Substance Use Copy

Research has shown that at least 30% of all early psychosis clients engage in problematic use of substances – in particular marijuana and alcohol are the most commonly abused substances though rates of use of amphetamines and cocaine are also relatively high. Substance use in early psychosis is associated with lower functioning, poorer quality of life and increased risk of relapse.

Client Partnered Care for Concurrent Disorders and EPI with Cindy Van Hoang.
The slides for this presentation are available HERE.
Additional resources: Window of Tolerance, Window of Tolerance Tips, and Trauma and Resilience Informed Practice.

For a thorough assessment of substance use, questions should be asked to gather an understanding of both current and past use including information on:

  • Drugs used
  • Frequency and duration of use
  • Dose and method of administration
  • Availability and financial cost
  • Positive and negative effects
  • Effect of use on psychiatric symptoms
  • Preferred times, situations, and other prompts for use
  • Attempts to quit (successful and unsuccessful)
  • Motivation for reducing and continuing use
  • Impact on functioning
  • Dangerous or high risk behaviour.

Assessment should also try to uncover prompts for drug use, as in treatment one focus could be to avoid or modify these prompts. Skills training including drug refusal skills and adaptive behavioural alternatives may all be guided by assessment.

The most effective method for treating substance use is through an integrated approach focusing on harm reduction and using motivational strategies to have the client decrease use. The assessment phase can involve asking non-judgemental questions about use and what the client sees as the positives and negatives. The initial focus would be to have the client begin to see some discrepancies between current behaviours and more attractive options. The decision to reduce use is, of course, ultimately the client’s own decision. Once the client makes efforts to reduce use, focusing on successes should support self-efficacy.

Crystal Meth

Use of methamphetamine (“crystal meth”‘”jib”, “ice”, “chalk”, “fire”) has increased significantly throughout British Columbia over the past several years especially in youth and young adults. It is cheap and relatively easy to obtain, as it is relatively easy to make in home laboratories (although often what is sold on the streets as crystal meth is not pure methamphetamine but a mix of drugs).

Methamphetamine is a potent central nervous system stimulant. It can be taken in a variety of ways including smoked, ingested, snorted or injected. It works in the brain to alter the levels of several neurotransmitters – most notably causing an increase in levels of dopamine, serotonin and norepinephrine. The short-term effects of these neurochemical changes include feelings of euphoria, increases in energy and activity, suppression of appetite and increases in heart rate and blood pressure. Other acute effects can include agitation, paranoia, confusion and violence. Grinding of teeth and obsessive picking at one’s body are physical signs of use. These acute effects can last anywhere from 8 to 24 hours.

Continued use of crystal meth often leads to intense cravings for use making it very difficult for an individual to discontinue use. With continued use a person will typically demonstrate rapid weight loss and may become malnourished. Longer-term use of methamphetamine appears to result in cognitive impairment and damage to the brain (for example, cell death in the cingulate complex and hippocampus, areas involved in many complex brain processes including emotional regulation and memory. It can also lead to the development of a psychotic condition that is difficult to treat.

It has been estimated that 10-20% of crystal meth abusers develop psychosis. The typical symptoms include paranoia and auditory hallucinations, which are not distinguishable from other psychotic disorders such as schizophrenia or bipolar I disorder. The onset of psychosis often occurs gradually with continued use but can sometimes occur suddenly following minimal use. The psychosis may persist following discontinuation of crystal meth.

Individuals with psychosis associated with crystal meth use may be less responsive to treatment and there is little published literature to guide treatment efforts. The first step is to have the person undergo detoxification through a drug treatment program and see if the psychosis persists following discontinuation. If the psychosis persists, then atypical antipsychotics are indicated (depot antipsychotics may be needed if the person is unwilling to have treatment) plus the full range of psychosocial treatments indicated (e.g., assertive outreach, psychoeducation, family involvement, reintegration, etc.). There is little literature on how to treat crystal meth dependence although guidance for the literature on cocaine dependence suggests that certain medications (such as buproprion) and cognitive behavioural therapies may help to control drug cravings.

To view a powerpoint presentation on crystal meth and psychosis click here


There has been increased interest in the relationship between cannabis and psychosis in recent years. Research has demonstrated a positive association between the use of cannabis and psychotic symptoms with longitudinal studies suggesting that early exposure to cannabis increases the risk of developing a psychotic disorder by two-fold. Although the vast majority of individuals who use cannabis will not develop a psychotic disorders, it appears that there is a small proportion of the population who are particularly vulnerable to the effects of cannabis in this regards. Current thinking is that cannabis use alone is not sufficient to cause a psychotic disorder but rather that it interacts with other vulnerability factors. Genetic factors, in particular, appear to mediate whether exposure to cannabis may contribute to the development of a psychotic disorder.

After an individual has developed a first-episode of psychosis (and regardless of whether cannabis use was involved as a risk factor), research shows that cannabis use will likely lead to an exacerbation of symptoms, may be a trigger for relapse and that continued use worsens long-term outcomes.

Having a young person with a psychotic disorder recognize the need to reduce use can be challenging. The person’s social circle may all be using cannabis and the person may not believe that reduced use is an important factor in their own recovery. Motivational interviewing, harm reduction strategies, drug refusal skills, and finding other social activities and interests may all be part of a multi-pronged approach to help the person decrease use


Review the 2018 report “Cannabis and Psychosis: A review of the links” by Tom Ehmann, PhD with input by Fred Ott. This is the full review document with full references. You may also review the Summary report (shorter and suitable for the public)

For more information and resources visit the Cannabis and Psychosis: Raising Awareness for Youth (A national project of the Schizophrenia Society of Canada) –

Find and review the “Substance Use Assessment” tool in care pathway page.

Using the substance use assessment tool (referred to just above), do an assessment of substance use with one of the clients on your current caseload. Try to capture all the information mentioned above in your assessment. Are there additional types of information or questions you would ask to help guide treatment for substance abuse? Please post any additional suggestions on the group blog.

Click HERE for a transcript of Dr. MacEwan interviewing David about Substance Use

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