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

By Hannah Rasiuk

person holding grey tongs and kush

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

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

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

What is psychosis? 

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

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

What are the symptoms of psychosis? 

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

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

Can psychosis be caught early on? 

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

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

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

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

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

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

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

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

Who might be vulnerable to developing psychosis after using cannabis? 

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

Did you begin smoking at a younger age?

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

Do you have a family history of psychosis? 

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

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

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

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

Frequency of cannabis use

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

Potency of cannabis used 

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

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

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

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

How sure can we be about these findings?

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

How might these research findings be applied to everyday life?

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

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

Resources for personal support available in Toronto:

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

Connex Ontario: Mental Health & Addiction Treatment Services

Partners in Care: Supporting Families in Patient Recovery

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

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References

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

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

3Loflin, M., & Earleywine, M. (2014). A new method of cannabis ingestion: The dangers of dabs?. Addictive behaviors, 39(10), 1430-1433. http://dx.doi.org/10.1016/j.addbeh.2014.05.013

4Government of Canada. (n.d.a). Addiction to cannabis. https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/health-effects/addiction.html

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

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

7CAMH. (n.d.). Psychosis. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/psychosis

8Schizophrenia Society of Canada. (n.d.). Annual report 2017-2018https://schizophrenia.ca/wp-content/uploads/2020/05/SSC-and-SSCF-Annual-Report-2017-2018.pdf

9NIMH. (n.d.). Fact sheet: Early warning signs of psychosis. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/fact-sheet-early-warning-signs-of-psychosis.shtml

10Government of Canada. (n.d.b). About cannabis. https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/about.html

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Image References

Pixabay. (2018). [Close-up of cannabis extracts] [Photograph]. https://pixabay.com/photos/cannabis-weed-pot-marijuana-3587706/

Unsplash. (2016). [Person holding grey tongs and kush] [Photograph]. https://unsplash.com/photos/h3PWUqxpP_0

Hyperlink References

Badii, C. (2019). Everything you need to know about hallucinations. Healthline. https://www.healthline.com/health/hallucinations

Better Health Channel. (n.d.). Genes and genetics explained. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/genes-and-genetics

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

Cafasso, J. (2021). Chemical imbalance in the brain: What you should know. Healthline. https://www.healthline.com/health/chemical-imbalance-in-the-brain#treatment

CAMH. (n.d.b). Patient and family engagement at camh. https://www.camh.ca/en/your-care/for-families

CAMH. (n.d.c). Access camh. https://www.camh.ca/en/your-care/access-camh

Connex Ontario. (n.d.). Free 24/7 access to health services information. https://www.connexontario.ca/en-ca/

CMHA. (n.d.) Schizophrenia. https://cmha.ca/mental-health/understanding-mental-illness/schizophrenia

Edelweiss Publications. (n.d.). Drug potency: Pharmacovigilance and pharmacoepidemiology. http://edelweisspublications.com/keyword/33/1469/Drug-Potency

Learning about cannabis use disorder. (2020, June 29).  My Health Alberta. https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=abr9729&

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

Knott, L. (2018). Antipsychotic medicines. Patient. https://patient.info/mental-health/schizophrenia-leaflet/antipsychotic-medicines

Psychotherapy. (n.d.). Mayo Clinic. https://www.mayoclinic.org/tests-procedures/psychotherapy/about/pac-20384616

Stunning free images & royalty free stock. (n.d.). Pixabay. https://pixabay.com/

University of Toronto Mississauga. (n.d.). Gta mental health resources: Culturally specific. https://www.utm.utoronto.ca/health/resources/gta-mental-health-resources-culturally-specific

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

Using Mindfulness as a Technique to Quit Smoking

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

By: Rhiannon Ueberholz

(Hyson, 2020)

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

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

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

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

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

(Venture Academy, 2020)

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

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

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

How does Mindfulness Treat Nicotine Addiction?

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

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

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

(Alphaspirit.it, 2020)

Is Mindfulness Effective?

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

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

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

What are the Limitations?

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

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

Getting Help During the Pandemic

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2), 144–156. https://doi.org/10.1093/clipsy.bpg016

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

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

MindSciences. (2021). Craving to quit. Retrieved from https://www.cravingtoquit.com/

Penberthy, J. K., Penberthy, J. M., Lynch, M., & Chhabra, D. (2017). Mindfulness based treatment for smoking cessation: How it works and future directions. Contemporary Behavioral Health Care, 2(1). https://doi.org/10.15761/CBHC.1000119 

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

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

Westbrook, C., Creswell, J. D., Tabibnia, G., Julson, E., Kober, H., & Tindle, H. A. (2013). Mindful attention reduces neural and self-reported cue-induced craving in smokers. Social Cognitive and Affective Neuroscience, 8(1), 73–84. https://doi.org/10.1093/scan/nsr076

Yang, H., & Ma, J. (2021). How the COVID-19 pandemic impacts tobacco addiction: Changes in smoking behavior and associations with well-being. Addictive Behaviors, 119, 106917. https://doi.org/10.1016/j.addbeh.2021.106917

Images

Alphaspirit.it. (2020). Stressed Businessman with Broken Mechanism Head Screams [Photograph found in Stock Images]. Retrieved from https://www.shutterstock.com/image-photo/stressed-businessman-broken-mechanism-head-screams-346270295 

Hyson. (2020). Balancing Stones [Photograph found in The Ultimate Morning Meditation for Relaxation]. Retrieved from https://www.onnit.com/academy/morning-meditation/ 

Venture Academy. (2019). Teen Smoking [Photograph found in Teen Behavioural Treatment]. Retrieved from https://www.ventureacademy.ca/troubled-teen-blog/teen-smoking/

Battling an Epidemic in the Face of a Pandemic:

COVID-19’s Detrimental Effects on the Opioid Epidemic 

By: Amy Rzezniczek

(Psychiatry Advisor, 2021)

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

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

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

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

Pandemic Social Isolation and Opioid Overdose

(Immigration Canada, 2020).

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

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

Safety Measures Acting as a Barrier to Accessing Treatment

(Wall Street Journal, 2020). 

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

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

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

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

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

Subjugated Groups Are Particularly at Risk

(The Conversation, 2020).

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


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

Where Can We Go From Here?

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Photograph References

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

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

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

Addressing Bisexual Substance Use: A Conversation Long Overdue

By: Karla Kovacek


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

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

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

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

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

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

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

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

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

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

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

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

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

Why are bisexual individuals at such a heightened risk?

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

Bi-negativity

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

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

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

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

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

Sexual violence and oversexualization

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

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

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

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

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

How can substance use issues in bisexual individuals be addressed?

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

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

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

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

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

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

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

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

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


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

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


Superscript References

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

Hyperlink References

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

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

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

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

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

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

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

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

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

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

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

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 Psychology9(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 Therapy49(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 Behaviors40, 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 & Misuse54(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 Behaviors102, 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 Research44(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 Psychiatry51(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].

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

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

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

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

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

“Woman Vaping on Electronic Cigarette (JUUL)”  by Vaping360 is licensed under CC BY 2.0

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 

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

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

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

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. 

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

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 Research44(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 Psychiatry177(11), 1031-1037.

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 [23]. 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 [78]. 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 [1718] 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 [1920] 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.

Wordcount: 1,998 words

References

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Images

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