Substance Use

Because the age of onset for most people with a psychosis is in the late adolescent early adulthood years, all types of substance use needs to be assessed and addressed. Substance use is a problem for a young person if they experience frequent cycles of intoxication, withdrawal, and craving, leading to relapse into further intoxication.

 Steps to assess for substance use: what to discuss with the client

  • Quantify substance use
  • Patterns of use
  • Diagnostic criteria for dependence or abuse
  • Impact of use: social, vocational, physical, financial, psychological
  • Risk of injury (impulse control problems, reckless behaviour, careless accidents, driving, using machinery, appetite changes)
  • Method of use
  • Safety of method of use
  • Withdrawal symptoms
  • Cravings
  • Family history of substance use
  • Polysubstance

 Assessment Tips

  • Be conversant with the lingo.  When in doubt ask!
  • Normalise drug use (expect that the client uses substances)
  • Avoid judgemental overtones
  • Look out for yea-saying, gain-saying and acquiescence
  • Look for physical signs of substance use

 
Motivational interviewing: strategies to assist a client with a substance use problem

The starting point for motivational interviewing (MI) is to ascertain the client’s ambivalence about their substance use. Can they list the advantages of using? Can they list some disadvantages of using? If this highlights ambivalence about use, the key to dealing with that feeling will unlock any barriers to change.
 
In the context of the stages of change model, a substance using person can be assisted most most in the stages: pre-contemplation, contemplation, and preparation. But motivational interviewing is not a transtheoretical model of change.
(More reading: "Transtheoretical therapy: Toward a more integrative model of change." Prochaska, J. O., DiClemente, C. C. Psychotherapy: Theory, Research & Practice Vol 19(3), Fal 1982, 276-288.)
 

In essence the utility of MI is that it is a goal-directed counselling method that assists in resolving ambivalence and promoting change by highlighting and strengthening a person’s motivation of change.
 

To practice MI in a substance use context, a clinician needs to:

  • Listen to the patient
  • Understand the patient’s motivations
  • Show capacity to ride out resistance to change
  • Show support for client’s self-efficacy

 

More information:

Miller, W.R. & Rollnick, S. (2002) Motivational interviewing: preparing people for change (2nd ed) New York: Guildford Press

Arkowitz, H., Westra, H.A., Miller, W.R., & Rollnick, S. (2007) Motivational interviewing in psychological problems New York: Guildford Press

Cannabis and Psychosis: An Early Psychosis Treatment Manual (Orygen Research Centre) This can be ordered online from the Orygen Resources Store here
 
 

Research indicates that addiction to substances affects dopamine levels in the mesolimbic pathway of the brain, which results in over-sensitization to the substance of abuse, and ultimately delusions, and possibly hallucinations.

Substance use amongst people of all ages with mental illness is relatively high:

  • Bipolar disorders 60%
  • Psychotic disorders 40-60%
  • Mood and anxiety disorders 20-25%

In young people with an merging mental illness, the rate of substance use is between 50-90%.

If there is a problem with substance use, the substance use problem needs to be treated as well as the primary psychotic condition.

Substance use can make psychotic symptoms worse, and needs to be confronted as a possible precipitant to relapse, and as a cause for a delay in achieving recovery from the acute episode of psychosis.

Substance use can also 'mask' the symptoms of psychosis, making treatment for the psychotic disorder more difficult by exacerbating cognitive difficulties.
 

Solvents and aerosols
Moderate to heavy consumption is indicated by feelings of power and recklessness, hallucinations, severe disorientation, and antisocial behaviour. Long term consumption leads to mental confusion, hostility, fatigue, depression, and psychosis. Withdrawal sometimes presents as: irritability, anxiety, depressed mood, insomnia, hallucinations, and delirium.
 
Alcohol
Moderate to heavy consumption is indicated by: depressed mood, suicidal behaviour, and violence. Prolonged consumption leads to: dysphoria, anxiety, alcohol hallucinosis, and delusions of morbid jealousy.
Acute withdrawal symptoms are characterized by: insomnia, unstable mood, fatigue, hostility. Chronic heavy use leads to: anxiety, sweating, tremors, seizures, hallucinations and delusions.
 
Cannabis
The role of cannabis in the development of psychosis has been the subject of much debate and research. The capacity for cannabis to induce psychotic-like symptoms such as hallucinations, delusions, paranoid thinking and thought disorder in non-psychotic people has led to theories that cannabis misuse causes psychosis. Many young people describe that the reason they use cannabis is to relieve the symptoms of psychosis.
Moderate consumption is indicated by: panic attacks, impaired short-term memory, cognitive deficit, such as the ability to perform complex tasks. Heavy consumption leads to: reduced levels of energy, decreased immunity, impaired judgement, hallucinations, and psychosis (on average 5-7 years after first use). Cannabis withdrawal is characterised by: insomnia, irritability, anxiety, loss of appetite, and depressed mood.
What can you do?

Always ask the client about their cannabis use.
 

  • Try and have the young person establish a link between symptom level and cannabis use as well as cannabis use and symptom level.
  • Take a harm minimisation approach
  • Seek specific help with intervention strategies

Methamphetamine
'Meth' is a psychoactive stimulant drug. The effect of taking 'meth' is to experience: an increase an increase in alertness and energy, euphoria, self-esteem, and sexual pleasure. In the brain, it increases levels of dopamine and norepinephrine.

Moderate use leads to: restlessness and insomnia, labile mood, and reduced appetite. Long-term use leads to: stronger highs followed by agitation, depression, erratically violent behaviour, and psychosis after 1-4 years of use.

Withdrawal is characterised by: depression, irritability, lethargy, anhedonia, anxiety, restlessness and agitation, insomnia, sexual dysfunction, residual psychosis and paranoia.
 

Ecstasy (MDMA)
The short-term effect of ecstasy is to experience: mild intoxication, euphoria, 'relatedness', increased sense of sociability to others, increased energy and confidence, anxiety and panic attacks.

Heavy consumption can lead to : psychotic symptoms, and hallucinations.

Withdrawal is characterised by: long-lasting anxiety, depressed mood.
 

Heroin
The immediate effect is to experience: pleasure, pain relief, drowsiness, nausea. The side-effects can be: depression of the central nervous system leading to reduced respirations and pulse, and a drop in blood pressure.

Withdrawal form heroin in the first 3-4 days is characterised by: runny nose, sore throat, profuse sweating, temperature fluctuations, stomach cramps, body aches, cramps, strong cravings, diarrhoea and vomiting, irritability, loss of appetite, insomnia, and occasionally, bizarre dreams.
 

Cigarettes
Cigarette smoking does not directly affect psychotic symptoms, however it is a major public health issue with young people who have a mental illness, and all people with a mental illnesses, being amongst the highest groups of cigarette smokers. Cigarette smoking has issues for the long term health of young people and their current financial situation.

When a young person is in a current episode of psychosis or early recovery, giving up cigarettes is possibly a stress that they can do without. Reducing use rather than stopping altogether is probably a more realistic aim. It is better to tackle the issue of stopping smoking more specifically in late recovery phase.
 
Caffeine
Many adults with a mental illness have a very high caffeine use. It is important to stress the importance of alternative drinks to those high in caffeine, such as coffee, cola drinks and energy drinks.

Weight management is also an issue as many people with a psychosis take medication which could have a side effect of lowering metabolism while increasing appetite, and as many caffeine drinks come laden with sugar, weight gain and associated problems can be an issue. Sustaining adequate exercise is also difficult while unwell and thus avoiding large quantities of sugar high drinks is important.