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

By Jenna Vieira

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

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

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

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

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

What the research says

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

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

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

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

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

Why does this matter?

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

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

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

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

What clinicians and universities can do

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

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

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

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

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

What you and I can do

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

Images

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

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

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

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

by Krisoula Kotassidis 

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

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

Let’s talk labels first

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

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

From minority stress to substance use to substance use disorders

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

Image by: NCTE
[Photo description: Activists on the street protesting for transgender rights. They are standing in front of a historical building and only their heads are depicted in the picture. One person, closest to the camera, holds a sign reading “We want to live free”. The rest of people are holding primarily transgender flags, and one person is holding the US flag].
This image has an empty alt attribute; its file name is K_Image3.jpg
Infographic made on Canvas by: Krisoula Kotassidis

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

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

Screening & timely intervention: An example 

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

  • identify users who are at risk of developing a substance use disorder
  • intervene when the individual is engaged in high-risk substance use, and
  • refer individuals with severe use to a specialist. 
Image by: SAMHSA
[Image description: Four smaller pictures places next to each other creating a square and showing images of family, friends, and a hospital setting with a doctor standing in front of the camera having their hands crossed. On the right side the background of the image is in blue reading “SBIRT: Screening, Brief Intervention and Referral to Treatment”].

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

Is SBIRT trans inclusive?

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

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

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

What if SBIRT (trans)itions?

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

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

How does peer support work?

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

How you can help 

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

Photo credit: John Keon, 2018
[Photo description: Portrait of writer and performance artist, ALOK. They are wearing a pink, blue, and light brown hair extension. Their make-up is in pink, white, and purple tone. They are also wearing long purple and white earrings and a navy blue and white striped, long sleeved top with gold buttons].
  • Learn more about transgender individuals through social media spaces. My favourite Instagrammer is ALOK. They have helped me so much in understanding gender. The best way to learn about transgender people and be an ally is to listen to them. It is the first big step in removing any  stereotypical thinking you might have adopted.
  • Remember the suggestion about SBIRT (trans)itioning? Well, you can do it too! You can change your language by using gender neutral pronouns when you feel ambivalent about one’s gender. Or even better: you can just ask the person what their preferred pronouns are. Trust me, they will very much appreciate it.
  • Call out (in a civilised manner) on transphobic jokes or other acts of discrimination against transgender people. If you actively show your allyship, a transgender person will feel more comfortable around you and even trust you in talking to you about their substance use. Take the first step to become an ally here.
  • Donate, donate, donate here. Even if you cannot donate, you can volunteer! Don’t have the time to volunteer? No worries! You can make the continuous effort to use the proper pronouns and simply accept transgenders for who they truly are. This is an important first step to allyship.

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

References

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

 Images & social media 

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

References

  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. https://pharmaceutical-journal.com/article/feature/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. https://www.nytimes.com/2020/07/25/fashion/weddings/me-my-relationship-and-ptsd.html

Horton, A. (2016). [Patient During “Inside Time”]. Stars and Stripes. https://www.stripes.com/feel-good-drug-ecstasy-one-step-closer-to-approval-as-ptsd-treatment-1.445361

MAPS Europe. (n.d.). [MDMA-Assisted Therapy Session]. MAPS Europe. https://mapseurope.eu/

PTSD Health (2020). [BIPOC Representation]. Health Magazine. https://www.health.com/condition/ptsd/relationship-ptsd

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When Society Gets in the Way of Health and Help

How stigma can prevent women from seeking treatment for addiction

Samantha Johnstone

Kathy sat on the floor of her bedroom, looking at the pile of gifts for her and her baby. Her friends and family had been so generous but seeing them stacked in the corner flooded her with an overwhelming sense of guilt. She poured another glass of wine. If anyone knew her secret, surely they would take back the gifts. She didn’t deserve them, she thought to herself.

Canva (March 2021). [Image cartoon girl sitting on floor, expressionless].Figure 1: Woman sitting on ground, slouched and expressionless. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement

Kathy knew that her drinking had gotten out of control before she found out she was pregnant. She tried really hard to stop once she found out because she knew the risks. But no matter how many promises she made to herself, she just couldn’t get it under control. She had thought about looking for a rehab clinic, but worried if people found out, no one would ever speak to her again. And even if it was possible to hide her therapy from the rest of the world, she would never be able to afford it alone. She would have to ask her parents, and what if they were disappointed in her? 

It was a never ending cycle of feeling guilty about drinking and then drinking to quell the guilt, again and again. If only she knew someone that could help, she thought.

Kathy faced numerous obstacles when trying to get treatment for her addiction. One of the recurrent issues was fear of negative judgement from her peers. She worried that the people around her would shame her for struggling to control her drinking. Kathy’s fear of negative judgement became a barrier in her way to accessing addiction treatment.1

What is a barrier to addiction treatment?


A treatment barrier refers to any element in a person’s life that makes it more difficult to access treatment.2. These are usually considered personal issues like not being able to take time off work, having to take care of children, or not feeling ready to seek help with your addiction.

Figure 2: Woman resting her head on her hand. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement

For example, if you need to access a treatment facility, but you don’t have anyone to look after your children, it would be helpful if the facility had funding to provide childcare. If the government did not allocate funding to this service because it wasn’t considered important, this would make it more difficult for you to seek treatment.

Are barriers to treatment different for women?


Women with addictions face unique barriers to treatment.2. Looking back at the previous example, we see that childcare is often a major obstacle. Women who need to access addiction treatment are more likely than men to be responsible for children.2. They are also less likely to have a stable partner that can take on the role of being the sole provider.2. As you can imagine, this makes it difficult for them to check into rehabilitative facilities when they need to.

Stigma as a treatment barrier: 

Figure 3: Speech bubble with the following text: “Quick Facts: People who experience high levels of stigma about substance use are less likely to seek treatment. Stigmas can also interact with each other. Negative attitudes about substance use interact with sexism and racism.”. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement

A key barrier to treatment that women with addictions face is stigma.2. Stigma refers to a set of unfair, negative beliefs about people based on certain characteristics.3 These beliefs are often about factors like sex or gender, sexual orientation, race, religion, or having an addiction. 

Addiction stigma may look like: thinking addiction is a choice, thinking people who use drugs are immoral, or that they deserve to be arrested.

Experiencing addiction stigma can result in people feeling judged, ashamed, or powerless, similar to how Kathy felt.3 They may feel like recovery is pointless. Let’s take a look at a couple of examples that help to illustrate the effects of stigma on women seeking treatment:

  • Stigma from the medical community: In the 20th century, doctors were prescribing stimulants and tranquilizers primarily to White women for weight management, general “housewife malaise”, a little “pick-me-up”, and other minor issues.4 On top of that, they weren’t warning women about the risks of developing an addiction to these drugs.4 At that time, a common negative belief in the medical community was that addictions were a “man’s issue” and doctors would often dismiss women when they asked for help.4 Some even went as far as to say that women were unable to develop an addiction.4

Imagine feeling that your use of a prescribed drug is out of control, but the doctor who gave it to you didn’t warn you that it was dangerous and didn’t take you seriously when you disclosed your concerns. You might convince yourself that nothing is really wrong and not feel motivated to seek out treatment. 

  • Stigma from the public: In the 1980s, the United States government declared a “war on drugs” and these policies were mostly being enforced in Black communities.4 This quickly became a way to reinforce racial power differences through unfair laws. The media contributed to this by promoting negative beliefs and shaming people from these communities. For example, Black women were continuously stereotyped as being sexually promiscuous in exchange for drugs.4 By targeting and shaming Black women specifically, the media was contributing to harmful attitudes about race, sex/gender, and addiction.

Widespread stigma about drug and alcohol use promoted by public entities like the media and government can be a barrier to treatment.4 Women who would otherwise want to seek treatment will see these messages, and may fear being judged if they ask for help. They may also worry about fulfilling racist or sexist stereotypes and being further discriminated against.4 

  • Stigma from friends and family: Similar to Kathy’s story, women can also face negative judgement from the people closest to them. Pregnant and parenting women report worrying about what will happen if people find out that they are using drugs or alcohol, which prevents them from seeking treatment.1 They worry others will perceive them as a “bad mother”.1 They may also be concerned about losing custody, or having child services get involved, and keep their addiction a secret rather than ask for help.2. 

Women are often judged more harshly than men by the people around them for using substances.4 People with negative beliefs about sex/gender and addiction may believe that pregnant women who use substances are undeserving of sympathy.4

The Motherisk Scandal: Taking a closer look at the intersection of sex/gender, race, and addiction stigma.

Figure 4: Six women holding hands in a circle. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement

We just discussed many examples of addiction stigma and how it may interact with sexism and racism in women. But often these forms of stigma are not distinct experiences.

The Motherisk scandal shows us how these stigmas can interact and act as barriers to treatment.

As recently as 2015, hospital policies in Toronto allowed doctors to administer faulty drug tests to pregnant women.5 The doctors would then involve child services. This punitive approach to addiction resulted in thousands of children being wrongfully removed from families.

  • The doctors involved ignored the fact that the tests were often wrong about the presence of drugs.5 Child services paid little attention to whether or not the mother took care of her children when deciding to remove the child. This shows a stigma against addictions.5
  • This practice was primarily aimed at pregnant and parenting women, although fathers were sometimes drug tested as well.7 This shows a stigma against women who use substances, specifically.
  • The majority of the women who lost custody of their children because of faulty drug tests in the Motherisk scandal were Black or Indigenous.5 This shows a stigma against Black and Indigenous women who use substances, specifically. 

The Motherisk scandal shows us how different forms of stigma can interact. The doctors and child service workers involved had negative beliefs about the women because of their race, the potential for drug use, and their sex/gender. The consequence? Thousands of wrongfully separated families, most of whom were Black and Indigenous.7  It also likely resulted many women avoiding medical care or treatment for addiction while pregnant or parenting out of fear of losing their children or being arrested.6 

Is there any good news?

The cool thing about being part of society is that we can help to influence other people’s negative attitudes and reduce stigma about addiction! 

  • Learn about language: The words we use matter. For example, terms like “junkie”, “addict” or “alcoholic” are considered rude, and diminish people to their illness. Instead, use person-first language like “people with addictions”. Other examples can be found here.
  • Educate others: Consider telling the people you know the facts about addictions, and how stigma and stereotypes can be harmful. You can start by sharing this article! Some other resources about addiction stigma that you can share can be found at the Recovery Village,  from the Government of Canada, and from the Stigma of Addiction Project.
Figure 5: Two women leaning on each other. Graphic by Samantha Johnstone, template from CANVA is licensed under a Free Media License Agreement
  • Break barriers: If you or someone you know is struggling with an addiction, consider looking into treatment options. Some reputable resources for addiction treatment can be found from the Government of Canada, as well as numerous online resources, and at Toronto’s Centre for Addiction and Mental Health (CAMH). There are also resources for family members at CAMH.

If you have questions or concerns about pregnancy and substance use, a fact sheet, along with a list of reputable resources can be found here. Additional resources for women and their families can be found at the Jean Tweed Centre in Etobicoke ON. 

References

1. Center for Substance Abuse Treatment. (2009). Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series 51. Retrieved from Rockville, MD: http://www.ncbi.nlm.nih.gov/books/NBK83252/

2. Greenfield, S. F., Brooks, A. J., Gordon, S. M., Green, C. A., Kropp, F., Mchugh, R. K., Lincoln, M., Hien, D., & Miele, G. M. (2007). Substance abuse treatment entry, retention, and outcome in women: A review of the literature. Drug and Alcohol Dependence, 86(1), 1-21. doi:10.1016/j.drugalcdep.2006.05.012

3. Kulesza, M., Matsuda, M., Ramirez, J. J., Werntz, A. J., Teachman, B. A., & Lindgren, K. P. (2016). Towards greater understanding of addiction stigma: Intersectionality with race/ethnicity and gender. Drug and Alcohol Dependence , 169, 85–91. https://doi.org/http://dx.doi.org/10.1016/j.drugalcdep.2016.10.020 0376-8716 

4. Becker, J. B., McClellan, M., & Reed, B. G. (2016). Sociocultural context for sex differences in addiction. Addiction Biology, 21, 1052–1059. https://doi.org/10.1111/adb.12383 

5.  Contenta, S., Rankin, J., & Mendleson, R. (2016, October 28). Motherisk tests played role in 10 families where children taken, first phase of review finds. Thestar.Com. https://www.thestar.com/news/insight/2016/10/27/motherisk-tests-played-role-in-10-families-where-children-taken-first-phase-of-review-finds.html

6. Illegal Drug Use While Pregnant is Not Child Abuse. (2019, April 4). American Bar Association. https://www.americanbar.org/groups/public_interest/child_law/resources/child_law_practiceonline/january—december-2019/illegal-drug-use-while-pregnant-is-not-child-abuse/

7.  “I haven’t seen her in almost six years”: Father on pain of losing daughter after Motherisk test. (2018, February 27). CTVNews. https://www.ctvnews.ca/health/i-haven-t-seen-her-in-almost-six-years-father-on-pain-of-losing-daughter-after-motherisk-test-1.3820345

Images

1. Canva (March 2021). [Image cartoon girl sitting on floor, expressionless]. 

2. Canva (March 2021). [Head of women resting her head on her hand]. 

3. Canva (March 2021). [Speech bubble with the following text “Quick Facts: People who experience high levels of stigma about substance use are less likely to seek treatment. Stigmas can also interact with each other. Negative attitudes about substance use interact with sexism and racism.”].

4. Canva (April 2021). [Six women holding hands in a circle].

5. Canva (March 2021). [Two women, leaning on each other]. 

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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

This image has an empty alt attribute; its file name is M_1.jpg
“Woman Vaping on Electronic Cigarette (JUUL)”  by Vaping360 is licensed under CC BY 2.0

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?”. 

“Blu, Vuse, Njoy e-cigarette” by Sarah-Johsnon is licensed under CC BY-SA 2.0

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.

“Man Vaping Thick Clouds From His E-cigarette”  by Sarah-Johsnon is licensed under CC BY 2.

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 teen.smokefree.gov are specially catered to youth seeking guidance and treatment.

References:

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. https://doi.org/10.1016/j.amepre.2016.06.018

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. https://doi.org/10.5993/ajhb.39.3.14

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. https://doi.org/10.1093/ntr/ntaa037

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. https://abcnews.go.com/US/teen-put-life-support-vaping-didnt-smoker/story?id=65522370 

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

Drugs Survey 2018-19 https://www.canada.ca/en/health-canada/services/canadian-student-tobacco-alcohol-drugs-survey/2018-2019-summary.html

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. https://kidshelpphone.ca/topic/emotional-well-being/substance-use

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

Blog.https://www.health.harvard.edu/blog/vaping-its-hard-to-quit-but-help-is-available-2019110118248#:%7E:text=For%20people%20who%20are%20motivated,for%20children%20under%20age%2018.

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. https://doi.org/10.1007/s00508-020-01711-z

Smokefree Teen. (n.d.). Become a Smokefree Teen. https://teen.smokefree.gov

The Center for Addiction and Mental Health. (2021). Nicotine Dependence Clinic. https://www.camh.ca/en/your-care/programs-and-services/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. http://dx.doi.org/10.1136/tobaccocontrol-2018-054900 

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

Youth and tobacco use. (2020, December 16). Retrieved March 10, 2021, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm 

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“You can’t do it for us, you can only do it with us” Understanding substance use in Indigenous communities and how to help

Samantha Johnstone, Yasmine Noureddine, Elena Kastoras, and Jenna Vieira

Indigenous peoples are much more likely than others to experience mental health issues, including substance use disorders.1 In fact, 16% of Indigenous peoples reported drinking heavily on a weekly basis, compared to only 7.9% of other Canadians.1 On top of that, over 50% of Indigenous survey respondents reported using at least one illegal drug in the past year, compared to less than 1% of the general Canadian population.1 

This image has an empty alt attribute; its file name is J_1.png
Figure 1: Cartoon therapist and patient, thought bubble coming from patient contains words such as “Indigenous” and “Oppression”. Graphic by Yasmine Noureddine, template from CANVA is licensed under a Free Media License Agreement.

A substance use disorder can be understood as when a person experiences a loss of control over their use of drugs or alcohol, misses important social and work-related events, and experiences cravings for the substance that can’t be ignored.2 Not only can facing a substance use disorder make it really hard for a person to cope with the demands of everyday life, but it can also worsen their mental health. This is particularly likely to be the case for Indigenous peoples.

A long history of colonization, racism, and other forms of discrimination have led Indigenous peoples to experience difficulty in accessing the same quality of healthcare, social services, and opportunities that other Canadians receive.3 Because the voices of this community have been silenced by discrimination for so long, it is important to listen to their personal challenges, opinions, and needs rather than imposing Western ideas of assistance on them.

Taking a look at Indigenous substance use and mental health

Focusing in on a subgroup of Indigenous peoples – university students – reveals that they are indeed at an increased risk of experiencing substance use disorders and other mental health issues.4 Researchers conducted a survey of 34 thousand Canadian students in hopes of determining if universities are meeting the needs of Indigenous students.4 As it turns out, they are not. Indigenous students were overwhelmingly more likely to be diagnosed with depression and anxiety.4 They also reported more self-harming behaviours and a longer history of suicide attempts.4 This is likely due to the lack of access to healthcare and poverty4 caused by years of colonization, oppression, and loss of cultural connections.5

So how does this relate to substance use? Well, the increased psychological distress faced by Indigenous students means that those who do engage in binge drinking or smoking are more likely than their non-Indigenous peers to have comorbid mental illnesses.5 Comorbidity simply means that two disorders are occurring at the same time in one person. Researchers have identified a few ways in which comorbidities can develop:

  • Substance use can increase the risk of developing a mental illness, like depression, due to changes in the brain.6 
  • Some people may try to self-medicate to deal with symptoms of their mental illnesses. This can increase the risk of becoming dependent.6
  • Common genetic risk factors can increase the risk of both substance use and mental health problems.6

Having to cope with a mental disorder and a substance use disorder at the same time can make it really hard to recover from either illness. This is concerning, as Indigenous students in the 2019 study also reported greater levels of binge drinking and drug use than their non-Indigenous peers.4 Along with the reports of overwhelming psychological distress, it is clear that Indigenous students are suffering to a great extent. Specifically, we see that Indigenous students who use substances have more negative outcomes and greater levels of psychological and social hardships compared to non-Indigenous students.5

Figure 2: Head of women each have a speech bubble emerging from them; the first head has a sad icon, the second alcohol and weed. Graphic by Yasmine Noureddine, template from CANVA is licensed under a Free Media License Agreement.

How can clinicians use this information?

It is important for clinicians to recognize the inequalities faced by Indigenous students and ensure that comprehensive assessments are conducted. This means that instead of just diagnosing the substance use disorder, clinicians also have to ask about psychological distress and assess the risk of suicide, to get to the full picture. But once we have the full picture, what do we do with it?

  1. Offering culturally appropriate services:

We emphasize that culturally appropriate services need to be available for Indigenous students. When healthcare is culturally appropriate it integrates the patients culture into delivery of the service while maintaining dignity and recognizing social and economic hardships.7 One way this can be achieved is by having Indigenous counsellors onsite that can help students maintain their cultural identity even when they are away from home.4

  1. When to step in: 

Indigenous counsellors can also help to maneuver decisions about when to provide treatment. Cultural differences play a role in deciding what does (or does not) constitute a substance use disorder. Western definitions of disordered substance use may not translate to what Indigenous communities see as problematic. For example, traditional ceremonies in Indigenous cultures often use tobacco 2, and it would be inappropriate to characterize this practice as disordered. We also know that Indigenous communities have not yet established a definition for binge drinking.4

  1. Proper diagnosis means better treatment:

Interventions, like sweat lodge ceremonies, address Indigenous mental health while promoting a holistic model.8 Holistic interventions heal the mind, body, emotion, and spirit in an integrated manner8, which is essential when treating comorbidities. These interventions are beneficial in improving mental health and reducing substance use. More importantly, Indigenous students have reported that they prefer these types of services over standard ones.4 

  1. Not only for students:

Although this study specifically focused on university students, comorbid substance use and mental illness are common in Indigenous communities.2 We can use this research to push for changes in government policies and practices. When Indigenous leaders have control over their health services, are able to use their traditional languages, and maintain cultural identity, there are notably lower rates of substance use and suicide.4 Supporting Indigenous self-governance is an important step in addressing the inequalities and hardships that Indigenous peoples face.

How can you and I help?

While researchers and clinicians may be the frontline responders to understanding and accurately assessing substance use in the Indigenous peoples and their youth, this doesn’t mean that you can’t contribute in your own way to provide help and support. Some tips on how to do this include9:

  1. Taking the time to learn about the history of Indigenous people in Canada.

Knowledge of the historical factors that contributed to today’s issues surrounding Indigenous mental health and substance use can provide a better understanding of how and why they are so prevalent. It also allows for a look at how circumstances have changed over the decades, and what still needs to be done to ensure equity and proper care. Checking out recommended books at your local library, as well as sources like podcasts, is a great way to start!

  1. Reaching out and building strong connections with the Indigenous peoples, organizations, and communities near your own. 

In supporting the communities, you are supporting everyone who is a part of it, including the older generation, as well as students. These relationships allow non-Indigenous peoples a chance to understand how substance use and mental health are viewed and best approached by Indigenous communities. Checking out your local Indigenous cultural centre and community organizations can be a launching pad for fostering good relations.

  1. Knowing what support services and programs are available for Indigenous peoples and their youth.

Familiarizing yourself with the services and programs available helps you to know exactly where to direct your support and allows for more access/reach to what is needed, by promoting the programs and making it known to the wider public that they exist, are available, and would benefit from support from outside of the Indigenous community (as a way of highlighting their importance). Some programs and services include:

This image has an empty alt attribute; its file name is J_3.png
Figure 3: Map of Canada with the population of Indigenous peoples by province/territory. Information from Statistics Canada10. Graphic by Yasmine Noureddine, template from CANVA is licensed under a Free Media License Agreement.

You can also get involved and spread awareness by following and interacting with social media pages run by and for Indigenous peoples. Pages such as: Indigenous Youth Voices and Ontario Indigenous Youth Partnership Project!

The mental health and well-being of marginalized groups is the responsibility of all to ensure a well-supported, equal-opportunity community that is free from stigma and risk factors. Given that Indigenous peoples reside all across Canada and broadly experience higher levels of disordered substance use compared to the general Canadian population2, supporting your local community is a way to help out Indigenous communities as a whole. Canadians can’t address and fix inequalities for Indigenous peoples; we can only do it with Indigenous peoples.11

References

  1. Firestone, M., Tyndall, M., & Fischer, B. (2015). Substance use and related harms among Aboriginal people in Canada: A comprehensive review. Journal of Health Care for the Poor and Underserved, 26(4), 1110-1131. https://doi.org/10.1353/hpu.2015.0108

  2. Urbanoski, K. A. (2017). Need for equity in treatment of substance use among Indigenous people in Canada. Canadian Medical Association Journal, 189(44), 1350-1351. https://doi.org/10.1503/cmaj.171002

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

  4. Hop Wo, N. K., Anderson, K. K., Wylie, L., & MacDougall, A. (2019). The prevalence of distress, depression, anxiety, and substance use issues among Indigenous post-secondary students in Canada. Transcultural Psychiatry, 57(2), 263–274. https://doi.org/10.1177/1363461519861824

  5. Sittner, K. J. (2015). Trajectories of Substance Use: Onset and Adverse Outcomes Among North American Indigenous Adolescents. Journal of Research on Adolescence, 26(4), 830–844. https://doi.org/10.1111/jora.12233

  6. Teesson, M., Degenhardt, L., Proudfoot, H., Hall, W., & Lynskey, M. (2005). How common is comorbidity and why does it occur? Australian Psychologist, 40(2), 81–87. https://doi.org/10.1080/00050060500094605 

  7. Caffery, L. J., Bradford, N. K., Smith, A. C., & Langbecker, D. (2018). How telehealth facilitates the provision of culturally appropriate healthcare for Indigenous Australians. Journal of Telemedicine and Telecare, 24(10), 676–682. https://doi.org/10.1177/1357633×18795764

  8. Rowan, M., Poole, N., Shea, B., Gone, J. P., Mykota, D., Farag, M., Hopkins, C., Hall, L., Mushquash, C., & Dell, C. (2014). Cultural interventions to treat addictions in Indigenous populations: findings from a scoping study. Substance Abuse Treatment, Prevention, and Policy, 9(1), 34. https://doi.org/10.1186/1747-597x-9-34

  9. Pharmacy Connection March 5, 2020 0 C. (2020, June 15). 5 tips on supporting the mental health and wellness of indigenous youth. https://pharmacyconnection.ca/5-tips-supporting-mental-health-indigenous-youth-winter-2020/.

  10. Government of Canada, S. C. (2020, October 2). Aboriginal Peoples Highlight Tables, 2016 Census. Government of Canada, Statistics Canada. https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/hlt-fst/abo-aut/Table.cfm?Lang=Eng&T=101&S=99&O=A.

  11. Caron, N. R. (2005). Getting to the root of trauma in Canada’s Aboriginal population. Canadian Medical Association Journal (CMAJ), 172(8), 1023-1024. https://doi.org/10.1503/cmaj.050304

Images

  1. Canva (February 2021). [Image of cartoon therapist with patient, patient has a thought bubble with words such as ‘Indigenous’ and ‘Oppression’ in a word cloud]. 

  2. Canva (February 2021). [Head of women each have a speech bubble emerging from them; the first head has a sad icon, the second alcohol and weed]. 

  3. Canva (February 2021). [Map of Canada with the populations of Indigenous peoples by province/territory. Information from Statistics Canada].

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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.

FICTION!

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. 

FACT!

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.

FICTION!

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.

FICTION! 

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.

FICTION!

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.

FICTION!

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

References

1Rider, D. (2020, August 11). Toronto overdose deaths hit a grim new record in July, taking more lives than covid-19. Toronto Star. https://www.thestar.com/news/city_hall/2020/08/11/toronto-overdose-deaths-hit-a-grim-new-record-in-july-taking-more-lives-than-covid-19.html

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. https://doi.org/10.1016/j.ypmed.2018.02.026

3CAMH. (2016). Opioids and addiction: A primer for journalists. http://www.camh.ca/-/media/files/5217-opdsaddic_primer-pdf.pdf

4CMHA. (n.d.). Stigma and discrimination. https://ontario.cmha.ca/documents/stigma-and-discrimination/

5CBC News. (2019, April 1). Province cut some injection sites because area residents ‘upset’, Ford says. https://www.cbc.ca/news/canada/toronto/province-cut-some-injection-sites-because-area-residents-upset-ford-says-1.5079616

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. https://www.albertahealthservices.ca/assets/programs/ps-1000286-odp-suboxone.pdf

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. https://doi.org/10.1007/s10461-013-0593-y

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. https://doi.org/10.1007/s11904-017-0363-y

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. https://www.ohtn.on.ca/rapid-response-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. https://www.toronto.ca/legdocs/mmis/2019/hl/bgrd/backgroundfile-126527.pdf

13City of Toronto. (n.d.). Supervised injection sites. https://www.toronto.ca/community-people/health-wellness-care/health-programs-advice/supervised-injection-services/

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. https://doi.org/10.1186/s12954-020- 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. https://doi.org/10.1007/s11524-012-9753-z

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. https://doi.org/10.1016/j.drugpo.2018.04.004

Image References

Noelville Pharmacy. (2020). [Naloxone kit]. NoelPharm.com. http://www.noelvillepharm.ca/opioid-overdose-risk-save-a-life-with-a-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. https://www.inquirer.com/opinion/commentary/safe-injection-sites-safehouse-philadelphia-20200203.html

The Star News. (2017). [Safe injection site in Surrey, British Columbia]. The Star News. https://www.thestar.com/news/canada/2017/06/27/health-canada-allows-oral-and-nasal-use-of-drugs-at-2-bc-safe-injection-sites.html

Resource References

CAMH. (2018). Harm reduction: Where to go when you’re looking for help. https://www.camh.ca/-/media/files/community-resource-sheets/harm-reduction-resources-pdf.pdf?la=en&hash=A175EF581BD43ACE51D964DEEBD09DD2738CB7D7

Canadian Centre for on Substance Use and Addiction. (2004). Needle exchange programs FAQ. https://www.ccsa.ca/needle-exchange-programs-neps-faqs 

National Institute on Drug Abuse. (2020, May). Drug facts: Prescription Opioids. https://www.drugabuse.gov/sites/default/files/drugfacts-prescriptionopioids.pdf

St. Michael’s Unity Health Toronto. (n.d.). Mental health and addictions service: Rapid access clinic. St. Michael’s Hospital. https://www.stmichaelshospital.com/programs/mentalhealth/rapid-access-clinic.php

True North Addiction Medicine Program. (n.d). Substance use and treatment. https://www.truenorthmedical.com/treatment

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From Quarantine to Quarantini: Understanding how COVID-19 Restrictions may be Impacting your Drinking

by Dr. Sarah Dermody

It is hard to believe that it has been one year since the first COVID-19 lockdowns occurred in the US and Canada. Over the past year, many people’s daily routines have completely changed as they physically and socially-distance from others. While this distancing has been crucial to reduce COVID-19-related deaths, a question that scientists and practitioners have been facing is “Have there been harmful effects on alcohol use and related deaths?” Let’s look at the data together and see what’s the matter.

The Quarantini

martini

Over the past year, many bars and restaurants have had to limit “drink-in” services. At the same time, many rules around alcohol sales and delivery have laxed (cocktail delivery – anyone?) and alcohol vendors have been deemed essential services.

It is not possible to know for sure if the pandemic has changed drinking. This is would require a study where we control people’s exposure to pandemic-like conditions and give them alcohol to see what happens (aka an experiment). What we do know, however, is that in some regions during certain periods of the pandemic there have been increases in the sale of alcohol. Of course, based on this alone, we do not know if people are drinking that extra alcohol they have purchased or if it is now part of a new pandemic trend of building a wine cellar.

We also know that people are telling us they are drinking more. In an online survey of 320 Canadian adults who drink, some individuals reported increased alcohol use when the pandemic started [1]. Some people reported greater increases in drinking than others, such as individuals who had children under the age of 18, had greater depression, or were less socially connected to others. An important question is why are certain people drinking more during the pandemic?

Tears in Your Beer

While alcohol use is often thought of as a social activity, how has social distancing and the pandemic affected people’s alcohol use?

The COVID-19 pandemic is a stressful ongoing event affecting the lives for many people. For quite some time, researchers have argued that feeling stressed, sad, or anxious can lead individuals to use substances (like alcohol) to cope with those unwanted feelings. Consistent with this idea, research supports that individuals who were more likely to report drinking alcohol to deal with negative emotions during the pandemic were most likely to increase their alcohol use.[1] Drinking to cope with negative emotions also was associated with experiencing consequences from drinking, such as being unhappy, getting in trouble, doing impulsive things, and harming relationships.

A Short-Term Solution that can create Longer-Term Problems

Attention has been drawn to recent increases in “deaths of despair” that include deaths from alcohol and other drug overdoses (as well as liver disease and suicide).[2] For instance, in Ontario, there was an increase in opioid-related deaths after the state of emergency was declared in March 2020 (see page 5 ).  While there are many possible explanations for this increase, one possibility that has been put forward is that the sudden and then ongoing stress of the COVID-19 pandemic has led individuals to drink to cope and this can fuel an increase in drinking and potentially harms from drinking (such as overdose and alcohol-related liver disease).

As the COVID-19 pandemic continues to burden us with considerable stress and worry, alcohol serves as only short-term solution to a longer-term problem. As stated by Koob and colleagues (2020):

“Alcohol can temporarily dampen negative emotional states, providing short-term relief…Over time, [changes to the brain] reduce the relief that is provided by alcohol and increase emotional misery between episodes of [alcohol] use.”

In other words, alcohol may help relieve distress in the short-term, but in the longer term, it can make distress much worse.

Finding Other Ways to Cope

Image by mohamed Hassan from Pixabay

Given the potential physical, emotional, and financial costs of drinking, alternative ways of coping with COVID-19 related distress are needed. It is important to find options that will work for you and your current pandemic lifestyle. It may not be easy, but your mind and body may thank you later for finding alternative ways to relax and take a break.

Here are some options that you could try!

  • Enjoy a different beverage: your favorite soda, a warm tea, or an indulgent hot chocolate
  • Find another way to temporarily escape: have a bubble bath, listen to your favourite album, or watch a new show
  • Develop new ways of coping: practice mindfulness, start a new exercise routine, go for a walk
  • Reconnect with others: plan a virtual game night or simply catch-up with others by phone

Where can I find out more about reducing my drinking?

[1]Wardell, J. D., Kempe, T., Rapinda, K. K., Single, A., Bilevicius, E., Frohlich, J. R., … & Keough, M. T. (2020). Drinking to Cope During COVID‐19 Pandemic: The Role of External and Internal Factors in Coping Motive Pathways to Alcohol Use, Solitary Drinking, and Alcohol Problems. Alcoholism: Clinical and Experimental Research, 44(10), 2073-2083.

[2] Koob, G. F., Powell, P., & White, A. (2020). Addiction as a coping response: hyperkatifeia, deaths of despair, and COVID-19. American Journal of Psychiatry, 177(11), 1031-1037.

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More than a craving? Can we experience withdrawal symptoms when we cut back on certain foods?

By Vincent A. Santiago (MA), 9 min read.

Khantho (2016). Photograph of a person holding an ice cream cone.

Every day you pick up a delicious ice cream cone on your way home from work. But this time you decide it might be better to skip a few days, maybe for health reasons or to save some money. It’s been a couple of days when you pass by the ice cream shop and notice that this treat has been on your mind all day, making it hard to concentrate at work. You notice a strong craving for one and you’re finding yourself feeling irritable without one. You think, “What’s going on? Do I have a problem?”.

At this point, you might wonder if you’re experiencing withdrawal symptoms by cutting back on this ice cream, like what might happen when someone who has substance or drug issues cuts back on their use. For example, when someone who often drinks a lot of alcohol cuts back on their drinking, they may feel uncomfortable or ill. They may experience anxiety, nausea, and sweating [1]. These symptoms that happen when substance use is reduced is called withdrawal. Even though withdrawal is well-known for substances, it is not well understood for food, despite food being necessary for survival and being readily available for many people, often in large quantities.

But why is this important? Some theories of why people develop substance problems (described more below) focus specifically on withdrawal symptoms. For these theories to apply though, understanding if withdrawal even exists for foods is important to know. This blog post reviews the current scientific evidence to answer the question: Can we experience withdrawal symptoms when we cut back on certain foods?

What is food addiction and how does withdrawal fit in?

Withdrawal is one symptom of many that people can experience when they have a substance use disorder, or more commonly known as an “addiction” [1]. The idea that food can also be addictive has attracted more scientific attention in the last decade and since the publication of a questionnaire called the Yale Food Addiction Scale or YFAS [2–3]. Before this questionnaire, there was no standard way of measuring “food addiction” [2]. This is the idea that people experience the same symptoms of drug addiction, including withdrawal, when eating a lot of highly processed foods that are high in fat and sugar, like ice cream, cookies, chips, burgers, and sugary drinks [4]. Examples of food withdrawal include experiencing irritability, sadness, headaches, fatigue, difficulty concentrating, or cravings when eating less of these foods.

Although food addiction is not an officially recognized disorder among scientists, the idea is not new. Some people do identify themselves as a “food addict” [5] and might join self-help programs such as Overeaters Anonymous, which has existed since 1960 [6]. Additionally, food addiction does appear in the media [7–8]. Symptoms such as overeating are often described, but others such as withdrawal are overlooked. Given this long history, do we have the evidence to back up the idea that people can experience food withdrawal?

What does the science say about food withdrawal?

The research on food withdrawal is mostly limited to animal studies, anecdotes among humans, and responses to the YFAS. One review of studies published in 2009 found that when rats were fed a diet of sugar and this food source was removed, the rats displayed symptoms similar to heroin withdrawal, such as aggression, teeth chattering, paw tremor, and headshaking [9, 10, 11]. In a more recent review of studies published in 2018, again only animal studies were discussed in the context of withdrawal [3]. The authors noted that given that the body’s responses to food are smaller than those to drugs, withdrawal symptoms might be present but not as noticeable in humans.  

Reports of sugar and other processed food withdrawal among humans, such as headaches and fatigue, have largely come from observations of people cutting back on these foods or from self-help books and websites [10, 12, 13, 14]. Although this anecdotal information is important, it has not been observed under controlled scientific conditions [10]. As a result, it is unclear if the withdrawal symptoms are a result of abstaining from certain foods, or if they are due to other factors, such as other lifestyle changes. An example of a controlled study would be randomly assigning individuals with food addiction to either: 1) abstaining from eating certain foods, or 2) not abstaining, and observing both groups over a period of time, perhaps in a controlled laboratory setting. If withdrawal symptoms emerge for the first group and not the second, then this would suggest that the withdrawal is caused by abstaining from certain foods, assuming that this is the one main variable that differed between the two groups.

Lastly, the research team behind the YFAS [15] pointed out that 19-30% of people in the community [4, 16] and 26-55% of patients with eating-related issues [17–18] who completed the YFAS did report withdrawal symptoms. However, like the anecdotal information, these studies were not experimental and so these withdrawal symptoms could be related to other factors.

Developing a questionnaire to measure food withdrawal

Recognizing that there was no standard way to measure food withdrawal in humans, the research team behind the YFAS developed and tested the Highly Processed Food Withdrawal Scale or ProWS [15]. A total of 231 online participants who attempted to cut down on highly processed foods in the past year completed the ProWS. They were asked when four symptoms (described below; see Figure 1 for two of the symptoms) were at their most intense following the cutting back attempt. These symptoms were chosen because they are seen in withdrawal across most drugs of abuse [1, 15].

Figure 1: Reported time course of two food withdrawal symptoms. Adapted from Schulte et al. (2018). This is the author’s interpretation of the general patterns observed. Interested readers can find the full figure in the original article.

The researchers found that overall, 55% of participants reported having cravings, 35% felt irritable, 27% felt tired, and 27% felt down after cutting back. These symptoms peaked after 2-3 days, except for sadness, which was at its worst after 4-5 days (see Figure 1). The authors mentioned that this pattern is similar to what might be seen with withdrawal from marijuana and cigarettes [19–20] and provides early evidence for withdrawal from highly processed foods [15]. This information may even help healthcare providers who are helping people cut back on processed foods, as clinicians can give information about withdrawal symptoms, set expectations for how long they last, and suggest strategies to manage them [15].

However, this early study is limited because it does not report how many people experienced more physical symptoms such as nausea, night sweats, hot flashes, and headaches [15]. Furthermore, because scientists have not identified a specific substance or ingredient that is addictive across different foods [21], withdrawal symptoms may actually vary depending on the food. For example, eating less candy might lead to different physical effects, such as low blood sugar, that you may not see if you ate less cheese [15]. Additionally, given that the dieting attempt could have been at any time in the past year, participants may not have always remembered accurately [15]. Using biological tests (for example to measure stress hormones) might provide more objective evidence of withdrawal symptoms [15]. Future studies will need to look at how withdrawal symptoms unfold in real-time, in controlled laboratory settings, and using other measures.

What can we say about food withdrawal at this time?

To return to the question of whether or not we experience withdrawal symptoms from cutting back on certain foods, the answer is maybe. The limited evidence we have points more to psychological symptoms, such as cravings, and not physical symptoms, such as nausea. However, psychological symptoms are still incredibly impactful. In fact, there are few physical symptoms when withdrawing from substances such as tobacco [1, 15]. If someone you know has tried to quit smoking, you know how irritable or anxious they can get right after quitting!  

Erfurt (2017). Photograph of a person with their hands on their face.

 Why is understanding food withdrawal important? Some theories about how people develop addictions depend on the idea that people use substances (or in this case, eat food) in order to feel relief from unpleasant withdrawal symptoms that develop after using that substance repeatedly [22]. These theories are called negative reinforcement models of drug motivation [22]. For these theories to apply to food addiction though, we still need a better understanding of withdrawal from food or we need to consider other theories. Negative reinforcement models within the past 20 years have now been expanded to focus more on psychological rather than physical withdrawal symptoms, as well as unconscious motivations resulting from learning repeatedly that use results in relief [22, 23]. Substance use may also be about escaping distress from one’s environment, and not just distress due to withdrawal symptoms [22]. For example, you may grab that ice cream after work because of cravings, because of habit, or because you had a stressful day. Given the limited evidence of food withdrawal, these other factors may be more relevant to developing food addiction. Regardless of the source of distress, drug-induced or environmentally prompted distress may result in similar internal cues in the body that can trigger substance use [22].

Another theory is the incentive sensitization theory of addiction [24]. This theory argues that the brain has two separate but related systems responsible for “liking” (pleasure) and for “wanting” (called incentive salience) [24, 25]. This “wanting” is an unconscious desire for rewards and cues that signal these rewards [25], such as fast food and fast-food advertising. Seeing such a cue may motivate someone to get in line for a burger. This model suggests that with repeated drug use, the brain changes such that processes responsible for “wanting” drugs become more sensitive [25]. Research shows that one can “want” something without “liking” it and vice-versa [25]. It appears that drugs of abuse, food, and gambling can hijack our “wanting” system; that is, “wanting” can increase and “liking” may stay the same or even decrease [25]. Tolerance to a drug occurs when it is no longer pleasurable, and it can lead to escalation of drug use as one searches for that initial pleasure [25]. Processed foods may trigger initially strong “liking” and “wanting” responses, resulting in overeating, which can further increase “wanting” of these foods and their cues [25]. Human and non-human animal research appears to support this theory when applied to food [25] and substances such as alcohol [26]. Given the currently limited evidence for food withdrawal, the incentive sensitization theory may better explain food addiction when compared to negative reinforcement models.

Understanding what is driving food addiction is important for creating effective treatments and policies related to eating, which is why more research is needed before making any conclusions and recommendations. It is also important to remember that research on food addiction and withdrawal is still in its early stages. The YFAS was published in 2009, the ProWS was published in 2018,and the ProWS for children was published in 2020 [2, 15, 27]. With more research, we will hopefully better understand if and how people experience withdrawal symptoms when cutting back on certain foods. At the moment, it is unclear but there is some promising evidence!

Conscious Design (2020). Photograph of a person reading a book.

You are still unsure if you have a problem with ice cream or not… Maybe the craving was not so much an effect of not eating ice cream but other things, like seeing the ice cream shop sign, having a stressful day at work and usually eating to relax, or something outside your awareness. Who knows! You think, “Maybe if I ride this craving out, it will go away. Let me do something else relaxing like read that book at home instead.”.

Resources

If you are wondering if you have food addiction symptoms, the YFAS and ProWS, the questionnaires of food addiction and food withdrawal discussed in the article, are freely available by the researchers here. However, if you are experiencing eating-related issues that are distressing for you, it may be helpful to talk to your doctor, as there are mental health professionals who can assess and treat eating disorders. For a description of eating disorders, treatments, and resources, visit the Canadian Mental Health Association, Ontario Division.

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References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
  2. Gearhardt, A. N., Corbin, W. R., & Brownell, K. D. (2009a). Preliminary validation of the Yale Food Addiction Scale. Appetite, 52(2), 430-436. https://doi.org/10.1016/j.appet.2008.12.003
  3. Naish, K. R., MacKillop, J., & Balodis, I. M. (2018). The concept of food addiction: A review of the current evidence. Current Behavioral Neuroscience Reports, 5(4), 281-294. https://doi.org/10.1007/s40473-018-0169-2
  4. Gearhardt, A. N., Corbin, W. R., & Brownell, K. D. (2016). Development of the Yale Food Addiction Scale Version 2.0. Psychology of Addictive Behaviors, 30(1), 113-121. https://doi.org/10.1037/adb0000136
  5. Meadows, A., Nolan, L. J., & Higgs, S. (2017). Self-perceived food addiction: Prevalence, predictors, and prognosis. Appetite, 114, 282-298. https://doi.org/10.1016/j.appet.2017.03.051
  6. Meule, A. (2015). Back by popular demand: A narrative review on the history of food addiction research. The Yale Journal of Biology and Medicine, 88(3), 295-302. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553650/
  7. Gunnars, K. (2019, December 4). How to overcome food addiction. Healthline. https://www.healthline.com/nutrition/how-to-overcome-food-addiction#what-it-is
  8. Scinto, M. (2020, September 28). What makes the McDonald’s Travis Scott Meal so concerning. Mashed. https://www.mashed.com/253289/what-makes-the-mcdonalds-travis-scott-meal-so-concerning/
  9. Avena, N. M., Rada, P., & Hoebel, B. G. (2008). Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake. Neuroscience & Biobehavioral Reviews, 32(1), 20-39. https://doi.org/10.1016/j.neubiorev.2007.04.019
  10. Davis, C., & Carter, J. C. (2009). Compulsive overeating as an addiction disorder. A review of theory and evidence. Appetite, 53(1), 1-8. https://doi.org/10.1016/j.appet.2009.05.018
  11. Wideman, C. H., Nadzam, G. R., & Murphy, H. M. (2005). Implications of an animal model of sugar addiction, withdrawal and relapse for human health. Nutritional Neuroscience, 8(5-6), 269-276. https://doi.org/10.1080/10284150500485221
  12. Gearhardt, A. N., Corbin, W. R., & Brownell, K. D. (2009b). Food addiction: An examination of the diagnostic criteria for dependence. Journal of Addiction Medicine, 3(1), 1-7. https://doi.org/10.1097/ADM.0b013e318193c993
  13. Ifland, J. R., Preuss, H. G., Marcus, M. T., Rourke, K. M., Taylor, W. C., Burau, K., Jacobs, W. S., Kadish, W., & Manso, G. (2009). Refined food addiction: A classic substance use disorder. Medical hypotheses, 72(5), 518-526. https://doi.org/10.1016/j.mehy.2008.11.035
  14. Pretlow, R. A. (2011). Addiction to highly pleasurable food as a cause of the childhood obesity epidemic: A qualitative Internet study. Eating Disorders, 19(4), 295-307. https://doi.org/10.1080/10640266.2011.584803
  15. Schulte, E. M., Smeal, J. K., Lewis, J., & Gearhardt, A. N. (2018). Development of the Highly Processed Food Withdrawal Scale. Appetite, 131, 148-154. https://doi.org/10.1016/j.appet.2018.09.013
  16. Hauck, C., Weiß, A., Schulte, E. M., Meule, A., & Ellrott, T. (2017). Prevalence of ‘food addiction’ as measured with the Yale Food Addiction Scale 2.0 in a representative German sample and its association with sex, age and weight categories. Obesity Facts, 10(1), 12-24. https://doi.org/10.1159/000456013
  17. Gearhardt, A. N., White, M. A., Masheb, R. M., Morgan, P. T., Crosby, R. D., & Grilo, C. M. (2012). An examination of the food addiction construct in obese patients with binge eating disorder. International Journal of Eating Disorders, 45(5), 657-663. https://doi.org/10.1002/eat.20957
  18. Meule, A., Hermann, T., & Kübler, A. (2015). Food addiction in overweight and obese adolescents seeking weight‐loss treatment. European Eating Disorders Review, 23(3), 193-198. https://doi.org/10.1002/erv.2355
  19. Budney, A. J., Moore, B. A., Vandrey, R. G., & Hughes, J. R. (2003). The time course and significance of cannabis withdrawal. Journal of Abnormal Psychology, 112(3), 393-402. https://doi.org/10.1037/0021-843X.112.3.393
  20. Hughes, J. R. (2007). Effects of abstinence from tobacco: Valid symptoms and time course. Nicotine & Tobacco Research, 9(3), 315-327. https://doi.org/10.1080/14622200701188919
  21. Hebebrand, J., Albayrak, Ö., Adan, R., Antel, J., Dieguez, C., de Jong, J., Leng, G., Menzies, J., Mercer, J. G., Murphy, M., van der Plasse, G, & Dickson, S. (2014). “Eating addiction”, rather than “food addiction”, better captures addictive-like eating behavior. Neuroscience & Biobehavioral Reviews, 47, 295-306. https://doi.org/10.1016/j.neubiorev.2014.08.016
  22. McCarthy, D. E., Curtin, J. J., Piper, M. E., & Baker, T. B. (2010). Negative reinforcement: Possible clinical implications of an integrative model. In J. D. Kassel (Ed.), Substance abuse and emotion (p. 15–42). American Psychological Association. https://doi.org/10.1037/12067-001
  23. Baker, T. B., Piper, M. E., McCarthy, D. E., Majeskie, M. R., & Fiore, M. C. (2004). Addiction motivation reformulated: An affective processing model of negative reinforcement. Psychological Review, 111(1), 33-51. https://doi.org/10.1037/0033-295X.111.1.33
  24. Robinson, T. E., & Berridge, K. C. (1993). The neural basis of drug craving: An incentive-sensitization theory of addiction. Brain Research Reviews, 18(3), 247-291. https://doi.org/10.1016/0165-0173(93)90013-P
  25. Robinson M. J. F., Fischer A. M., Ahuja, A., Lesser, E.N., & Maniates H. (2015). Roles of “wanting” and “liking” in motivating behavior: Gambling, food, and drug addictions. In E. Simpson & P. Balsam (Eds.), Behavioral neuroscience of motivation. Current topics in behavioral neurosciences (Vol. 27). Springer. https://doi.org/10.1007/7854_2015_387
  26. Cofresí, R. U., Bartholow, B. D., & Piasecki, T. M. (2019). Evidence for incentive salience sensitization as a pathway to alcohol use disorder. Neuroscience & Biobehavioral Reviews, 107, 897-926. https://doi.org/10.1016/j.neubiorev.2019.10.009
  27. Parnarouskis, L., Schulte, E. M., Lumeng, J. C., & Gearhardt, A. N. (2020). Development of the Highly Processed Food Withdrawal Scale for Children. Appetite, 147, 104553. https://doi.org/10.1016/j.appet.2019.104553

Images

Conscious Design. (2020). [Photograph of a person reading a book]. Unsplash. https://unsplash.com/photos/5o_doner5YY

Erfurt, Christian. (2018). [Photograph of a person with their hands on their face]. Unsplash. https://unsplash.com/photos/sxQz2VfoFBE

Khantho, Puk. (2016). [Photograph of a person holding an ice cream cone]. Unsplash. https://unsplash.com/photos/BDqF5-P7LHM

Schulte, E. M., Smeal, J. K., Lewis, J., & Gearhardt, A. N. (2018). Development of the Highly Processed Food Withdrawal Scale [Author’s interpretation adapted from Fig. 1. Time course of highly processed food withdrawal symptoms]. Appetite, 131, 148-154. https://doi.org/10.1016/j.appet.2018.09.013

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Money Talks and Science Listens: How Big Corporations Impact Research Agendas

By: Arielle Dryer, Vincent Santiago, and Aleksandra Usyatynsky

You lurch awake in the early hours of the morning with a searing pain in your lower back. Being so sedentary during the pandemic has been making your muscle pain worse. You pull out your ibuprofen bottle from your nightstand and are surprised to see it’s running low. “Maybe I’ll see my doctor, just in case,” you think.

As you arrive at the doctor’s office later that day, you notice a new poster on display. “Missing out on your life because of pain? Relief is just a pill away, so you can get back to what really matters.” The logo in the corner looks familiar but you can’t remember where you’ve seen it before… A moment later your doctor glides in.

“Pain acting up again? Today I’m going to try a new drug instead of the over-the-counter stuff. It’s called ‘Strainadol’, you might have seen the poster in the waiting room. They just did a large clinical trial and it’s supposed to be really effective. Is that all for today?”

National Cancer Institute (no date)

You leave the office put at ease; the new medication sounds promising!

Research can become biased when one research question or result is favoured over another, intentionally or not. When research is biased it lessens how much we can trust the findings. How can you tell if research is biased? Well, the source of research funding can be an important sign. Like any other project, research often does not happen without the proper funds. Scientists need to buy equipment, pay research participants, and pay the salaries of research staff. Research is often funded by government agencies and non-profit organizations, but it is also funded by private industries. Industry funding is a major way that bias can creep into scientific research.

Have you ever questioned the findings of public health research? You may not have, because we usually trust that scientific research is objective. But when research has the power to influence our policies and the choices set before us in our day to day lives, it’s important to consider who has the power to influence our research.

There are a number of ways that this bias can affect research findings. Let’s say I am a researcher funded by a pharmaceutical company to test their new drug. Compared to my colleague funded by the government, I am more likely to design my study in a way that shows that the drug is effective.1 I am more likely than my colleague to draw stronger conclusions about the drug’s effectiveness, even if we have the same set of results. I am also more likely to only publish the findings that support the drug’s effectiveness.1

Industry funding can also influence research agendas, or the types of questions scientists ask in the first place. This type of bias is less studied, but can be powerful because it influences the rest of the research process and changes what information is available to us. To better understand this type of bias, in 2018 Fabbri and colleagues2 reviewed and brought together studies on how industry sponsorship has affected research agendas across a number of fields like medicine, tobacco, and food. The information presented here is the sum of findings from 36 studies between 1986 and 2017. With the information they reviewed, they answered 3 questions.

1) Does industry sponsorship impact research topics?

The review found that studies with industry funding tended to focus on research with commercial applications that results in more profits for the company. Within the health field, industry sponsorship means more research focused on money-making drugs and devices, rather than on talk therapy, physical activity, or dietary changes.

For example, most industry funded diabetes research focuses on oral medication or devices to measure blood glucose.3 In comparison, non-commercially funded studies research things like the causes, consequences, and complications of diabetes, and nonmedical ways of managing the disease.

One concern is that over-reliance on drugs to solve public health problems can have severe and unintended consequences. For example, the prescription opioid epidemic is partly due to the lack of existing non-drug alternatives to manage pain.4 Now, more than ever, we need to invest in deeper understandings of public needs and problems, rather than quick “band-aid” solutions. Due to the industry focus on their own interests, governments and nonprofits are left as the main sources of funding for these projects.

2) How do industries change what we research?

Industries have a few research tricks up their sleeves to make their products sell. One industry tactic is to focus research attention away from their product’s flaws. For decades the tobacco industry funded research focusing on how genetics puts certain people at risk of becoming addicted to smoking. This helped them make their case against claims that smoking causes cancer.5

Stanford Research (no date)

Another industry tactic is presenting research results so that they appear believable and trustworthy. The tobacco industry reported that its second-hand smoke research was determined by experts in the field who select research projects based on scientific value. It was revealed that some of these projects were actually chosen by tobacco industry executives and lawyers.6 As you can imagine, these individuals were not as likely to fund projects that could reveal the negative health effects of second-hand smoke. The tobacco research available at the time was used to inform policies that have directly impacted public health.

3) What are scientists doing with the money? What are their opinions?

For scientists who receive industry funding, their research agendas tend to shift away from basic research, which aims to understand the world around us (“Why does this exist?”), towards more applied research with specific commercial applications (“How can we use this?”). In fact, every 10% increase in private funding is associated with a 1.2% drop in a program’s basic research.7 Asking “why” questions is so important because it lays down a foundation for other science to build on.8 As an example, mathematical models used in basic psychological research have been applied to understand how people who use substances make decisions.9

But what do the scientists doing the work think about this shift? It depends on who you ask. Fabbri and colleagues2 found that across a few studies, scientists in academia and industry agreed that there is a risk of research becoming more commercial and applied with industry funding. In one study, industry funded researchers were more likely to think that the funding would lead to new and promising areas of research, whereas those who were not funded by industry were more likely to think the funding would lead to quick fixes, rather than long-term basic research.10

Nonetheless, some laboratories have collaboratively set a research agenda with their industry funders that was both basic and applied, with oversight by company executives and an academic research director.11 Such collaborations may be the key to balancing industry involvement in the future.

What can I do as a research participant?

You might be thinking, “So scientists know that their research is likely being influenced by industry research. What can I do about it?” Here are some tips.

  1. Whenever you’re participating in research, look out for funding disclosures in the consent forms. Who funded the study? Governmental agencies? Private companies?
  2. If you’re unsure, have a discussion with the research staff and principal investigator. Ask about the influence of their funding on the design and publication of the study.
  3. You can also inquire with the institutional Research Ethics Board (REB). The REB is meant to protect the rights and safety of research participants. Their contact information is typically listed on consent forms.
  4. Advocate for greater independent research funding (e.g., by governmental agencies) by lobbying local government officials. In Canada, the government pledged $4 billion in 2018 over 5 years for science across its main funding agencies.12
  5. According to the Government of Canada’s 2018 Panel of Research Ethics,13 REBs are required to have one community member with no affiliation to the institution, so consider joining an REB to represent community voices that are not influenced by industry.
  6. If you’re reading the results from a study in the media, check to see if the funding disclosures are reported. This may mean finding the original publication and/or getting in touch with the researchers.
Cytonn Photography (no date)

Remember, researchers are always looking for study participants and you can choose which studies you participate in. Your participation may ultimately guide the development of new products, drugs, therapies, and treatments. So next time you’re at your doctor’s office, wondering about your treatment options, ask yourself: Why is this my best treatment option? Where did this claim come from? Who may be benefiting from me choosing this option?

This doesn’t mean you should be suspicious of all science, but if you follow the money, you might be surprised at what you find.

As you leave the doctor’s office to pick up a bottle of that new “Strainadol” drug that your doctor prescribed, you take another look at the poster. You realize the logo in the corner might be for a pharmaceutical company you saw in the news recently. You think, “Maybe I’ll look up what that clinical trial was all about and ask my doctor more about it.”

References

  1. Lundh, A., Lexchin, J., Mintzes, B., Schroll, J. B., & Bero, L. (2017). Industry sponsorship and research outcome. Cochrane Library, 2017(2), MR000033. http://dx.doi.org/10.1002/14651858.mr000033.pub3
  2. Fabbri, A., Lai, A., Grundy, Q., & Bero, L. A. (2018). The influence of industry sponsorship on the research agenda: A scoping review. American Journal of Public Health, 108(11), e9-e16. https://doi.org/10.2105/ajph.2018.304677
  3. Arnolds, S., Heckermann, S., Heise, T., & Sawicki, P. T. (2015). Spectrum of diabetes research does not reflect patients’ scientific preferences: A longitudinal evaluation of diabetes research areas 2010–2013 vs. a cross-sectional survey in patients with diabetes. Experimental and Clinical Endocrinology & Diabetes, 123(05), 299-302. https://doi.org/10.1055/s-0034-1398591
  4. Phillips, J. K., Ford, M. A., Bonnie, R. J., & National Academies of Sciences, Engineering, and Medicine. (2017). Evidence on Strategies for Addressing the Opioid Epidemic. In Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK458653/
  5. Gundle, K. R., Dingel, M. J., & Koenig, B. A. (2010). ‘To prove this is the industry’s best hope’: Big tobacco’s support of research on the genetics of nicotine addiction. Addiction, 105(6), 974-983. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911634/
  6. Barnes, D. E., & Bero, L. A. (1996). Industry-funded research and conflict of interest: An analysis of research sponsored by the tobacco industry through the Center for Indoor Air Research. Journal of Health Politics, Policy and Law, 21(3), 515-542. https://doi.org/10.1215/03616878-21-3-515
  7. Buccola, S., Ervin, D., & Yang, H. (2009). Research choice and finance in university bioscience. Southern Economic Journal, 1238-1255. https://ideas.repec.org/a/sej/ancoec/v754y2009p1238-1255.html
  8. Lee, C. (2019, January 28). Not so basic research: The unrecognized importance of fundamental scientific discoveries. Harvard University. http://sitn.hms.harvard.edu/flash/2019/not-so-basic-research-the-unrecognized-importance-of-fundamental-scientific-discoveries/
  9. Narayana Chernoff, N. (2003, February 13). Basic research translates to addiction treatment. Association for Psychological Science. https://www.psychologicalscience.org/observer/basic-research-translates-to-addiction-treatment
  10. Harman, G. (1999). Australian science and technology academics and university-industry research links. Higher Education, 38(1), 83-103. https://doi.org/10.1023/A:1003711931665
  11. Webster, A. (1994). University-corporate ties and the construction of research agendas. Sociology, 28(1), 123-142. https://doi.org/10.1177/0038038594028001008
  12. Owens, B. (2019, April 24). Why are Canada’s scientists getting political? Nature. https://www.nature.com/articles/d41586-019-01244-0
  13. Government of Canada (2019, September 23). TCPS 2 (2018) – Chapter 6: Governance of research ethics review. Panel on Research Ethics. https://ethics.gc.ca/eng/tcps2-eptc2_2018_chapter6-chapitre6.html
  14. Government of Canada (2020, March 20). Recruitment of external research ethics board members. Health Canada. https://www.canada.ca/en/health-canada/services/scienceresearch/science-advice-decision-making/research-ethics-board/recruitment-regularalternate-external-members.html
  15. SickKids (n.d.). Research ethics board. http://www.sickkids.ca/Research/Research-Ethics/REBoffice/membership/reb-membership.html
  16.  Public Health Ontario. (2019, October 1). Ethics review board. https://www.publichealthontario.ca/en/about/research/ethics/ethics-review-board
  17. Ryerson University. (n.d.). Research ethics. https://www.ryerson.ca/research/resources/ethics/

Image References

Cytonn Photography (n.d.) [Photograph of hand signing a paper]. https://unsplash.com/photos/GJao3ZTX9gU

National Cancer Institute (n.d.). [A woman reading a booklet at a pharmacy counter while a pharmacist works in the background]. https://unsplash.com/photos/jqBOb3IThyA

Stanford Research. (n.d.). [Photograph of 1949 Viceroy Cigarette Advertisement]. https://metro.co.uk/2018/09/12/these-are-the-insane-adverts-that-told-people-smokingwas-good-for-them-7936951/?ito=cbshare