Substance Use

What Works? Don’t Know!

As I’ve gotten older I’ve become more open to using interventions I should’ve used earlier in my psychiatric career.  Especially for persons with addictions I’m more open to trying naltrexone, and even , in appropriate situations, benzodiazepines in a controlled fashion where I see evidence for crippling anxiety/panic symptoms.

This does leave me open to occasionally feeling ‘scammed‘; where a patient leaves me feeling like my openness to trying to help was taken advantage of.  It happens.

I console myself by going back to other’s wisdom such as William L. White’s chapter Some Closing Reflections on the Lessons of History in Slaying the Dragon: The History of Addiction Treatment and Recovery in America.

An example on “What works? “:

“Addicts make numerous attempts at aborting active addiction, and success and failure are all too often measured by a single intervention rather than combined or cumulative interventions. It is always the last attempt that is judged to be successful when, in fact, what may have proved the crucial factor was time, experience, maturity, the sudden opening of some developmental window-of-opportunity for change, or the cumulative effect of numerous interventions. What history tells us is that the early reports of such breakthroughs in the understanding and treatment of addiction are notoriously unreliable and should be treated with great caution and skepticism.”

I know that I’m going to get taken advantage again at some point by a patient who has addiction issues, but it’s still worth it. Trying to help individuals who are locked in powerful struggles is tricky and there’s much we still don’t know.  Persons with addictions are wrestling, torn between what they know and what their brain tells them they “need“.  As always it comes back to the issue of ambivalence:

“The history of addiction as experienced by America’s addicts is a history of SlayingTheDragonBookCoverambivalence. Addicts simultaneously want – more than anything – both to maintain an uninterrupted relationship with their drug of choice and to break free of the drug” …
“…one of the constant rediscoveries in this history is that espoused motivation to be drug free at the time of admission to treatment is not a predictor of positive treatment outcome. …  There has been a growing recognition that motivation is best viewed, not as a precondition of treatment, but as something that emerges out of an effective treatment process. Motivation is increasingly being viewed, not as something inside the client, but as something that emerges out of the interaction of the client’s intimate social network, the therapist and the broader treatment milieu.”

The work is more marathon than sprint.  Change takes time, lots of time.  Don’t get cynical and start thinking “people never change“.  Don’t you believe it!  Personality stays reasonably intact over longer periods of time but life happens, everyone experiences losses, joys, changes and traumas.  People do change, it’s just that we’re not good at predicting when.

In the meantime clinicians and agencies should stay focused on building dual disorder capacity. The goal should be what Dr. Ken Minkof wrote several years ago: “universal competency, including attitudes and values, as well as knowledge and skill”.   Please consider having a look at my post RUCCISC? from 3 years ago.  Dual disorders is such an important issue for ACT clinicians there should be an education session devoted toward one of the many aspects of it every 4-6 months.

Have a look at my two pages of excerpts from White’s book (click to view pdf) Slaying The Dragon Excerpts .  Even better, buy the book itself, which is available on Amazon.

Shalom Coodin MD FRCPC


Shalom CoodinS

Change The Topic

By July 2018 Canada will have legalized marijuana. Will this result in  northern reefer madness? I think not.  I do hope the discussion shifts to more pressing issues than that of marijuana.  However the next topic – that of medicalizing drugs of abuse  – is likely to be even more polarizing for the psychiatric community.

The opiate crisis needs to be addressed.  A New York Times article reports NYT OpiateDeathsthere were an estimated 59,000 drug overdose deaths in 2016 in the U.S.  Drug overdose is now the leading cause of death for Americans under 50.

At least half of ACT clients will struggle with co-occurring substance use problems at some point.  This, in combination with psychotic illnesses, poverty and the multiple other challenges ACT clients face, may make them even more at risk than the general population.  (I haven’t found any publications on how the opiate crisis is affecting ACT clients. If you  know of any please let me know.)

I blogged about this issue previously – if you have time read Relativity Risk (click to view).  Note where cannabis falls on the graphs!Drug Harm Graph

Dr. Nutt, an expert in the field wrote how:

“We saw no clear distinction between socially acceptable and illicit substances. The fact that the two most widely used legal drugs lie in the upper half of the ranking of harm is surely important information that should be taken into account in public debate on illegal drug use. Discussions based on a formal assessment of harm rather than on prejudice and assumptions might help society to engage in a more rational debate about the relative risks and harms of drugs.”

Some European countries have moved to medicalizing drugs of abuse.  In a 2014 legal journal article titled Uses and Abuses of Drug Decriminalization in Portugal (click to view pdf) the author says  that “The dire predictions of critics—“from rampant increases in drug usage among the young to the transformation of Lisbon into a haven for ‘drug tourists’ ”—did not come to pass.” She points out that “Portugal’s 2001 decriminalization law did not legalize drugs as is often loosely suggested. The law did not alter the criminal penalty prohibiting the production, distribution, and sale of drugs, nor did it permit and regulate use. Rather, Portugal decriminalized drug use…”

So what has been the effect? While still debated, the author concludes that “The removal of criminal penalties for drug use was intended to de-stigmatize addicted users and encourage treatment. According to Portuguese drug policy officials, the new system has effectively done just that.”

The fentanyl-related deaths that have hit communities such as Vancouver  – but also smaller centers, including my home of Winnipeg – have prompted the Canadian government to take steps, even ordering prescription-grade heroin.HealthCanadaHeroin

I know some will shudder at the thought of physicians ‘prescribing’  heroin.  I do!  However the issue isn’t whether we, as physicians and mental health professionals, ‘support’ drug abuse.  I think using drugs is BAD!  However the choice is not between good and bad options – it’s between bad and worse. Nearly 60,000 Americans and 2,500 Canadians died of opiates in 2016!

ACT clinicians, like other front-line staff may be equipped with naloxone kits, but naloxone is a fleeting intervention for what is almost always a long-term problem.  ACT clinicians should always be listening for opportunities to help clients work towards abstinence but the reality of the work is going to remain focused on harm-reduction.  There are not enough treatment options out there to begin with. For ACT clients who, for multiple reasons, can’t tap into or benefit from conventional treatment settings, there are even fewer.

BTW if your team doesn’t have a copy of Muesser et al’s Integrated ITDD CoverTreatment of Dual Disorders, buy one now! (click to view my previous post on this)  

I don’t  presume to have the answers but I do think we need to have discussions.

Thank you for listening.

Shalom Coodin


SG’s Landmark Report

In November the Surgeon General came out with a comprehensive report titled facing-addiction-in-americaFacing Addiction in America.  Much of the content won’t come as a surprise to ACT clinicians.  For example in the executive summary it notes that:

“Our health care system has not given the same level of attention to substance use disorders as it has to other health concerns that affect similar numbers of people. Substance use disorder treatment in the United States remains largely segregated from the rest of health care and serves only a fraction of those in need of treatment. Only about 10 percent of people with a substance use disorder receive any type of specialty treatment. Further, over 40 percent of people with a substance use disorder also have a mental health condition, yet fewer than half (48.0 percent) receive treatment for either disorder.”

It’s a definite step forward when the Surgeon General, Dr. Vivek Murthy is making the rounds of various media outlets  trying to get the message out on the need for change.  Watch his interview on PBS Newshour (click to view)


When I was a young psychiatrist I had a simple solution for patients who had substance use problems – “you have to go to AA (or CA or NA or GA or …)”.  I did my patients no good.

Two years ago I wrote a blog titled RUCCIS (click to view) pointing out how Ken Minkoff has, for years, been calling on mental health programs to provide Comprehensive, Continuous, Integrated System of Care (CCISC). He writes how

In a CCISC processevery program and every person delivering clinical care engages … to become welcoming, recovery- or resiliency-oriented, and co-occurring capable.  Further, every aspect of clinical service delivery is organized on the assumption that the next person or family entering service will have multiple co-occurring conditions, and will need to be welcomed for care, inspired with hope, and engaged in a partnership to address each and every one of those conditions in order to achieve the vision and hope of recovery.”

In that blog I commented how “on Minkoff’s webpage, the word ‘chronic’ appears only once! That word has a pernicious, disempowering effect on clients and care providers. It should be expunged from our vocabularies. Long lasting, long term, long-standing – I’m okay with all of these, but chronic – NO!”.  The Surgeon General’s report does use the ‘C’ word and I appreciate that the authors have their reasons for this.  I do think we need to see these problems realistically but we also have to leave room for that mysterious element of recovery.  Tony Bennett just celebrated his 90th birthday and I just recently learned that he went through years of addiction and nearly died of a cocaine overdose.  Meeting him at that time in his life could anyone have seen where he would be 35 years later, what with having a ‘chronic’ condition?

There are no simple answers.  ACT teams should, as always, focus on delivering the best services possible.

With the holiday season upon us, Roman, Kevin and I want to wish you and yours all the best of the season and a happy and healthy New Year!

Shalom Coodin

Relativity Risk

Professor David Nutt, a British mental health researcher, surveyed addiction experts for their views on the risks of various drugs.  Dividing the issue into personal risk (i.e. harm to self) and social risk (harm to others), they assembled the results into a paper published in The Lancet in 2010.  The graphs below summarize the results.

Nutt - Mean Harm graph
Drug Harm Graph 1

Examining such a subject shouldn’t be a big deal right? Well, Dr Nutt’s Wikipedia entry notes that:

“…Nutt published a controversial study on the harms of drug use in The Lancet. Eventually, this led to his dismissal from his position in the Advisory Council on the Misuse of Drugs (ACMD)…  Subsequently, Nutt and a number of his colleagues who had subsequently resigned from the ACMD founded the Independent Scientific Committee on Drugs. “

The Guardian newspaper published an article on the work titled Alcohol ‘more harmful than heroin or crack’.

Professor Nutt challenged conventional thinking in pointing out that:

“We saw no clear distinction between socially acceptable and illicit substances. The fact that the two most widely used legal drugs lie in the upper half of the ranking of harm is surely important information that should be taken into account in public debate on illegal drug use. Discussions based on a formal assessment of harm rather than on prejudice and assumptions might help society to engage in a more rational debate about the relative risks and harms of drugs”

Others have replicated Nutt’s survey and come up with their own graphs that differ slightly.  A Scottish group did a similar survey and their graph looks like this:

Drug Harm Graph

Dr. Nutt has been an outspoken advocate for medicalizing drugs of abuse. In a blog entry a few years ago he writes:

“I strongly believe that we should focus on public health approaches to the drug problem, and decriminalise the possession of drugs for personal use, for the following simple reason;- If users are addicted then they are ill, and criminal sanctions are an inappropriate way to deal with an illness.”

How should this information affect and inform how ACT clinicians approach their clients?  Will  ACT teams in the future be providing certain clients with methadone? With needles for injection drug users?  Should they? If they did would they risk consequences such as losing funding?

What do you think?

Shalom Coodin MD


“We have consensus in the U.S. about what alcoholism is and what it is not, a consensus so nearly complete that to question its basic assumptions is to be either rejected as a dangerous heretic or pitied as misguided and misinformed.”

William R Miller

In his paper Haunted by the Zeitgeist Miller goes on to question those basic assumptions.  And yet I don’t think anyone would label Bill Miller – of MI fame – a dangerous heretic, misguided or misinformed. HauntedZeitgeist

Haunted by the Zeitgeist is a great piece for ACT team teaching!  Though published in 1986 it remains just as relevant today.

Miller touches on six assumptions on alcoholism that are still firmly held on this side of the Atlantic. He asks:

So what is alcoholism, really? If you ask most any informed American you are likely to have it explained to you that alcoholism is an irreversible disease that causes a person to lose control over drinking. Broken down into its component assumptions, the elements of this traditional American conception of alcoholism are as follows:

  1. Alcoholism is a disease. It is recognizable as a unitary syndrome with certain symptoms and a predictable progression.
  2. Alcoholism is a disease. Although the etiology is not completely known at present, it probably has a physical cause as well as psychological and spiritual elements.
  3. Loss of control is the central symptom. An alcoholic loses the ability to control his or her drinking. “One drink, one drunk.”
  4. Alcoholism is irreversible. One can never become a recovered alcoholic, only a recovering alcoholic. Return to drinking causes resumed deterioration. “Once an alcoholic, always an alcoholic.”
  5. The only possible hope for an alcoholic is total and permanent abstinence from alcohol.
  6. Far and away the most effective means for achieving this is through the fellowship of Alcoholics Anonymous (AA)…

The origin of these assumptions is not scientific data… The pervasiveness of this view in the US is difficult to explain to those living in other nations, where wholly different assumptions may be held…

He goes on to address each of these assumptions, presenting evidence to support or challenge them. For example on the idea that Alcoholism is Irreversible he writes “…to any reasonable reader of the scientific research on alcoholism treatment outcome, this assertion must be regarded as soundly refuted…Suffice it to say that there is no scientific basis for maintaining the possibility of nonproblem drinking outcomes, and that there is substantial evidence to the contrary.”Alcohol and Culture

He concludes with “Perhaps our best guiding principle through all of this is to remain close to the data. The current American conception of alcoholism and the treatment system that has been perpetuated by it exemplify how far it is possible to stray when a particular theory becomes more important than evidence itself… It is premature to claim to have the answers when we are still searching for the right questions.”

The ideas Miller presents are still very true and this article provides food for thought and discussion.  It’s worth taking small pieces of it and using it for a team education session. Get someone on the team to distil it down and present some of the ideas – perfect role for the team psychiatrist!  (Don’t make everyone read through the whole paper.)  After such a session your team members should have more questions, not less.  And isn’t that the goal?- to have better questions, not simplistic answers.

Sorry I can’t post a pdf of the whole article- I did ask the NY Academy of Sciences and was politely told that it is accessible online for a fee (as little as $6 – click here to view).  Or you can still buy a used copy of this publication (click to view via Amazon) for about the cost of a venti pumpkin spice Starbucks.

Shalom Coodin

ACT Curriculum, Part II

” In the ongoing battle against mental illness, some of our most valiant warriors are on the front lines ITDD Coverworking with dually diagnosed, seriously ill individuals – that is, individuals who present not only with chronic and severe mental illness such as schizophrenia or bipolar disorder, but also with substance abuse. These patients confound the best efforts of public mental health systems and networks of treatment programs for addiction. As the authors of this book point out, the traditional approach has been to choose one diagnosis and focus treatment efforts on that before moving on to treat the second diagnosis. Typically and tragically, these efforts have most often been futile. Now Kim Mueser and his coauthors describe in this ground-breaking work a treatment for these difficult patients that provides a “Seamless integration of psychiatric and substance abuse interventions in order to form a more cohesive unitary system of care.”

                                                                                                                Dr. D. Barlow, from the Editor’s Note

If your team doesn’t have a copy of Integrated Treatment for Dual Disorders you must, must, must get a copy. This compilation covers a slew of stuff, from the basics, to assessment, group interventions to working with families and more. It really is a necessary resource that every ACT team should have on the bookshelf.

“…persons with severe psychiatric illness are at much greater risk for developing a substance use disorder than people in the general population. What accounts for the very high rate of comorbidity of the psychiatric and substance use disorders? Understanding the factors that contribute to the high rate of comorbidity may provide clues useful in the treatment of dual disorder.”

Rather than expecting clinicians to read it cover to cover use the chapters as jumping off points for education session discussions. Has your team ever tried offering persuasion groups (see Chapter 9)? How is a persuasion group different from an active treatment group? What are the problems associated with traditional twelve-step groups for clients with dual disorders (see page 187)?

Norway1 And if you’re going to be in Norway this June consider attending the EAOF’s 3rd European Congress on Assertive Outreach and hear Dr. Robert Drake, one of the authors addressing Assertive outreach for people with co-occurring disorders. (btw sunrise in Oslo on June 24th is 3:55 AM, sunset 10:44 PM!)

Shalom Coodin

“Whatcha Using?”

That’s not usually the way I open a dialogue with a client around substance use.  Rather, I’ll say “Everyone’s exposed to alcohol growing up and there’s lots of marijuana, coke, E, meth and other stuff.  What’s been your experience?”  Better to normalize things and then begin with an open-ended question.  It beats So, do you abuse alcohol and street drugs?”

In my opinion ACT teams don’t need substance use screening tools like the CAGE, the AUDIT or the DAST as much as they need tracking tools.  Most individuals have had lots of contact with services before getting to ACT.  And screening tools are a pretty ‘blunt instrument’,  so to speak.

DrugAlcPicThere are lengthy survey tools that have been used, including those detailed in Allness and Knoedler’s PACT manual.  My team came up with a modification of those.   Clinicians print off the Drug&AlcoholUseTemplate (click to view) – and either go through it with the client or, simply have the client fill it out.  The format is straight-forward, if the answer to the first question, for example:  Have you ever used an amphetamine or crystal meth, what some people call an ‘upper’ or ‘speed’ on your own, either without a doctor’s prescription or in greater amounts or more often than prescribed? is a No, you just flip to the next page.

The results are put in the PACTwise database (yes, a flagrant product placement/plug) and out comes a one page Drug and Alcohol Review (click to view).  This single page report provides an overview – age of first use for each drug, last use, use in theDrugAlcoholReview past 12 months – that gives clinicians an understanding of the client’s pattern of use over time.

This is certainly not the only way to track this kind of info. What do you use? How is it? What do you think would be the ideal tool?

Shalom Coodin






Ken Minkoff came to our community a number of years ago. Dr. Minkoff’s area is co-occurring disorders- helping health care systems meet the needs of those with mental health AND substance use issues (who are many). I came away from his visit with a much deeper understanding of co-occurring disorders. I also came away with CCISC.

Services should be measured by CCISC; are they Comprehensive, Continuous and Integrated? (the final letters standing for “System of Care”) ACT is, by its very nature CCI; if a client needs help with housing,  meds, education and employment, that’s what the team does.

CCISC Webpage

ACT is not the only resource needed in a community. But this measure of services being continuous, comprehensive and integrated is the right one. Most mental health issues – mood problems, anxiety, psychotic symptoms, eating disorders, PTSD – aren’t short term ones. We don’t yet have interventions that can be dished out in walk-in clinics or one-stop settings.

Minkoff describes that

In a CCISC process, every program and every person delivering clinical care engages … to become welcoming, recovery- or resiliency-oriented, and co-occurring capable.  Further, every aspect of clinical service delivery is organized on the assumption that the next person or family entering service will have multiple co-occurring conditions, and will need to be welcomed for care, inspired with hope, and engaged in a partnership to address each and every one of those conditions in order to achieve the vision and hope of recovery.”

I especially like Minkoff’s emphasis on all clinicians developing “universal competency, including attitudes and values, as well as knowledge and skill”.   For years I was an inpatient psychiatrist who would tell patients “Well Joe, I can help you with the schizophrenia, but the alcohol and drug stuff isn’t my area so you’ll have to go elsewhere for that.” What a disservice I did to my patients; as if they could fragment off pieces of themselves for the convenience of, or because of the limitations of their psychiatrist.

I’m delighted that, in the 2685 words on Minkoff’s webpage, the word ‘chronic’ appears only once! That word has a pernicious, disempowering effect on clients and care providers. It should be expunged from our vocabularies. Long lasting, long term, long-standing – I’m okay with all of these, but chronic – NO!

Minkoff, in point #2 writes The foundation of a recovery partnership is an empathic, hopeful, integrated, strength-based relationship.” The C word does the opposite.

If you’re in a position of responsibility for effecting system change in your agency or community, make Minkoff’s page a ‘favorite’ in your browser.  Call it up and review it before every meeting where system change is going to be discussed.  Then go into those meetings asking yourself – Is what we’re discussing CCISC and, if not, how do we get it there?

Shalom Coodin

Click here > CCISCmodel < for the pdf/ printer friendly version of Minkoff’s page


Google Clients?

Two suggestions for this Thanksgiving week.

If you’re following this blog that’s great. Next step – follow Patricia Deegan’s blog. Her blogpost this week raises very interesting questions around privacy and professionals. Check it out.

Pat Deegan Blog2

My other recommendation is to watch Ethan Nadelmann’s thought provoking TED talk. In ACT we’re working with individuals wrestling with substance use every day. We should also think about the big picture issues which are, not surprisingly, complex.TED War onn Drugs

Original material next time.

To our American friends and followers have a Happy Thanksgiving!

Shalom Coodin

Just Three Things

I’ve often said that at its core ACT is about three things – relationship, relationship, relationship. Medication, recovery planning, psychosocial rehab all have to occur within the context of relationship.

In terms of the practical skills ACT clinicians need to do their work, I recommend three things – MI, MI, MI (you saw that coming now, didn’t you?) The skills of Motivational Interviewing – active listening, open-ended versus closed-ended questions, acknowledging ambivalence, using reflection, enhancing self-efficacy etc… – are absolute necessities for the day to day task of helping people effect change in their lives.

MI TitleMI is not a panacea. Even if you become most skilled at it you’ll still be working with clients who will continue to have profound struggles with addictions, with symptoms and with relationships. It’s like what Churchill said : “democracy is the worst form of government, except for all the others”. MI is better than bombarding with questions and much better than confrontations and ‘interventions’. Yes, there are times when I’ve laid it out in black and white to a patient – “Joe, you’re either agreeing to go into hospital or you’re not agreeing on going into hospital, but you ARE going into hospital.” But that kind of conversation should never be my ‘go to’ tool for anything.

How to acquire MI skills? Wish I could tell you it’s ‘quick and easy’ but it’s not. It’s worth investing time and energy learning them but it’s like exercise, I have to keep doing it and doing it and…

Miller, Rollnick and MoyerMiller and Rollnick’s Professional Training DVDs are an invaluable tool. Better than their book – is it ever as good reading an exchange between client and clinician versus watching and hearing? – these discs should be made available to all ACT clinicians.

If you’re an agency director buy your ACT team the set for $110 through the University of New Mexico. (Click to open the pdf order form) If you’re a team leader, program director or the like and have $110 left in your budget, buy the set. If you’re a front line clinician put it on your Xmas/ Hanukah/Kwanza/Winter Solstice wish list and casually leave this visible to your team leader come November. When you get the DVDs start watching them; watch with others, watch just 10 minutes then discuss some of the concepts; bring it to a team education session and talk about one thing. Slowly, slowly clinicians start to pick up some of the lingo, then become more aware, hearing that little voice in the back of their head asking “What I just said, was that a closed-ended question? How could I have made it into an open-ended question? How could I have put it as a reflection?”

On the DVD Theresa Moyers’ interview with ‘Jim’, demonstrating how to Roll with Resistance is masterful and it alone is worth the price of admission. Yes, the client may be an actor but Moyers is going in cold, no script, and her technical skills are so wonderful to watch. I’ve seen it at least a dozen times and still learn something new each time.

Try not to think of learning MI as an event; it’s a process, a long-term one that has to be returned to again and again.

I’ll be back with more on MI.

PS: I was saddened to get the recent email that ACTA will be shutting down. Thank you Cheri Sixbey and Alexandra Sixbey-Spring for keeping it going as long as you did.

To paraphrase Joni Mitchell, sometimes you don’t know what you’ve got till it’s gone.

Shalom Coodin