substance use

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

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