Tag: addiction

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ADHD in Disguise: The Missing Link in Addiction Treatment

by Bree Lawrence

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

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

Attention Deficit Hyperactivity Disorder

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

The Complexity of Co-Occurring Diagnoses

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

Executive Functioning

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

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

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

The Influence of Executive Functioning on Treatment

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

Intense Emotions and Impulsivity

Image designed by FreePik (2020)

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

Why is this Connection Important?

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

So What Do We Do? 

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Mind Myths: The Addictive Personality

A podcast episode written and produced by Susanna Lee

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

References

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

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

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

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

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

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

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

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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 
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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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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