substance use. Recreational drug use is often adopted by people struggling with extreme distress as a result of BDD in order to cope, with the most common substances being alcohol and cannabis (Gunstad & Phillips, 2003; Phillips et al., 2005; as cited in Kelly et al., 2017; Grant et al., 2019; Grant et al., 2008). The amount of individuals both struggling with a substance use disorder as well as BDD is considered extremely high. Dealing with both disorders at the same time can further exacerbate issues with day-to-day functioning, suicidality, and overall well being (Phillips, 2007; as cited in Kelly et al., 2017; Grant et al., 2005). This relationship has been of particular concern following a 2008 study by Grant et al., in which approximately half of a group of young adults adolescents with body dysmorphia reported that their symptoms relating to BDD were partly responsible for their drug use in the first place. Despite many individuals reporting using substances as a coping mechanism to deal with their emotions, research has suggested that those with substance use disorders tend to have extreme symptoms related to BDD, such as more hospitalizations and poorer overall functioning (Grant et al., 2008). Additional research has found links between poor body image and dangerous drinking specifically in the undergraduate university population, and that main reasons for drinking may be to cope with concerns about one’s body image concerns in public social settings (Cunnningham et al., 2017; Kellelly et al., 2017). Despite numerous studies highlighting the relationship between substance use and BDD, it is not yet entirely known why this specific relationship occurs. Instead, the focus is primarily on treating individuals with both of these disorders. Co-occurring drug use with body dysmorphia is complicated, and due to shame and embarrassment, some individuals may be reluctant to tell their clinician that they have BDD when entering treatment for a substance use issue. Failure to treat one or the other can result in poor health outcomes, especially if BDD is not addressed as a potential underlying influence for the substance use (Grant et al., 2008). More research is needed to fully understand the complex relationship between the two disorders and how they can negatively impact one’s quality of life and treatment outcomes.

Minority Groups at Risk: LGBTQ+ 

            A particular group has been highlighted in numerous research studies to be particularly vulnerable to issues with both substance use and BDD. Previous research examining the relationship between body dysmorphic disorder and sexual and gender minorities suggests that individuals identifying as gay, lesbian, bisexual, and/or transgender are at risk for intense concerns regarding their body image and appearance. The Minority Stress model (Meyer, 1995; as cited in Oshana et al., 2020) suggests individuals that are part of the LGBTQ+ community are exposed to stress constantly, and this stress leads to negative expectations for interacting with other people. In order to minimize the amount of potential poor, a person might try to hide any potential indicators of their minority status and focus intently on the way they present themselves to others, including through their appearance and behaviour (Meyer, 2003; as cited in Oshana et al., 2020). Minority stressors that are unique to individuals of minority status includes:

  • Fear of rejection
  • Concealment of sexual orientation
  • Prejudice and discrimination
  • Stigma
  • Violence
  • Internalized homophobia

Exposure to stressors like these tend to be chronic for many individuals, which unfortunately can increase one’s risk for developing mental health issues (Parker & Harriger, 2020). Body dysmorphia research has noted increased rates of body dissatisfaction in male college students who are gay or bisexual compared to heterosexual men, and further research has noticed that university students who reported symptoms consistent with BDD had a tendency to also identify as trans or gender queer, noting the added stress in this population on top of the challenges associated with young adulthood possibly has a major impact in the development of body image issues (Oshana et al., 2020; Grant et al., 2019). This is an extremely underdeveloped area of research, however. A growing focus on the relationship between substance use and body dysmorphia might suggest that sexual and gender minorities may particularly be at risk for substance use issues. Additional research on unique health outcomes and effective methods of treatment (especially those that are sensitive to the unique experiences of sexual/gender minorities) thus must be prioritized.

What can we do to help?

            While this is a relatively new field of research, there is enough existing research on treating body dysmorphic disorder and substance use disorders separately to suggest that we’re heading in the right direction. In the case of Annie, entering college is an extremely formative period that can increase one’s stress greatly. Similar to many other individuals with co-occuring issues using drugs while struggling deeply with their body image, body dysmorphia has consistently been found to be the initial mental health concern that leads to substance use as a coping mechanism. People in Annie’s situation will be glad to know that cognitive behavioural therapy combined with psychoeducation is considered to be an effective mode of treatment for both body dysmorphic disorder and substance use disorders (Buhlmann et al., 2008; McHugh, Hearon, & Otto, 2010; as cited in Cunningham et al., 2017). However, due to the complexity of both disorders and potential complications of treating one and ignoring the other, it is extremely important for clinicians to ensure they adequately screen individuals for BDD as a co-occurring condition. Populations that require this extra level of care include young adults as well as marginalized individuals (including sexual and gender minorities, and perhaps even ethnic minorities as well). Future research on the impact of minority stress and treatment is needed, especially on how to potentially adapt existing forms of treatment to become more sensitive to the unique experiences of individuals from minority groups.


Both body dysmorphia and substance use disorders run into the issue of stigma, and one of the major barriers to treatment for individuals struggling with either or both disorders is shame and secrecy. It is important to remember that both body dysmorphic disorder and substance use issues are not taboo, and honest, public dialogue is the best way to ensure that anyone struggling no longer feels alone.

If you or anyone you know is having thoughts of suicide, please contact:

  • Canada Suicide Prevention Service at 1-833-456-4566 (24/7)
  • Kids Help Phone at 1-800-668-6868
  • Hope for Wellness at 1-855-242-3310


Ahmedani B. K. (2011). Mental Health Stigma: Society, Individuals, and the Profession. Journal of social work values and ethics, 8(2), 41–416.

Buhlmann, U., Reese, H. E.eese, Renaud, S., & Wilhelm, S. (2008). Clinical considerations of treatment of body dysmorphic disorder with cognitive-behavioural therapy. Body Image, 5, 39-49.

Cunningham, M., Stapinski, L., Griffiths, S., & Baille, A. (2017). Dysmorphic Appearance Concern and Hazardous Alcohol Use in University Students: The Mediating Role of Alcohol Expectancies. Australian Psychologist, 52(6), 6), 424-432.

Grant, J. E., Lust, K., & Chamberlain, S. R. (2019). Body Dysmorphic Disorder and Its relationship to Sexuality, Impulsivity, and Addiction. Psychiatry Research, 273, 260-265.

Grant, J. E., Menard, W., Pagano, M. E., Fay, C., C., & Phillips, K. A. (2008). Substance Use Disorders With Body Dysmorphic Disorder. Journal of Clinical Psychiatry, 66(3), , 309-405.

Kelly, M. M., Simmons, R., Wang, S., Kraus, S., Donahue, J., & Phillips, K. A. (2017). Motives to drink alcohol among individuals with body dysmorphic disorder. Journal of Obsessive-Compulsive and Related Disorders, 12, 52-57.

Oshana, A., Klimek, P., & Blashill, A. J. (2020). Minority Stress and body dysmorphic disorder symptoms among sexual minority adolescents and adult men. Body Image, 34, 167-174.

Pagano, M. E., Phillips, K. A., Stout, R. L., Menard, W., & Piliavin, J. A. (2007). Impact of Helping Behaviors on the Course of Substance-Use Disorders in Individuals with Body Dysmorphic Disorder. Journal of Studies on Alcohol and Drugs, 68, 291-295.

Parker, L. L. & Harriger, J. A. (2020). Eating disorders and disordered eating behaviors in the LGBT population:: a review of the literature. Journal of Eating Disorders, 8(51).

Ruffolo, J. S., Phillips, K. A., Menard, W., W., Fay, C., & Weisberg, R. B. (2005). Comorbid. Ity of body dysmorphic disorder and eating disorders: Severity of psychopathology and body image disturbance. International Journal of Eating Disorders, 39(1)1), 11-19.

Schneider, S. C., Turner, C. M., Storch, E. A., & Hudson, J. L. (2019). Body dysmorphic disorder symptoms and quality of life: The role of clinical and demographic variables. Journal of Obsessive-Compulsive and Related Disorders, 21, 1-5.

Zimmerman, M. &  Mattia, J. I. (1998). Body dysmorphic disorder in psychiatric outpatients: Recognition, prevalence, comorbidity, demographic, and clinical correlates. Comprehensive Psychiatry, 39(5), 265-270.

The Effects of Gender Minority Stressors on Substance Use for Transgender Populations

By Tara Raessi

Photo by @alicia_mb. Retrieved from

            During Pride month, many of us celebrate how far LGBTQ2S+ communities have come in advocating for the rights they so long deserved. For plenty, though, it is a reminder of how much work we have ahead of us. Various significant changes occurred only recently, such as Canada’s ban on conversion therapy less than a year ago (Government of Canada, 2021).  Even with historical events such as the Diagnostic and Statistical Manual removing homosexuality as a paraphilia, actual changes within our societies have been slow (Drescher, 2015). The reality is that populations have come to a bare-minimal acceptance of LGBTQ2S+ communities and have only just started to accommodate such minority groups. For example, we know little regarding the effects of gender minority stressors on substance use for transgender populations, a discussion that has only risen in academic discussion in the late 21st century. 

What are Gender Minority Stressors?

            In brief, gender minority stressors are distressing stimuli experienced by persons with gender identities that are commonly victimized (Tan et al., 2020). These stressors exist because social norms on gender identity (e.g., the ideology of only male and female genders, the nuclear family, etc.) do not reflect the culture of these less-common gender identities (Tan et al., 2020). As a result of these conflicting interests, “other” gender identities are perceived negatively, which creates adverse experiences for those identifying with those outcasted genders (Tan et al., 2020). One of the biggest social norms pertaining to gender identity involves cisnormativity, which refers to the belief that a “normal” gender identity is one whose gender identity reflects their biological sex at birth (Tan et al., 2020).

Substance Use

There are mixed findings on whether exposure to gender minority stressors is associated with a higher probability of alcohol use. Some studies have identified an association between increased exposure to gender minority stressors and alcohol use (Katz-Wise et al., 2021; Watson et al., 2019). Specifically, family functioning and social support positively influenced this relationship, though Watson et al. (2019) did not identify any factors to protect against problematic drinking for transgender youth (Katz-Wise, 2021). Internalized homophobia and enacted stigma were negatively influential on alcohol use for gender minority adolescents (Katz-Wise et al., 2021; Watson et al., 2019). Others have identified a correlation only with transgender men (Gonzalez et al., 2017). This discrepancy may be due to the limitations commonly found in transgender research, such as small sample size, predominantly white participants, geographic constraints, self-reported data, non-random sampling, and the awareness of confounding variables such as the impact of hormone treatment. Additionally, this discrepancy may still exist because of the gap in the literature. For example, in 2018, Kidd et al. were unable to find any research on gender minority youth and substance use. 

Similar to alcohol, there were various findings on cannabis, tobacco, and illicit drug use. Katz-wise (2021) found that gender minority stressors did not significantly influence cannabis use. Another study found an association between gender minority stressors and cannabis use only in transgender women, which was further exacerbated by young age and lower annual income (Gonzalez et al., 2017). For gender minority adolescents, there was no significant association between gender minority stressors and tobacco use (Katz-wise, 2021). There was no primary literature evaluating the relationship between tobacco use with transgender populations. Gender minority stressors were not found to be a significant predictor of illicit drug use for transgender populations (Gonzalez et al., 2017); yet, Reisner et al. (2014) found an association between illicit drug use and exposure to gender minority stressors for transgender women. Reisner et al. (2014) additionally found that this association was strengthened when financial hardship was involved. There is insufficient literature on these associations and limitations in the existing research.

Overall, there appears to be a lack of research in understanding how gender minority stressors affect transgender populations’ substance use. While such research is increasingly being developed, such as at TMU’s own Clinical Addictions Research Equity Lab, there are many barriers to studying transgender populations. There seems to be difficulty in conducting random sampling with replacement, which in turn causes disproportionate sample graphics. While this research hurdle may never be overcome, we can hope that with continued advocacy more transgender persons will be able to safely and confidently participate in research studies.

What Can You Do?

Image designed by FreePik.

There are many ways to act as an ally and support transgender communities. Here are some actions to consider:

  • Advocate for nonbinary accommodations at your workplace, educational institution, or local businesses. This can include: requesting the implementation of a non-gendered bathroom and/or bathrooms that explicitly associate their bathrooms with gender identity, not biological sex; requesting a zero-tolerance policy for gender discrimination at work or school; encouraging the identification of pronouns during introductions, and/or; requesting for workshops that educate about transgender experiences and ways to be a better ally in the classroom/workplace.
  • Support transgender organizations and events. This may include volunteering at a local organization, attending fundraising or advocacy events, and requesting that organizations/events be gender-inclusive.
  • Listen! Do not assume that all transgender experiences are the same, or that all transgender persons express their gender identities the same. Ask persons you recently met for their preferred pronouns, be mindful and open to discussing transgender experiences, and place yourself in a position to learn.


If you identify as LGBTQ2S+ and would like support for substance use, consider reaching out to the following organizations:

Gender Identity Clinic CAMH

Rainbow Services CAMH

Sherbourne Health

The 519 Programs: LGBTQ2S Communities


Drescher, J. (2015). Out of DSM: Depathologizing homosexuality. Behaviour Science, 5(4), 565-575. 

Government of Canada. (2021, November 29). Proposed changes to Canada’s Criminal Code relating to conversion therapy. 

Katz-Wise, S. L., Sarda, V., Austin, S. B., & Harris, S. K. Longitudinal effects of gender minority stressors on substance use and related risk and protective factors among gender minority adolescents. PLoS ONE 16(6), e0250500. 

Kidd, J. D., Jackman, K. B., Wolff, M., Veldhuis, C. B., & Hughes, T. L. (2018). Risk and protective factors for substance use among sexual and gender minority youth: A scoping review. Current Addiction Reports, 5, 158-173. 

Reisner, S. L., Gamarel, K. E., Nemoto, T., & Operario, D. (2014). Dyadic effects of gender minority stressors in substance use behaviours among transgender women and their non-transgender male partners. Psychology of Sexual Orientation and Gender Diversity, 1(1), 63-71. 

Tan, K. K. H., Treharne, G. J., Ellis, S. J., Schmidt, J. M., & Veale, J. F. (2020) Gender minority stress: A critical review. Journal of Homosexuality, 67(1), 1471-1489. 

Watson, R. J., Veale, J. F., Gordon, A. R., Clark, B. A., & Saewyc, E. M. (2019). Risk and protective factors for transgender youths’ substance use. Preventive Medicine Reports, 15, 100905. 

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

Image designed by FreePik (2020)

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.


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.

Attention Deficit Hyperactivity Disorder (ADHD). (n.d.). Retrieved April 1, 2021, from

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.

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.

Executive Functioning – Centre for ADHD Awareness Canada. (n.d.). Retrieved April 20, 2021, from

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.

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.

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.

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.

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.

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.

Moos, R. H. (2007). Theory-based active ingredients of effective treatments for substance use disorders. Drug and Alcohol Dependence, 88(2-3), 109–121.

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.

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.

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.

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.

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).

Svets, A. (2020). Medication Pills Isolated on Yellow background [Photo].

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.

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.

Wilens, T. E. (2006). Attention deficit hyperactivity disorder and substance use disorders. The American Journal of Psychiatry, 163(12), 2059–2063.

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.

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.

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.



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.

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

3Loflin, M., & Earleywine, M. (2014). A new method of cannabis ingestion: The dangers of dabs?. Addictive behaviors, 39(10), 1430-1433.

4Government of Canada. (n.d.a). Addiction to cannabis.

5Radhakrishnan, R., Wilkinson, S.T., & D’Souza, D.C. (2014). Gone to pot: A review of the association between cannabis and psychosis. Frontiers in Psychiatry, 5(54), 1-24. doi:10.3389/fpsyt.2014.00054

6Badcock, J., & Paulik, G. (2020). A clinical introduction to psychosis: Foundations for clinical psychologists and neuropsychologists. Elsevier.

7CAMH. (n.d.). Psychosis.

8Schizophrenia Society of Canada. (n.d.). Annual report 2017-2018

9NIMH. (n.d.). Fact sheet: Early warning signs of psychosis.

10Government of Canada. (n.d.b). About cannabis.

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.

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.

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.

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.

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?.

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

Image References

Pixabay. (2018). [Close-up of cannabis extracts] [Photograph].

Unsplash. (2016). [Person holding grey tongs and kush] [Photograph].

Hyperlink References

Badii, C. (2019). Everything you need to know about hallucinations. Healthline.

Better Health Channel. (n.d.). Genes and genetics explained.

Byrne, P. (2007). Managing the acute psychotic episode. British Medical Journal, 334(7595), 686-692. doi:10.1136/bmj.39148.668160.80

Cafasso, J. (2021). Chemical imbalance in the brain: What you should know. Healthline.

CAMH. (n.d.b). Patient and family engagement at camh.

CAMH. (n.d.c). Access camh.

Connex Ontario. (n.d.). Free 24/7 access to health services information.

CMHA. (n.d.) Schizophrenia.

Edelweiss Publications. (n.d.). Drug potency: Pharmacovigilance and pharmacoepidemiology.

Learning about cannabis use disorder. (2020, June 29).  My Health Alberta.

Kiran, C., & Chaudhury, S. (2009). Understanding delusions. Industrial Psychiatry Journal, 18(1), 3-18. doi:10.4103/0972-6748.57851

Knott, L. (2018). Antipsychotic medicines. Patient.

Psychotherapy. (n.d.). Mayo Clinic.

Stunning free images & royalty free stock. (n.d.). Pixabay.

University of Toronto Mississauga. (n.d.). Gta mental health resources: Culturally specific.

Unsplash: The internet’s source of freely-usable images. (n.d.). Unsplash.

Using Mindfulness as a Technique to Quit Smoking

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

By: Rhiannon Ueberholz

(Hyson, 2020)

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. 

(Venture Academy, 2020)

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).

(, 2020)

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. 


American Lung Association. (2021). Freedom From Smoking. Retrieved from

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.

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.

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.

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.

Davis, J. (2021). Quit resources. Retrieved from

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.

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.

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.

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.

Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits. Journal of Psychosomatic Research, 57(1), 35–43.

Guendelman, S., Medeiros, S., & Rampes, H. (2017). Mindfulness and Emotion Regulation: Insights from Neurobiological, Psychological, and Clinical Studies. Frontiers in Psychology, 8.

Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2), 144–156.

Klein E., Brewer J. (2021). Ezra Klein Interviews Judson Brewer [Audio Podcast]. Retrieved from 

Larimer, M. E., Palmer, R. S., & Marlatt, G. A. (1999). Relapse prevention. An overview of Marlatt’s cognitive-behavioral model. Alcohol Research & Health: The Journal of the National Institute on Alcohol Abuse and Alcoholism, 23(2), 151–160.

MindSciences. (2021). Craving to quit. Retrieved from

Penberthy, J. K., Penberthy, J. M., Lynch, M., & Chhabra, D. (2017). Mindfulness based treatment for smoking cessation: How it works and future directions. Contemporary Behavioral Health Care, 2(1). 

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.

Westbrook, C., Creswell, J. D., Tabibnia, G., Julson, E., Kober, H., & Tindle, H. A. (2013). Mindful attention reduces neural and self-reported cue-induced craving in smokers. Social Cognitive and Affective Neuroscience, 8(1), 73–84.

Yang, H., & Ma, J. (2021). How the COVID-19 pandemic impacts tobacco addiction: Changes in smoking behavior and associations with well-being. Addictive Behaviors, 119, 106917.

Images (2020). Stressed Businessman with Broken Mechanism Head Screams [Photograph found in Stock Images]. Retrieved from 

Hyson. (2020). Balancing Stones [Photograph found in The Ultimate Morning Meditation for Relaxation]. Retrieved from 

Venture Academy. (2019). Teen Smoking [Photograph found in Teen Behavioural Treatment]. Retrieved from

Battling an Epidemic in the Face of a Pandemic:

COVID-19’s Detrimental Effects on the Opioid Epidemic 

By: Amy Rzezniczek

(Psychiatry Advisor, 2021)

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).3 They 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

(Immigration Canada, 2020).

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

(Wall Street Journal, 2020). 

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.17 Harm 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

(The Conversation, 2020).

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.


1Blancher, P. (2021, Feb 10). Opioid overdose numbers rise during pandemic. The Canadian Press.

2Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioids and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada; March 2021.

3CAMH. (n.d). Opioid Addiction. CAMH.

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. 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.

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.

9Myers, J., & Compton, P. (2018). Addressing the potential for perioperative relapse in those recovering from opioid use disorder. Pain Medicine, 19(10), 1908-1915.

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.

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.

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.

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.

15Centers of Disease Control and Prevention. (n.d). Syringe Services Programs.

16City of Toronto. (2019). Supervised Consumption Sites. City of Toronto.

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.

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.

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.

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.

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.

Photograph References

Immigration Canada. (2020). COVID-19 Isolation [photograph].

Psychiatry Advisor. (2021). Expert Perspective: The Opioid Crisis and COVID-19 [photograph]. Psychiatry Advisor.

The Wall Street Journal. (2020). Individual receiving opioid-use disorder medication treatment [photograph]. The Wall Street Journal.

Addressing Bisexual Substance Use: A Conversation Long Overdue

By: Karla Kovacek

Infographic by Karla Kovacek, template from CANVA is
licensed under a CC BY-NC-ND 2.0.

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:

  1. Compared to straight women, bisexual women have higher rates of alcohol use, cannabis use, and illicit drug use (including misuse of opioids).
  2. Compared to straight women, bisexual women are more likely to have a substance use diagnosis, and a nicotine dependence.
  3. 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:

  1. Compared to lesbian women, bisexual women have higher rates of binge drinking, cannabis use, illicit drug use (including misuse of opioids).
  2. Compared to lesbian women, bisexual women were more likely to be diagnosed with alcohol use disorder.
  3. 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.


Infographic by Karla Kovacek, template from CANVA is
licensed under a CC BY-NC-ND 2.0.

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?

Infographic by Karla Kovacek, template from CANVA is
licensed under a CC BY-NC-ND 2.0.

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.

Infographic by Karla Kovacek, template from CANVA is
licensed under a CC BY-NC-ND 2.0.

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

  1. Gates, G. (2011, April). How many people are lesbian, gay, bisexual, and Transgender? Retrieved April 20, 2021, from
  2. Government of Canada, S. (2020, September 09). Health risk behaviours, by sexual orientation and gender. Retrieved April 20, 2021, from
  3. 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:
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Livingston, N. A. (2017). Ecological momentary assessment of daily microaggressions and stigma-based substance use among lesbian, gay, and bisexual individuals
  9. 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:
  10. 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
  11. 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.

Hyperlink References

APA Dictionary (n.d.). Affirmative therapy. In dictionary. Retrieved April 1, 2021, from

APA Dictionary (n.d.). Coping strategy. In dictionary. Retrieved April 1, 2021, from

APA Dictionary (n.d.). Multicultural education. In dictionary. Retrieved April 1, 2021, from

Juergens, J., & Parisi, T. (2019, January 2). Illicit drug abuse and addiction. Addiction Center. Retrieved April 01, 2021, from

Mayo Clinic. (2017, October 26). Drug addiction (substance use disorder). Retrieved April 01, 2021, from

Mayo Clinic. (2018, July 11). Alcohol use disorder. Retrieved April 01, 2021, from

Mayo Clinic. (2020, March 14). Nicotine dependence. Retrieved April 01, 2021, from

Merriam-Webster. (n.d.). Microaggression. In dictionary. Retrieved April 1, 2021, from

Merriam-Webster. (n.d.). Monogamy. In dictionary. Retrieved April 1, 2021, from

Merriam-Webster. (n.d.). Prejudice. In dictionary. Retrieved April 1, 2021, from

The Center. (n.d.). Defining LGBTQ. Retrieved April 01, 2021, from

Destigmatizing MDMA-Assisted Therapy: Unlocking Why Legal PTSD Treatments Do Not Always Work

By: Victoria Donkin

Approximately 76% of individuals in Canada experience or witness a traumatic event in their lifetime.1 Of those individuals, approximately 10% will be diagnosed with posttraumatic stress disorder (PTSD).1 Individuals diagnosed with PTSD often avoid thoughts and feelings related to their trauma; however, despite this avoidance, the traumatic event is often re-experienced through nightmares, flashbacks, and intrusive recollections.5 This can be highly debilitating for the individual, impairing every day activities such as sleep and work and can lead to harmful coping strategies such as isolating oneself, addiction, and self-harming behaviours.2

Therefore, receiving treatment is critical! However, of the individuals that are able to receive treatment, only 32% of patients actually recover from their PTSD and demonstrate healthy functioning.3 4 5  Due to the low amounts of treatment success, researchers aim to identify new treatment methods to alleviate PTSD symptoms for individuals who do not respond well to traditional treatment. This includes the assistance of MDMA.

Infographic by Victoria Donkin, template from CANVA is licensed under a CC BY-NC-ND 2.0.

What are traditional treatments used to treat PTSD?

  1. Medication 

Although specific medication for PTSD does not exist, some psychologists recommend PTSD patients to take antidepressants to target certain mood symptoms associated with PTSD; however, this method of treatment shows low to modest effects in helping the overall disorder. Therefore, evidence-based psychotherapies are often the first-line of treatment.6

  1. Evidence Based Therapy (EBT) 

There are several evidence based treatment methods used to alleviate PTSD severity, predominantly: Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), Cognitive-Behavioural Conjoint Therapy (CBCT) and Prolonged Exposure Therapy (PE). 

Limitations to Current Treatment Methods 

Although the aforementioned treatments can be effective for many individuals with PTSD, the dropout rates from these treatments are fairly high, averaging to about 30% of patients. However, some patients may not even be able to obtain treatment due to high costs, inaccessibility, or stigmatization. Of the individuals able to obtain treatment, approximately 58%  still have diagnosable levels of PTSD after going through with their treatment.2 4 5  

Although many treatment options exist in treating PTSD, they often require a long-term commitment to attend multiple sessions, which can be financially costly, and difficult to maintain alongside family and work-related commitments. Additionally, to be able to engage in this healing process, patients need to be able to retrieve the emotions, thoughts, and memories central to their traumatic event; however, not all patients have the emotional ability to handle the distress that comes with treating PTSD. This distress can cause patients to resist treatment, distrust their clinician, or quit altogether. 7  

Therefore, clinicians have now begun to explore alternative treatment methods, such as MDMA assisted therapy, to help patients feel safe, open and trusting to the treatment process. 

The Mind on MDMA (Conner, 2020)

What is MDMA and how does it work? 

MDMA is a monoamine releaser that promotes the release of serotonin (stabilizes mood and feelings), dopamine (pleasure), noradrenaline (regulates arousal and vigilance), and oxytocin (encourages social-bonding and connection). Therefore, the bodily effects of MDMA allow patients to enter an “optimal arousal zone” where their distress and anxiety are mitigated, and they can better respond to therapy by feeling more open to trusting their therapist and partner if engaging in conjoint therapy.8

By including MDMA in psychotherapy treatment, patients can decrease their fear response without blocking their accessibility to trauma-related memories so that they can engage in the process of identifying their emotions and thoughts without feeling distressed by them. This is because MDMA has also shown to decrease activity in the fear processing system of our brain  (where PTSD individuals have increased levels), and an increase in areas responsible for processing information.8 However, it is essential to clarify that MDMA-assisted therapy is not for ALL patients with PTSD. It is ONLY recommended for those that are physically, emotionally, and mentally unable to process their trauma in regular treatment.6

MDMA-Assisted Therapy Session (MAPS Europe, n.d.)

How was MDMA introduced into the therapeutic setting? 

MDMA was combined with therapy starting from the 1970s, where psychotherapists acknowledged its ability to allow patients to have insight into their own problematic patterns, heightening their self-reflection. However, the euphoric, pro-social feelings that MDMA provides garnered traction as a recreational substance within night-club settings rather than a therapeutic one. This became problematic, as the drug itself can moderately increase body temperature and blood pressure, which, combined with other substances and the warm atmosphere of dance clubs, led to several heatstroke deaths. This contracted some concern leading to its criminalization in 1985. However, many physicians, clinicians, and researchers protested and testified in favour of using MDMA in a therapeutic setting, gaining special permission and regulation to use MDMA for research purposes within the last 15 years for clinical testing.9

What is MDMA assisted therapy? 

MDMA assisted therapy incorporates the substance “3,4- methylenedioxymethamphetamine” (also known as MDMA) into regular evidence-based psychotherapies.10  For example in CBCT there are 15 sessions in total that enable a traumatized individual and their close other to engage in cognitive work to address what thoughts are central to their trauma, and develop skills to communicate effectively with one another. 

When performing MDMA-assisted CBCT, two additional MDMA sessions are added to the original protocol. The protocol guidelines of MDMA assisted sessions are regulated broadly across all research.8 In these sessions participants are given 75 mg of MDMA, and are offered an option half-dose (37.5 mg) after 90 minutes of the first dose (the approximated time that the first-dose takes to display full effects) due to potential differences in substance tolerances. 

Participants are then seated in reclinable lounge chairs, where they are encouraged to spend time alternating from independent “inside” time (with headphones playing pre-selected music and eyeshades) and “outside” time where their headphones and eye shades are taken off and they converse with their partner and or therapists. The alternations between “inside” and “outside” time are six hours long. Their feelings of distress and blood pressure/temperature are checked to ensure safety during substance consumption. The participants then stay overnight during the night of the MDMA-assisted session, where they are checked on by a night assistant to ensure continuous safety. They then are debriefed and assigned out-of-session assignments by their two therapists, that continue to work on the skills taught in the CBCT sessions. The second MDMA session follows the same protocol, but participants are offered a choice between 75mg or 100mg to start, and once again, an additional half-dose after 90 minutes.11 

Patient During “Inside Time” (Horton, 2016)

Is MDMA safe to use alongside treatment?

MDMA-assisted therapy is carefully controlled and has been shown to be safe in the therapeutic setting. Particularly, because MDMA is typically only used in 2-3 sessions, health concerns are constantly monitored when taking the substance. Additionally, several studies have used drug screens after treatment to test whether the use of MDMA within a few sessions could cause dependence or recreational use outside of treatment. It was found that no participants used MDMA following treatment or during treatment. 8 12 13

How Has MDMA Shown To Be Successful in Treating PTSD? 

In a study by Mithoefer and colleagues (2013), 74% of the participants who underwent MDMA-assisted therapy demonstrated long-lasting relief of PTSD symptoms. 89% of the participants also had continued self-awareness and understanding post-treatment, 68% had increased emotional ability, and 58% of the participants had improved relationships with their close others. Mithoefer and colleagues (2018) continued their MDMA-assisted therapy research, examining veteran and first responder patients. 85% of the participants treated with 75 mg of MDMA no longer met PTSD diagnoses at the end of treatment. Two-thirds of those participants had continued remission after one full year.8

Of those participants, an individual identified as Lubecky provided his thoughts on how the therapy helped him. Lubecky expressed that his suicidal ideation disappeared after treatment, and his depression was now almost 70% gone, whereas his PTSD reduced by 50%. He states that he feels like a better father, son, and husband to his family. The treatment allowed him to function in his everyday life, enabling him to return to work. His goal post-treatment is that everyone with PTSD knows that this MDMA-assisted treatment is coming and that there is hope, and that others don’t get to the point that he was, where he wanted to take his own life.14

There are some barriers preventing wider use of assisted therapy:

If MDMA-assisted therapy is so beneficial, why is it not widely used? 

1.The criminalization of MDMA makes funding for research difficult, which can serve as a barrier to making MDMA-assisted therapy accessible!

2. Stigmatizing myths that perpetuate criminalization misinform the public on the effects of MDMA, further creating barriers to making this treatment widely available!

Common Misconceptions about MDMA

1. Researchers examining the effects of MDMA-assisted therapy are NOT attempting to pass MDMA as a sole PTSD medicinal treatment. If MDMA becomes approved for general clinical practice, it would not be something prescribed to patients to pick up independently at the pharmacy, it would be given to specialized clinics under supervision.8 Therefore it should always be referred to as MDMA-assisted therapy, as MDMA itself is not the treatment. 

2. MDMA is NOT “ecstasy” or “molly.” When MDMA-assisted therapy research entered mainstream media, individuals were using MDMA and ecstasy interchangeably. Street substances sold under the name ecstasy, molly, or even MDMA, often do not contain pure MDMA and are made from unknown and dangerous components. In research utilizing MDMA, a purified substance is used, where small to moderate doses are given. The doses given are scientifically measured to be of safe human consumption. Media suggesting that MDMA-assisted therapy utilizes ecstasy, undermines the success of these treatments, and makes it harder to decriminalize the substance for clinical use. 6

3. The use of MDMA in clinical settings does NOT cause substance-abuse post-treatment. Several studies utilizing drug-tests have examined if MDMA-assisted therapy enables other recreational drug use, and they have all shown that it does not. 8 12 13

BIPOC Representation (PTSD Health, 2020)

Limitations of MDMA-Assisted Therapy 

Much research has identified that trauma and PTSD disproportionately affect BIPOC individuals as well as low-income communities. However, these populations also demonstrate higher rates of comorbid substance use disorder with their PTSD diagnoses. Due to these dual disorders, it is unlikely that these populations were used in MDMA-assisted therapy research trials. Individuals with active-substance use disorders were excluded from research to date as the effects of MDMA causing addiction post-treatment had not been examined. However, by decriminalizing MDMA from clinical settings, more funding for research can be provided to better support marginalized communities through this treatment method. 15 16 17 18

Future Steps

1. Help legalize the use of MDMA in clinical settings to provide more accessibility to marginalized communities. Clinicians must advocate for this form of treatment and support novel research that demonstrates a significant alleviation of PTSD severity.

2. Train various forms of “therapists” to administer MDMA-assisted therapy to reach different communities. Different mental health practitioners such as social workers, psychotherapists, psychiatric nurses, clinical psychologists, and psychiatrists reach diverse populations with varying incomes. By training various professionals, more populations will be able to receive this treatment.  

3. Be vocal to local administrators and government representatives on the necessity of a diverse range of treatments! Having a “one treatment fits all” mentality actually worsens society’s mental health; by educating the public on different modes of treatment and how they benefit their target recipient, we can de-stigmatize treatment and mental illness! 


  1. Van Ameringen, M., Mancini, C., Patterson, B., & Boyle, M. H. (2008). Post‐traumatic stress disorder in Canada. CNS neuroscience & therapeutics, 14(3), 171-181.
  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
  1. Bisson, J. I., Cosgrove, S., Lewis, C., & Roberts, N. P. (2015). Post-traumatic stress disorder. Bmj, 351.
  1.  Cloitre, M. (2009). Effective psychotherapies for posttraumatic stress disorder: a review and critique. CNS spectrums, 14(1), 32-43.
  1. Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (Eds.). (2010). Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. Guilford Press.
  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
  1. Zepinic, V. (2015). Treatment resistant symptoms of complex PTSD caused by torture during war. Canadian Social Science, 11(9), 26-32.
  1. Lawrence, J. (2018). Like a hug from everyone who loves you- how MDMA could help patients with trauma. The Pharmaceutical Journal. Doi: 10.1211/PJ.2018.20205586
  1. Hutchison, C. A., & Bressi, S. K. (2018). MDMA-Assisted psychotherapy for posttraumatic stress disorder: Implications for social work practice and research. Clinical Social Work Journal, 1-10.
  1. Danforth, A. L., Struble, C. M., Yazar-Klosinski, B., & Grob, C. S. (2016). MDMA-assisted therapy: a new treatment model for social anxiety in autistic adults. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 64, 237-249.
  1. Wagner, A. C., Mithoefer, M. C., Mithoefer, A. T., & Monson, C. M. (2019). Combining cognitive-behavioral conjoint therapy for PTSD with 3, 4-methylenedioxymethamphetamine (MDMA): A case example. Journal of psychoactive drugs, 51(2), 166-173.
  1. Lawrence, J. (2021, February 12). ‘Like a hug from everyone who Loves you’ – How MDMA could help patients with trauma. 
  2. Feduccia, A. A., Holland, J., & Mithoefer, M. C. (2018). Progress and promise for the MDMA drug development program. Psychopharmacology, 235(2), 561-571.
  1. Mithoefer, M. C., Mithoefer, A. T., Feduccia, A. A., Jerome, L., Wagner, M., Wymer, J.,… & Doblin, R. (2018). 3, 4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for post-traumatic stress disorder in military veterans, firefighters, and police officers: a randomised, double-blind, dose-response, phase 2 clinical trial. The Lancet Psychiatry, 5(6), 486-497.
  1. Slopen, N., Shonkoff, J. P., Albert, M. A., Yoshikawa, H., Jacobs, A., Stoltz, R., & Williams, D. R. (2016). Racial disparities in child adversity in the US: Interactions with family immigration history and income. American journal of preventive medicine, 50(1), 47-56.
  1. Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C. (2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychological medicine, 41(1), 71.
  1. McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: Policy implications. Health Affairs, 27(2), 393-403.
  1. Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2012). Physical health conditions associated with posttraumatic stress disorder in US older adults: results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of the American Geriatrics Society, 60(2), 296-303.

Image References

Conner, C. (2020). [The Mind on MDMA]. The New York Times.

Horton, A. (2016). [Patient During “Inside Time”]. Stars and Stripes.

MAPS Europe. (n.d.). [MDMA-Assisted Therapy Session]. MAPS Europe.

PTSD Health (2020). [BIPOC Representation]. Health Magazine.

E-Cigarettes: The First Step in Treating Addiction is Recognizing a Problem Exists in the First Place

Research study shows an effective way to measure nicotine addiction in teenagers.

By: Taylor Meiorin, Eden Prisoj, Rhiannon Ueberholz, Katherine Lara Derikon

Electronic cigarette (e-cigarette) consumption has been rapidly increasing among adolescents. Recent findings from the 2018-2019 Canadian Student Tobacco, Alcohol and Drugs Survey found that 20% of students in grades 7 to 12 reported using e-cigarettes in the past 30 days (Health Canada, 2019). Even though e-cigarettes are promoted as a smoking cessation tool and a healthier alternative to traditional combustible cigarettes, the risks associated with such products are vast (Vogel et al., 2019). Specifically, these products have been associated with pulmonary damage, exposure to harmful toxins, and throat cancer (Youth and tobacco use, 2020).

The story of Simah Herman (Hawkins et al., 2019) provides an example of the detrimental effects that e-cigarettes can have on adolescent’s health. Herman is an 18-year-old girl who, like other teenagers, started using e-cigarettes because ‘’she thought it made her look cool’’. However, after having trouble breathing, she was rushed to the hospital and was diagnosed with what the doctors initially believed to be pneumonia. Two days after being admitted to the hospital, Herman’s health rapidly declined; she was put on a ventilator and shortly after, a medically induced coma. Her cousin revealed that Herman had been regularly smoking e-cigarettes, leading her doctors to conclude that Herman’s condition was caused by vaping. As Herman began to recover, she vowed to start a “No vaping” campaign, using her experience as an example of the terrible consequences that e-cigarettes can have on adolescents’ health.

Herman’s story highlights an interesting difference between adults and teenagers’ reasons for using e-cigarettes. Adults largely use these products to control and overcome their nicotine addiction. Conversely, teenagers may use these products because they see them as a cool trend among their peer group and are appealed by the variety of flavours (Youth and tobacco use, 2020). Stories like this also make us remember that there is a reason why consumption of nicotine is illegal for underage individuals. 

We might be shocked by a 14-year-old holding a Marlboro cigarette, but perhaps not so much when we see them smoking e-cigarettes that mainly look like ‘’cute electronic sticks’’. Moreover, 42% of adolescents who use electronic cigarettes have never smoked a traditional cigarette which shows how this trend is becoming even more popular than cigarette consumption (Health Canada, 2019). These findings make it even more imminent to establish accurate ways to assess e-cigarette intake and hazardous youth consumption patterns.  

Unfortunately, research in this area has primarily focused on adults, and there are currently no validated or rigorously tested methods for assessing levels of e-cigarette addiction and frequency of use among adolescents. For instance, The Penn State E-cigarette Dependence Index has been widely used as an assessment tool and measure of e-cigarette dependence among adults (Vogel et al., 2019). However, its ability to accurately detect e-cigarette addiction in adolescent populations remains a mystery (Vogel et al., 2019).

Studying Nicotine Addiction in Adolescents

Due to these gaps in scientific literature, researchers from the University of California devised a fascinating study to measure e-cigarette addiction and frequency of e-cigarette use among adolescents (Vogel et al., 2019). This study’s primary goal was to identify an accurate test that clinicians and researchers can administer to adolescents to assess how often they are using e-cigarettes and whether or not they are addicted to such products.

Participants enrolled in this study were asked to provide saliva samples in order to measure their levels of nicotine exposure. Participants then completed two tests which were designed to assess how often they use e-cigarettes. The first test titled, Sessions Per Day (SPD), asked participants to report how many times a day they use e-cigarettes, and the second test asked participants to estimate how many days per month they use e-cigarettes.

The researchers then had participants complete three additional tests, which were specifically designed to measure e-cigarette addiction. The first of which was the Penn State Electronic Cigarette Dependence Index (ECDI) which asked questions such as “do you use an e-cigarette now because it is really hard to quit?” and “do you ever have strong cravings to use an electronic cigarette?”. The second test participants completed was the Heaviness Vaping Index (HVI) which contained questions such as, “on days that you can use your electronic cigarette freely, how soon after you wake up do you first use your electronic cigarette?”. Lastly, participants completed the E-Cigarette Addiction Severity Index (EASI), which contained one question asking, “On a scale of 0%–100% (not addicted to extremely addicted), how addicted to e-cigarettes do you think you are?”. 

Which Test Was The Best?

After participants completed each test, the researchers compared their responses with the actual nicotine levels in their saliva. In making these comparisons, researchers were trying to find which tests have the strongest association with actual nicotine exposure. Finding a strong association allows the researchers to determine which test can best predict how much adolescents are actually vaping compared to what they report on the tests, which is needed to accurately diagnose e-cigarette addiction. 

When testing how often adolescents were using e-cigarettes, both these tests (vaping sessions per day or days vaping per month) were equally accurate at predicting nicotine levels in saliva, but since it is a lot easier for adolescents to report how many days in a month they are vaping, this was concluded to be the best way of assessing how often e-cigarettes are being used. Out of all the tests used to assess e-cigarette addiction, the best one was the Self-Described Degree of Addiction (the EASI). This EASI did just as well as the other tests at predicting nicotine levels, but since it is the fastest to complete, having only one question, the researchers decided it was the most logical to use. 

When deciding which test is best in identifying high risk nicotine use, researchers are always looking for parsimony: the simplest and most accurate way to diagnose addiction. Sometimes a diagnostic test contains a lot of questions that aren’t needed and don’t actually relate to addiction. Parsimony helps researchers make sure the tests they’re using actually captures the thing they are trying to measure. 

The recommendations that the researchers make are that two questions are sufficient to determine how often adolescents are vaping and their level of addiction: (1) “How many days in a month do you vape?”, and (2) “Rate your perceived level of addiction”. They also state that the longer questionnaires, like how many vaping sessions a day adolescents engage in and the ECDI can be used to get a bigger picture of addiction.

Thinking Critically

It’s important to think critically about any research study. It should therefore be noted that since the researchers are trying to define addiction and amount of vaping over a longer period of time, measuring nicotine levels only once might not be the most useful way of determining if these tests are accurate. Think about it this way: if an adolescent vaped a lot the night before coming to the experiment, they would have high levels of nicotine in their saliva. If this is out of character for them, they would still report that they don’t vape that often and wouldn’t rate their addiction as severe, so their answers on these two tests would not accurately reflect the level of nicotine found. So for future studies, it might be more beneficial to look at nicotine levels over a longer period of time.

It can also be noted that the participants in this research were mostly young, white males. To make sure the EASI accurately captures e-cigarette addiction in all adolescents, it would be important to look at a larger demographic. Factors of gender, race, and socioeconomic status might affect the way individuals perceive e-cigarette use and their willingness to admit that they have an addiction. Individuals from different groups define addiction differently, so asking everyone to rate their addiction might lead to varying interpretations of the test, meaning the EASI might not work the same for everyone.

Next Steps and Treatment 

E-cigarettes are effective at helping those with tobacco use disorder in quitting. However, they are now being viewed as a public health concern due to their misuse – particularly among youth. Adolescents tend to view e-cigarettes as less harmful than combustible cigarettes, as previously mentioned, and mistakenly believe that they entail different social and health outcomes (Chaffee et al., 2015). In reality, e-cigarette use actually heightens exposure to nicotine and several other toxic (and potentially cancerous) substances and increases risk of transitioning to using other substances, like alcohol and cannabis (Gilbert et al., 2020).

This perception of e-cigarettes is incredibly worrying, given the negative health effects that continued use can lead to. Even in the short-term, e-cigarette use can damage various organ systems, resulting in a range of adverse effects, including shortness of breath, wheezing, nausea, and ulcers (Seiler-Ramadas et al., 2020). On the extreme end, tragic circumstances similar to those of Simah Herman can ensue. E-cigarette use is particularly advised against for adolescents due the fact that their brain is still developing, and the consequences on memory and learning that follow use may end up lasting.

Vogel et al. (2019) took a step towards correcting these issues by conducting research on adolescent e-cigarette use and singled out the EASI as the best general measure of addiction. This was a considerable achievement, as there was previously little agreement among researchers regarding what tests to use when assessing e-cigarette use, so this finding allows for accurate comparison across studies.

Future research should be aimed at studying the relationships with other indicators of addiction, such as withdrawal. It may also be useful to conduct this research again using a more representative sample (with participants of differing ages, races, and so on), given how similar subjects in this study were demographic-wise.

Until such research is carried out, efforts should be focused on preventing e-cigarette use by implementing policies and laws that make it clear that they are to be used as cessation aids for adults with tobacco use disorder – they are not intended to be substitutes for smoking combustible cigarettes.

For those looking to quit using e-cigarettes, treatment typically involves prescribed medication, such as nicotine replacement therapy (NRT), in which the person uses nicotine patches that deliver constant doses of nicotine to suppress withdrawal. Behavioural counselling can also be extremely helpful. CAMH is a resource that can assist those of all ages in combating addiction, and resources like Kids Help Phone and are specially catered to youth seeking guidance and treatment.


Brown-Johnson, C. G., Burbank, A., Daza, E. J., Wassmann, A., Chieng, A., Rutledge, G. W., & Prochaska, J. J. (2016). Online Patient–Provider E-cigarette Consultations. American Journal of Preventive Medicine, 51(6), 882–889.

Chaffee, B. W., Gansky, S. A., Halpern-Felsher, B., Couch, E. T., Essex, G., & Walsh, M. M. (2015). Conditional Risk Assessment of Adolescents’ Electronic Cigarette Perceptions. American Journal of Health Behavior, 39(3), 421–432.

Gilbert, P. A., Kava, C. M., & Afifi, R. (2020). High-School Students Rarely Use E-Cigarettes Alone: A Sociodemographic Analysis of Polysubstance Use Among Adolescents in the United States. Nicotine & Tobacco Research, 23(3), 505–510.

Hawkins, S., Walker, K., Riegle, R. & Rivas, A. (2019) Teeen who was put on life-support for vaping says ‘’I didn’t think of myself as a smoker’’. ABC News. 

Health Canada. (2019). Summary of Results for the Canadian Student Tobacco, Alcohol and  

Drugs Survey 2018-19

Johnson, S. (2017). Blu, Vuse, Njou e-cigarette [Online image]. Flickr. 

Johnson, S (2018). Man Vaping Thick Clouds From His E-cigarette [Online image]. Flickr. 

Kids Help Phone. (2021). Substance use.

Levy, S. (2019, November 1). Vaping: It’s hard to quit, but help is available. Harvard Health 


Seiler-Ramadas, R., Sandner, I., Haider, S., Grabovac, I., & Dorner, T. E. (2020). Health effects of electronic cigarette (e‑cigarette) use on organ systems and its implications for public health. Wiener Klinische Wochenschrift, 1–8.

Smokefree Teen. (n.d.). Become a Smokefree Teen.

The Center for Addiction and Mental Health. (2021). Nicotine Dependence Clinic.

Vogel, E. A., Prochaska, J. J., & Rubinstein, M. L. (2020). Measuring e-cigarette addiction among adolescents. Tobacco Control, 29(3), 258-262. 

Woman Vaping on Electronic Cigarette (JUUL) [Online image]. (2018). Flickr. 

Youth and tobacco use. (2020, December 16). Retrieved March 10, 2021, from 

The Real Culprit of Unsafe Drug Use: STIGMA

Debunking Stigmatizing Myths: Why Harm Reduction Matters in Your Community

Victoria Donkin, Sara Mansueto, Hannah Rasiuk & Amy Rzezniczek

Protest against Safe Injection Sites in Philadelphia (Reed, 2020)

Rates of overdose-related deaths in Toronto reached new records in 2020, exceeding COVID-19 mortalities in the month of June1. While media attention remains focused on the local impact of the pandemic, the opioid crisis continues after claiming over 14,000 Canadian lives over the past four years.1 The severity of this public health issue has prompted researchers to investigate the barriers that prevent access to harm reduction services for those affected by addiction. Harm reduction utilizes an evidence-based, public health framework, to decrease substance-related risk.2 This includes reducing rates of overdose, spread of infectious diseases, and ensuring safer substance use practices.3

In a study by McGinty and colleagues (2018) it was found that individuals with a substance use disorder were highly stigmatized and were seen as less deserving.2 Stigma refers to the negative attitudes and beliefs that are developed about an individual or a group.4 This ultimately reduced public support for harm reduction strategies, affecting the accessibility to these services.2 A local example of this can be seen in Premier Doug Ford’s decision to defund safe injection sites in the affluent neighbourhood, Cabbagetown, due to residential complaints.5 

We aim to further examine the effects of stigma and debunk common false beliefs about harm reduction strategies and those who use substances. Therefore, this post provides factual information on what these services actually do and how they are essential in supporting those with substance use disorders. To engage in the process of de-stigmatization, it is necessary to identify our own stigmatizing beliefs to improve the opioid crisis.6 The “Fact or Fiction” portion of this post serves to assist readers in this process. Additionally, how stigma impacts the lived experience of those with a substance use disorder is crucial in identifying barriers to harm reduction services and how it maintains the opioid health crisis. In order to do this, we interviewed an individual with an opioid-related substance use disorder, who also is a harm reduction worker. N.S. is a 24 year old male, who works at a homeless shelter in an affluent Toronto neighbourhood, where he provides safe syringe services and clean supplies for substance use and disposal. 

Firstly, we asked N.S. what the response has been within the neighbourhood surrounding his workplace, to better understand how citizens from affluent communities react to harm reduction services:

Debunking Myths About Harm Reduction Strategies 

5 Types of Harm Reduction Strategies and What They Actually Do 

1. Opioid Agonist Therapy: In this service, medication based treatment plans are provided to individuals with severe opioid-related substance use disorders. Opioid agonist therapy can enable individuals who are addicted to opioids to stabilize their lives, as it alleviates cravings of opioids, terminates withdrawal symptoms, and prevents the “high” feeling that opioids provide.7

There are two main opioid agonist therapies available in Canada: 

a) Methadone Maintenance Therapy (MMT): an orally provided synthetic opioid used to transition individuals off of opioids. This is a long term program that intends to reduce and ultimately eliminate opiate use, as well as reduce the contraction of injectable drug-related infections such as HIV, and Hepatitis B and C.8

b) Buprenorphine Maintenance Treatment (BMT; also known as Suboxone): an orally provided synthetic opioid that is composed of both buprenorphine and naloxone. This form of therapy bears similar results and effects as MMT with the addition that the suboxone blocks the effects of other opioids. Therefore, it also causes immediate withdrawal-like symptoms (e.g. uncontrollable vomiting) if individuals on this program partake in additional opioid consumption.7

We asked N.S. how MMT has helped him:

2. Naloxone Services: Naloxone is a medication based therapy that is an opioid antagonist, used  during an overdose to rapidly reduce its effects, similarly to an epipen during an allergic reaction. It can save someone from an opioid overdose as it works by immediately stopping the effects of the opioid. It comes in injectable or intranasal (i.e. inhalable) forms. Many safe injection sites, homeless shelters and healthcare facilities provide this service, as well as train others to be able to help community members in case of overdose emergencies.3

Naloxone Kit (Noelville Pharmacy, 2020)

3. Safe Syringe Programs/Services: The distribution of sterile syringes for individuals who use injectable substances, as well as the safe disposal of materials to ensure no cross contamination occurs, reducing rates of HIV and Hepatitis.9

Fact or Fiction? Supervised Injection Sites Provide Individuals With Drugs.


4. Supervised injection sites do not provide individuals with substances. Those wishing to consume substances within supervised injection sites bring their own injectables onto site, and are provided with sanitary supplies (e.g. syringes) to consume their substance in a safe, neutral, sanitary and supervised environment, reducing rates of infectious diseases and overdoses.3 Once the individual has injected their substance, they are then monitored to ensure they do not experience a negative drug reaction or overdose.10 Additionally, individuals can be provided with further resources or referrals related to health or social support.11

Safe Injection Site in Surrey, British Columbia (The Star, 2017)

Fact or Fiction? There are Harm Reduction Services That DO Provide Substances. 


5. Safe Supply Programs prescribe pharmaceutical grade substances (e.g. hydromorphone; also known as dilaudids) to individuals at risk for overdoses. These services aim to regulate opioid use as the opioids distributed in unregulated markets (the streets) have a higher chance of causing death as they are often of high-potency, or are unknowingly mixed with other substances such as fentanyl. Between 2016 and 2018, 10,000 Canadians died due to an opioid related overdose. Of these individuals, 73% were accidental opioid related deaths caused by fentanyl.

Therefore, safe supply programs are necessary as they:

a) Reduce the rate of injectable drug use by 25% by providing an oral alternative.

b) Reduce the rate of contracted HIV and Hepatitis11.

To see how this myth posed as a barrier to receiving harm reduction services, we asked N.S. what his experience was:

Fact or Fiction? Harm Reduction Services Encourage Drug Use.


The success of harm reduction strategies is NOT measured by lower rates of drug use, but is measured by an increase in quality of health. This misconception is often what perpetuates societal stigma, as people think that harm reduction efforts perpetuate drug use. No research has shown that these services increase drug use.12 The stigma around these programs have led to the devaluation of the research that supports these evidence-based strategies. Many individuals using these services already have long-term substance use disorders; therefore, these services aim to prevent overdoses and decrease public drug use.10 Additionally, no research has found that these services enable individuals to relapse.13 

Fact or Fiction? Harm Reduction Services Increase Criminal Activity In My Neighbourhood.


Harm reduction services have not been shown to increase crime rates in neighbourhoods.13 These sites are specifically placed in neighbourhoods where there is a pre-existing need for them (where drug consumption already has an impact on that community). Some research has even demonstrated that these services are associated with a decrease in crime.13 Additionally, using drugs is not a criminal concern, however, using this framework criminalizes people who need help. The stigma surrounding substance use instills unnecessary fear and labels populations who need harm reduction services as “dangerous.” This stigmatizing narrative further encourages residential protests against services from populating in neighbourhoods that need it most.

How Do Harm Reduction Services Benefit My Community? 

1. Lowers public drug use.3

2. Decreases the usage of other healthcare services, enabling lower wait times for community members, and providing a cost-effective solution.13

3. Provides resources and makes referrals for individuals interested in mental health, physical health or social services. This connection enables an increase in the use of detox programs and medication assisted therapy (e.g. MMT), which can reduce drug use.3

Debunking Myths About People Who Use Substances

Fact or Fiction? People Who Are Addicted To Drugs Lack Self-Control and Have Failed Morally.


Addiction cannot be reduced to the simple conclusion that individuals just lack self-control. Many more complicated physiological and psychological factors contribute to drug use. Additionally, using drugs has nothing to do with morality. People who have a substance use disorder do not have control over their drug use. This is why treatment and harm reduction strategies like syringe service programs or safe consumption sites exist.

Fact or Fiction? Individuals Who Use Substances Are Different From Everyone Else In Society.


People who use drugs are more similar than dissimilar from those who do not. People who use drugs are human, but social stigmatization constructs them as inherently different. This stigmatization isolates people who use drugs from society, creating a sense of alienation that has real consequences. 

What is different in people who use drugs is the way they respond to the drug being used. Serious substance use can actually rewire the brain of individuals.14 When people use drugs, the brain’s pleasure pathway is activated. When drugs are used frequently this pleasure pathway can become less active in response to using the drug. Therefore, the experience of pleasure from using drugs diminishes. Instead, the pathway starts to activate before drugs are even consumed.14 This causes an increase in wanting a drug and a simultaneous decrease in liking a drug. Evidently, rewiring begins to occur making serious substance use a health issue rather than a personal issue! As a health issue, rehabilitation methods can be used to work towards rewiring the brain back to its previous state. 

(Recovery Centers of America, n.d)

What are the Consequences of Stigmatizing Drug Use?

On the individual level, stigmatization can be internalized which can lead to feelings of shame and to self-blame for drug using behaviour.15 This can lead to further mental health problems, such as depression, which may maintain and exacerbate drug use.16 Individuals who use drugs are affected on a social level by learning to fear the discriminatory effects of stigma. This fear has real-world consequences, as it impacts health care behaviour, seeking treatment, and healthcare system engagement. Stigmatization is associated with dangerous health behaviours. For example, people who use drugs often avoid stigmatization that may be experienced when buying syringes at the pharmacy by reusing or sharing syringes with others.16 This increases risk for contracting and spreading HIV. Additionally, individuals with addictions struggle to enroll in treatment because they fear being stigmatized for needing help.

N.S. demonstrates this stigma by stating: 

In the healthcare system, individuals with addictions report experiencing discrimination.15 They report slower care, receiving less empathy, being dismissed or ignored and experiencing poorer quality treatment. Individuals who use drugs quickly learn to expect future discrimination; therefore, they are less likely to seek care from the healthcare system. This can be dangerous, as untreated needs can lead to death.17

N.S. elaborates on how he has experienced discrimination in healthcare: 

What Can We Do Moving Forward? 

Although evidence based research has aimed to dismantle misconceptions on harm reduction practices, negative beliefs continue to be held by the general population. It is quite common to rely on our automatic negative thoughts and others’ opinions when it comes to matters such as these; however, it is important to fact check and do research before making assumptions about harm prevention programs, and the people they serve. 

As demonstrated  throughout this blog post, opinions of community members have a strong influence on decisions made by the government – especially when it comes to implementing safe injection programs, homeless shelters and safe syringe exchange programs. It is our job as civilians to properly educate not only ourselves, but those around us about the importance of these programs, as well as to debunk myths and dissolve these stigmas.

It is also the government and public health organization’s responsibility to determine ways in which the general public can easily understand the importance of these programs. Experts in the field suggest that using personal stories, evidence-based stigma reduction content and educational information can increase public support for policy decisions regarding safe injection sites and syringe exchange programs.2 Therefore, it is critical that we continue to amplify the voices of those that use harm reduction services, and advocate for the widespread implementation of these services where they are needed.  

To Learn More About:

Safe Injection Sites

Syringe exchange programs

Toronto Harm Prevention Locations (Safe Injection Sites and Syringe Exchange Programs)

Opioid Agonist Therapy and GTA Locations

Opioid Agonist Therapy and Canada Wide Locations


1Rider, D. (2020, August 11). Toronto overdose deaths hit a grim new record in July, taking more lives than covid-19. Toronto Star.

2McGinty, E. E., Stone, E. M., Kennedy-Hendricks, A., & Barry, C. L. (2019). Stigmatizing language in news media coverage of the opioid epidemic: Implications for public health. Preventive Medicine, 124, 110-114.

3CAMH. (2016). Opioids and addiction: A primer for journalists.

4CMHA. (n.d.). Stigma and discrimination.

5CBC News. (2019, April 1). Province cut some injection sites because area residents ‘upset’, Ford says.

6Strike, C., Miskovic, M. (2017). Zoning out methadone and rising opioid-related deaths in Ontario: Reforms and municipal government actions. Canadian Journal of Public Health, 108(2), 205-207. https://doi:10.17269/CJPH.108.5858

7Alberta Health Services. (2018). Opioid dependency program: Suboxone information for clients.

8CAMH. (2020, August). Methadone: Modifications to opioid agonist treatment delivery – march 22, 2020. 

9Abdul-Quader, A. S., Feelemyer, J., Modi, S., Stein, E. S., Briceno, A., Semaan, S., Horvath, T., Kennedy, G. E., & Des Jarlais, D. C. (2013). Effectiveness of structural-level Needle/Syringe programs to reduce HCV and HIV infection among people who inject drugs: A systematic review.AIDS and Behavior, 17(9), 2878-2892.

10Kennedy, M. C., Karamouzian, M., & Kerr, T. (2017). Public health and public order outcomes associated with supervised drug consumption facilities: A systematic review. Current HIV/AIDS Reports, 14(5), 161-183.

11Ontario HIV Treatment Network. (2020, April). Possible benefits of providing safe supply of substances to people who use drugs during public health emergencies such as the COVID-19 pandemic.

12City of Toronto. (2019, February 12). Expanding opioid substitution treatment with managed opioid programs.

13City of Toronto. (n.d.). Supervised injection sites.

14Erickson, C. K. (2018). The science of addiction: From neurobiology to treatment. WW Norton & Company.

15Muncan, B., Walters, S. M., Ezell, J., & Ompad, D. C. (2020). “They look at us like junkies”: Influences of drug use stigma on the healthcare engagement of people who inject drugs in new york city. Harm Reduction Journal, 17(1), 1-9. 00399-8

16Latkin, C., Davey-Rothwell, M., Yang, J., & Crawford, N. (2013). The relationship 

between drug user stigma and depression among inner-city drug users in Baltimore, MD. Journal of Urban Health, 90(1), 147-156.

17Paquette, C. E., Syvertsen, J. L., & Pollini, R. A. (2018). Stigma at every turn: Health services experiences among people who inject drugs. The International Journal of Drug Policy, 57, 104-110.

Image References

Noelville Pharmacy. (2020). [Naloxone kit].

Recovery Centers of America. (n.d). [Support group]. Recovery Centers of America. 

Reed, M. (2020). [Protest against safe injection sites in Philadelphia]. The Philadelphia Inquirer.

The Star News. (2017). [Safe injection site in Surrey, British Columbia]. The Star News.

Resource References

CAMH. (2018). Harm reduction: Where to go when you’re looking for help.

Canadian Centre for on Substance Use and Addiction. (2004). Needle exchange programs FAQ. 

National Institute on Drug Abuse. (2020, May). Drug facts: Prescription Opioids.

St. Michael’s Unity Health Toronto. (n.d.). Mental health and addictions service: Rapid access clinic. St. Michael’s Hospital.

True North Addiction Medicine Program. (n.d). Substance use and treatment.